European Archives of Oto-Rhino-Laryngology (2021) 278:159–165

https://doi.org/10.1007/s00405-020-06238-7

LARYNGOLOGY

Vocal resistance among choir singers

Fernanda Onofre1 · Hilton Ricz1 · Yuka de Almeida Prado2 · Gleidy Vannesa E. Rojas1 · Denny Marcos Garcia1 ·
Lilian Aguiar‑Ricz1

Received: 23 April 2020 / Accepted: 22 July 2020 / Published online: 4 August 2020
© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose The purpose of the present study was to compare the voice of choir singers before and after 60 min of singing and
after an absolute rest.
Methods Twenty-one female choir singers aged on average 26.59 years, with experience in choir singing of at least one
year were instructed to emit the vowel /a/ before and after singing and after a vocal rest of 30 min for an analysis of acoustic
measures, and for the evaluation of their tactile–kinesthetic self-perception. Vocal warm-up was performed for 10 min. The
participants were instructed to sing the “Ave Verum” music continuously for 60 min.
Results f0 (p = 0.0001) and Flo (p = 0.0002) increased after the singing test and were reduced after the vocal rest, in con-
trast to Fhi (p = 0.001), which continued to be increased compared to the pre-test measure even after the vocal rest. The
vAm parameter (p = 0.05) was reduced after continuous singing and rest. All self-evaluation symptoms increased after the
continuous singing task and were reduced after the 30 min rest, except for complaints of low voice, pain when swallowing
and cough/throat clearing.
Conclusion 60 min of continuous use of the singing voice induced signs of vocal fatigue with an increase in f0, with improve-
ment of symptoms and a reduction of f0 occurring after 30 min of vocal rest.

Keywords Vocal loading · Vocal loading task · Voice health · Voice resistance · Vocal fatigue

Introduction Vocal complaints are frequent after singing, even with

An excessive vocal demand has negative effects on a variety
of professions, with the occurrence of fatigue of the vocal
cord muscles and heavy vocal loading [1]. Singers are pro-
fessionals who depend on the quality of their voice for their
performance. Thus, to preserve their voice and prepare it
for singing activity, they have adopted techniques of vocal
warm-up and cool-down for rehearsals and presentations; if
these procedures are not followed, voice professionals are at
risk for injuries [2].
* Lilian Aguiar‑Ricz
liricz@fmrp.usp.br
1
Department of Ophthalmology, Otorhinolaryngology
and Head and Neck Surgery, Ribeirão Preto Medical School,
University of São Paulo, Av. Bandeirantes, 3900. Monte
Alegre, Ribeirão Preto, SP 14048‑900, Brazil
2
Department of Music, Faculty of Philosophy, Sciences
and Letters at Ribeirão Preto, University of São Paulo,
Ribeirão Preto, SP, Brazil
vocal warm-up [3], especially among more experienced
singers who usually report more symptoms after a perfor-
mance by paying more attention to throat sensations and
to vocal quality [4]. This also applies to those who study
the voice since they have reasonable knowledge and aware-
ness of perception and more preoccupation about their vocal
health [5].
Singing is still little understood regarding its mechanism
and vocal behavior in high musical performance. Heavy
vocal loading or effort is defined as the prolonged and con-
tinuous use of the voice and has been reported to include
four phases: warm-up (adaptation to the speaking task), per-
formance (adaptation), fatigue (self-report of physical effort
associated with voice changes), and recovery [6,7].
Among teachers, voice recovery occurs 4–6 h after 2 h
of prolonged use of the voice, alhough full voice recovery
occurs only after 12–18 h [8]. A lower effort to speak can
be observed after 15 min of vocal silence [9], although the
phonation pressure threshold returns to normal only after
1 h of vocal rest [10]. Among opera singers, a vocal rest on

13
Vol.:(0123456789)
160
the day after a performance may facilitate recovery [11].
Among choir singers, the vocal parameters are altered after
60 min of singing and the fundamental frequency increases,
appearing to be the parameter that is able to characterize
vocal resistance or effort [12].
However, it is not known how long it is possible to sing
without generating vocal fatigue or how much time is suf-
ficient to characterize vocal loading or effort for the vocal
tract, or even what rest time is needed for the voice to return
to normal conditions after singing. Thus, the objective of
the present study was to compare the voice of young choir
singers before and after a continuous singing task lasting up
to 60 min, and after a 30 min rest.
Methods
Ethical considerations
The study was approved by the Research Ethics Committee
of the University Hspital, School of Medicine of Ribeirão
Preto, University of São Paulo (protocol number 7716/2012),
and all subjects gave written informed consent to participate.
Sample
A prospective cohort study was conducted on 21 music stu-
dents, all of them soprano choir singers aged 18–39 years
(mean: 26.59 years) with experience of at least 1 year in
choir singing. Exclusion criteria were: a history of dyspho-
nia, a previous diagnosis of gastroesophageal reflux, hormo-
nal alterations, a diagnosis of rhinitis, diseases of the res-
piratory apparatus, and hearing, neurological or psychiatric
disorders. Regarding habits, also excluded were smokers,
users of psychoactive substances or of continuous medica-
tions, such as antihistamines and antidepressant, antihy-
pertensive, blood glucose lowering and anti-inflammatory
drugs.
Procedures
A vocal resistance test was applied in the afternoon, with the
singers being instructed to consume a bland diet and to have
the last meal 2 h before the test, so that gastric emptying
would occur and gastroesophageal reflux would be avoided.
Before the test, the participants performed a previously
standardized vocal warm-up of 10 min by singing the vowel
habitually used by each singer to exercise vocalization, with
the voice rising and falling a semitone of a vocally com-
fortable note, from the lowest to the highest, while being
accompanied by a singing teacher using the sound of a
keyboard. The participants were instructed to sing continu-
ously for 60 min, with respiratory pauses to avoid any vocal
13
European Archives of Oto-Rhino-Laryngology (2021) 278:159–165
discomfort and without water intake. The piece chosen was
the Ave Verum Corpus motet Ré3 to Mi4 by Wolfgang Ama-
deus Mozart (1756–1791), previously selected taking into
consideration the knowledge and the training of the choir
singers. The performance was accompanied by a playback
of 1′58 duration of the recorded music sung, being repeated
from the beginning to the end (“da capo al fine”) up to the
time when the singer was able to execute it, with a mean of
30 repetitions. Each participant sang in the appropriate tone
for a soprano. After singing for up to 60 min, the singers
remained absolutely silent for 30 min.
For the analysis of the vocal register, the singers recorded
three prolonged emissions of the vowel /a/ in the habitual
register, intensity and vocal frequency for more than 3 s
using a unidirectional microphone at three time points:
before the test (basal), after the 60 min vocal resistance
test (singing test), and after 30 min of absolute vocal rest.
Acoustic analysis was carried out using the Advanced Multi-
Dimensional Voice Program (MDVP-Adv) software (Com-
puterized Speech Lab, Kay P ­ entax®). The parameters used
are listed in Table 1.
The self-perception of signs and symptoms was assessed
with a psychometric instrument consisting of a self-assess-
ment questionnaire covering tactile, kinesthetic and auditory
manifestations [13,14]. The participants responded to the
questionnaire before and after the test of prolonged use of
the voice, considering the 13 following signs and symptoms:
hoarseness, dry throat, voice breaks, sore throat, difficulty
in speaking, high-pitched voice, low voice, vocal fatigue,
cough, and/or throat clearing. The participant was asked
to quantify each item of the questionnaire using a 100 mm
Table 1  Acoustic parameters used for vocal evaluation
Acoustic measurements
Advanced multi-dimensional voice program—MDVP Adv, Kay
­Pentax®
f0 (Hz): Average fundamental frequency
Fhi (Hz): Highest fundamental frequency
Flo (Hz): Lowest fundamental frequency
PFR (Semi-Tones): Phonatory fundamental frequency range
vF0 (%): Coefficient of fundamental frequency variation
PPQ (%): Pitch period perturbation quotient
APQ (%): Amplitude perturbation quotient
RAP (n): Relative average perturbation
Fftr (Hz): f0-Tremor frequency
Fatr (Hz): Amplitude-tremor frequency
FTRI (%): Frequency tremor intensity index
NHR (n): Noise-to-harmonic ratio
vAm (n): Peak amplitude variation;
VTI (n): Voice turbulence index
SPI (n): Soft phonation index
European Archives of Oto-Rhino-Laryngology (2021) 278:159–165
visual analogue scale, where 0 indicated absence and 100
indicated maximum.
The 60 min vocal resistance test started after the initial
recordings of the voice samples and of self-perception. The
participant performed in an acoustically treated room (noise
of less than 50 dB) with monitoring of air relative humidity
(mean: 42.3%) and temperature (mean: 24.7 °C).
Statistical analysis
The intra- and inter-subject results of the computed acoustic
analysis and of the numerical scale for perceptive-auditory
and tactile–kinesthetic self-evaluation of the voice were
compared before and after the singing test. Data are reported
as mean ± SE and were submitted to descriptive and inferen-
tial analyses. The mean data for the three distinct times were
compared by unifactorial analysis of variance with repeated
measures (one-way ANOVA-RM). When a significant differ-
ence between means was observed, the Tukey HSD (honest
significant differences) post test for multiple comparisons
was applied. The analyses were carried out using the Origin
Pro 9.0 software (OriginLab, Northampton, MA), with the
level of significance set at 5%.
Results
The acoustic vocal parameters obtained from the analysis
of the sustained emission of the vowel /a/, modal record-
ing, before the vocal resistance test (basal), after the 60 min
test of vocal resistance (singing test) and after 30 min of
absolute vocal rest (rest) are listed in Table 2. An increase
in mean values was observed after the vocal singing test,
followed by a decrease after rest for the f0 (p = 0.0001) and
Flo (p = 0.0002) parameters. An increase in mean results
occurred after the vocal resistance test and after rest for Fhi
(p = 0.001), while a decrease in mean results was observed
for vAm (p = 0.05) at the same time points.
Table 3 lists the values obtained at the pre- and post-sing-
ing time points and after rest for the analysis of questions of
perceptive–auditory and tactile–kinesthetic self-assessment
of phonation.
Discussion
A wide variety of methods, as well as different samples, are
used to study vocal resistance. The proposal of the present
study was to report the results of prolonged use of the voice
for 60 min by choir singers and to determine whether there
are changes in vocal parameters and in self-perception of
vocal signs and symptoms after an absolute rest of 30 min.
161
It is generally accepted that variables that influence the
tension of normal skeletal muscles include morphological,
biomechanical, neurological, metabolic and biochemical
factors. For this reason, in the present study, we controlled
motor activity during the singing of the same music, as well
as the environment, hydration and feeding, so that these fac-
tors would not interfere with the final response. Even people
with a normal voice report vocal fatigue in the presence
of allergies or infections when the vocal folds are likely to
become inflamed [15]. Another aspect considered is the uni-
formity of choir singers.
It is understood that a prolonged use of the voice may
lead to increased fundamental frequency, a fact that can be
interpreted as a normal physiological adaptation of the vocal
apparatus to speech, and therefore as a sign of vocal health
[16].
An hour of prolonged use of the voice causes an increase
in F0, a reduction of the glottic noise, an increase in vocal
pitch, loudness, projection and stability, and a reduction
of the general degree of dysphonia, vocal roughness and
breathiness, indicating that the increased tonicity of the
laryngeal adductor muscles for phonation and self-percep-
tion reveals a phonatory effort [17]. The increase in f0 may
be a sign of warm-up, but may also be a marker of voice
resistance or heavy loading.
After 60 min of singing, the fundamental frequency of
the choir singers increased. This increase is an alert signal
regarding the importance of a situation of vocal fatigue and
may not simply be a condition of muscular warm-up. Among
voice professionals, frequency breaks followed by hoarse-
ness are observed after vocal abuse or after a prolonged use
of the voice, suggesting vocal loading with the excessive use
of force and contraction of layngeal muscles that signal to
the larynx that there is vocal effort and resistance [18]. Nev-
ertheless, it seems that the vibratory capacity of the vocal
folds is maintained even after the prolonged use of the sing-
ing voice [19], and even with incomplete glottic closure,
there is no influence on the pitch and loudness of either the
speaking or the singing voice of young women [20].
There is no consensus about whether or not the prolonged
use of the singing voice can induce resistance to vocal
fatigue. It is not known how much time of use of the singing
voice can impair the normal functioning condition of the
larynx, with the possible occurrence of an individual varia-
tion in vocal resistance [21]. It is necessary to take into con-
sideration the conditions, experience, profissionalism and
musical style of the singers since even trained opera singers
exhibit changes with the continued use of the voice without
a rest, suggesting that a vocal rest is essential [11].
However, singing is an action that requires a large amount
of energy on the part of the singer. It should be kept in mind
that professional singers develop a physiological adaptation
of the muscles, with a consequent adaptation to excessive
13
 162

13
Table 2  Acoustic parameters determined before and after 1 h of singing and after a 30 min rest
Parameters Pre-singing After singing Rest p value
Mean ± standard Range Median Mean ± standard Range Median Mean ± standard Range Median
deviation deviation deviation

f0 (Hz) 227.9 ± 20.7 188.2–275.3 228.3 247.1 ± 28.3 200.4–300 239.8 245 ± 28.5 186.5–291 249 0.0001
Fhi (Hz) 238.4 ± 26 190.6–296 237.7 255 ± 29.7 203.6–306.5 250.1 257.1 ± 33.2 195.6–335.6 258.6 0.001
Flo (Hz) 218.2 ± 18.9 184.2–254.2 221.3 239.8 ± 27.7 198.1–293.3 233.8 234.3 ± 28.4 180.7–285.4 238.3 0.0002
PFR (Semi-Tones) 2.5 ± 1.26 1–5 2 2.27 ± 0.63 1–4 2 2.52 ± 1.5 1–7 2 0.65
vF0 (%) 1.08 ± 0.54 0.43–2.45 1.02 0.83 ± 0.31 0.44–1.4 0.74 1.03 ± 0.58 0.443–2.8 0.83 0.09
PPQ (%) 0.61 ± 0.41 0.14–1.54 0.53 0.43 ± 0.25 0.12–1.08 0.35 0.59 ± 0.45 0.11–2.05 0.5 0.15
APQ (%) 2.05 ± 0.82 0.86–3.72 1.82 1.92 ± 0.7 0.83–3.99 1.74 2.47 ± 2.56 1.1–13.28 1.86 0.406
RAP (n) 0.62 ± 0.42 0.14–1.49 0.57 0.44 ± 0.25 0.12–1.08 0.37 0.61 ± 0.44 0.1–1.98 0.51 0.14
Fftr (Hz) 4.09 ± 1.25 2.06–7.14 4.1 4.67 ± 1.84 2.21–9.09 4.7 4.56 ± 2.06 2.19–11.11 4.39 0.48
Fatr (Hz) 4.17 ± 1.68 2.06–7.54 4.08 3.85 ± 1.79 2.11–7.01 3 3.88 ± 1.41 2.13–6.06 3.47 0.6503
FTRI (%) 2.66 ± 2.63 0.06–9.54 2.55 1.76 ± 1.75 0.01–6.53 1.47 1.65 ± 2.03 0.13–5.73 0.31 0.09
NHR (n) 0.11 ± 0.01 0.08–0.15 0.12 0.11 ± 0.02 0.07–0.15 0.11 0.11 ± 0.01 0.07–0.139 0.11 0.47
vAm (n) 9.71 ± 4.53 4.31–20.36 8.68 8.16 ± 3.45 3.63–19.56 7.44 7.59 ± 2.79 3.7–15.27 7.2 0.05
VTI (n) 0.05 ± 0.01 0.01–0.09 0.04 0.04 ± 0.01 0.01–0.07 0.04 0.04 ± 0.01 0.01–0.05 0.04 0.18
SPI (n) 8.53 ± 4.97 4.02–21.75 7.04 9.01 ± 5.24 2.58–25.80 8.16 10.45 ± 6.02 2.13–21.52 8.46 0.3353
European Archives of Oto-Rhino-Laryngology (2021) 278:159–165
European Archives of Oto-Rhino-Laryngology (2021) 278:159–165 163

vocal loading. In the present study, after 1 h of continuous

< 0.0001
0.0002
< 0.0001
0.0004

0.005
0.007
0.007
0.033
0.002
0.005
p value
singing, the choir singers demonstrated increased tension

0.06
0.16
0.8
of the musculature, suggesting vocal warming [16,22,23].
Changes in acoustic measures, such as F0 elevation and a
reduction of perturbation of the measures, such as jitter and
Median

shimmer, indicate an increase in muscle activity (increased

0.63
0.85
1.8 tonus) in an attempt to adapt phonation [24]. Vocal warm-

0
0
0
0
0
0
0
0
0
0

up promotes the quality of the voice, and acoustic analysis

appears to be a valuable and sensitive instrument for the
Range

0–4.4
0–4.6
0–2.4
0–5.5
0–6.5
0–2.4
0–8.5
0–5.5
0–2.1
0–7.5
0–8.4

quantitation of this effect [25]. When there is an increase

0–0
0–7

in pitch, there is possibly a greater gain in muscle activ-

ity which contributes to the tension of the vocal folds [26],
Mean ± standard

since it is understood that there is the need to recruit a larger

0.65 ± 1.16
0.89 ± 1.56
0.72 ± 1.61
1.72 ± 2.28
0.38 ± 1.22
0.10 ± 0.45

number of fibers and muscles in the presence of heavy vocal

0.6 ± 0.83
0.46 ± 0.8
2.6 ± 2.57
0.8 ± 1.96
deviation

0 ± 1.53
1.07 ± 2

loading to maintain the force and tension of the vocal folds.

0±0
Rest
Table 3  Self-assessed values of signs and symptoms (0–100 visual analogue scale), before, after one hour of singing and after a 30 min rest

Although f0 seems to be the most robust parameter for the

determination of laryngeal muscle fatigue [27], it should be
pointed out that it is extremely complex to determine vocal
Median

fatigue [23]. An increase in f0 is not always demonstrated

1.05
1.65
3.15
1.75

1.8
3.5
5.4

after a test involving the continuous use of the voice [28]

0
0
0
0
2
0

and other parameters, such as RAP, APQ, SPI and vAm,

may also change [22]. A reduction of vAm was detected in
Range

0–8.2
0–8.2
0–8.4
0–7.9
0–1.4
0–6.9
0–4.1
0–7.9
0–7.9

0–10
0–10
0–10

the 21 singers studied here after continuous singing and rest.

0–4

Another parameter that was modified among the choir

singers studied was Flo, which increased after the sing-
Mean ± standard

ing test and decreased after rest. This finding permits us to

After singing

1.83 ± 2.46
2.65 ± 2.27
2.27 ± 2.74
2.01 ± 2.75
0.11 ± 0.37
1.66 ± 1.81
0.65 ± 1.32
3.61 ± 3.21
0.65 ± 1.23
2.41 ± 2.43

infer that a 30 min rest was sufficient for the recovery of the
2.21 ± 2.2
3.27 ± 2.6
5.13 ± 2.9
deviation

laryngeal adaptations that occurred during singing since the

lower fundamental frequency observed cycle by cycle in the
singers was reduced with rest and with the consequent vocal
cool-down. However, Fhi continued to be high even after the
Median

rest, revealing the difficulty in finding acoustic parameters

1.45
1.75
2.7

that are related to vocal fatigue [29].

0
0
0
0
0
0
0
0
2
0

It is difficult to compare studies due to the lack of uni-

formity regarding tests, subject gender and age. It is neces-
Range

0–7.9
0–1.4
0–3.1
0–2.1
0–3.8
0–7.1
0–1.1
0–1.5
0–8.1
0–6.8
0–5.9

sary to reflect about the results of acoustic measurements in

0–4
0–0

studies of resistance to vocal fatigue, with questions raised

about how sensitive the method really is to provide a reliable
Mean ± standard

result, or how effective these parameters are to identify cor-

Pre-singing

1.46 ± 1.89
0.68 ± 1.01
0.27 ± 0.94
0.17 ± 0.55
0.61 ± 1.15
2.04 ± 2.30
0.21 ± 0.49
2.35 ± 2.67
1.07 ± 1.66

rectly which of the individuals evaluated really show char-

0.25 ± 0.5
0.1 ± 0.31
3.1 ± 2.12
deviation

acteristics of resistance or how specifically a method is in

0±0

revealing the individuals who do not have vocal fatigue [24].

The duration of rest after an intense use of the voice
is also not clearly defined. 15 min of vocal rest may pro-
Pain/tension in shoulders and neck

mote a lower effort in speaking [9], and 1 h of rest per-

mits the phonatory pressure threshold to return to normal
Cough and throat clearing

[10]. Among the choir singers sudied here, after 30 min,

Pain when swallowing

there was a clear improvement of self-perception of signs

Difficulty in speaking
Signs or symptoms

and symptoms related to vocal production, in addition to

Effort to speak

evidence regarding the acoustic parameters. Subjects with

Vocal fatigue
Voice breaks

Weak voice
Hoarseness

Sore throat

High voice

greater vocal experience report more vocal complaints after

Low voice
Dry throat

a performance by valuing more the sensations of the throat

and the vocal quality [4].

13
164
This finding favors the prescription of absolute vocal rest
so that the musculature will reorganize and return to its natu-
ral state. Thus, after a vocal rest, singers can use their voice
again without hurting their health, with a greater longevity
of their artistic career. However, the resistance of laryngeal
tissue is one of the major aspects of vocal fatigue, with the
curve of the trajectory of recovery being similar to that of
the recovery from a chronic dermal wound. Thus, with the
intensive daily use of the voice, the continuous damage to
the laryngeal mucosa causes the cure mechanisms to be in
a constant state of repair and, in the short term, 50% of the
recovery occurs after about 4–6 h and full recovery occurs
after 12–18 h of intense use of the voice [8]. A rest before
[30] and after a performance [11] is essential for singers.
The practice of vocal cool-down is extremly important for
singers [12], although it is not commonly applied [3].
Complaints, or signs and symptoms are parameters that
characterize vocal fatigue [1]. It is understood that, the larger
the number of vocal complaints, the higher the f0 and, the
longer the time of vocal intensity, the greater the vocal prob-
lems [31].
Among the choir singers studied here, the indications of
tactile–kinesthetic and auditory symptoms were obtained
with the use of a visual analogue scale, demonstrating an
increase in the auditory, tactile and kinesthetic perception
after the prolonged use of the voice, as also observed in pre-
vious studes of vocal resistance [4,9,10,23,24,32].
The present singers were asked about hoarseness to
obtain information about the tactile–kinesthetic and auditory
manifestations after singing and after a rest. They reported
increased hoarseness after the test and a reduction after the
rest. The complaint of hoarseness is not usually noted after
tests of resistance to vocal fatigue. The present singers prob-
ably have a more refined auditory sense regarding the ques-
tion of vibration of the vocal cords.
A dry throat is a change easily observed after the use of
the voice [19] and the studied singers reported an increase
in this sennsation after the vocal resistance test, with reduc-
tion after the rest.
Singers who do not have the habit of resting or of using
vocal cool-down techniques may report perceptive voice
complaints after an intense use of the voice. In the present
study, the singers pointed out an increased perception of
effort and fatigue in speaking after the singing test, and a
reduction after the resting period.
The singers were asked whether “there were breaks of the
intensity frequency of their voice” and responded that there
was an increase in auditory perception after the test and a
decrease after the rest. They also stated that after singing,
they observed an increase in voice frequency and a reduction
of vocal pitch after resting, as well as a weak voice. There
is a correlation between time of use of the voice and vocal
intensity [31,32].
13
European Archives of Oto-Rhino-Laryngology (2021) 278:159–165
The methodology applied here to the singers provided
advances in the knowledge about this topic, with answers
regarding the situation of vocal resistance to vocal fatigue.
For the study, a low-magnitude test, repetitive and sustained
for 60 min, was applied, with the evaluation not only of
the acoustic measures, but also of the self-perception of
symptoms.
New studies of the effects of vocal resistance to fatigue
are needed to establish effective methods for the training of
vocal resistance and the use of cool-down techniques after
a musical performance, thus providing scientific evidence
and supporting singers in the refinement of the execution
of their art.
Conclusion
The test of continuous voice use for 60 min applied to choir
singers induced a high effort, increasing f0, Flo and Fhi,
demonstrating that the fundamental frequency was sucepti-
ble to singing uninterruptedly for 1 h. However, the increase
in symptoms indicated the occurrence of vocal fatigue.
In addition, we observed that 30 min of rest was sufficient
to attenuate the symptoms and to reduce f0.
Funding None.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethics approval All procedures in studies involving human participants
were in accordance with the ethical standards of the national research
committee and with the 1964 Helsinki.Declaration and its later amend-
ments. This study was approved by the Research Ethics Committee of
the Clinics Hospital of the School of Medicine of Ribeirão Preto of
the University of São Paulo according to protocol number 9711/2008.
Informed consent Informed consent was obtained from all individual
participants included in the study. Participants signed informed consent
regarding publishing their data.
References
1. Vilkman E (2004) Occupational safety and health aspects of voice
and speech professions. Folia Phoniatr Logop 56:220–253
2. Smith B (2018) The art and science of lifelong singing. J Voice
32(3):291–299
3. Gish A, Kunduk M, Sims L, McWhorter AJ (2012) Vocal warm-
up practices and perceptions in vocalists: a pilot survey. J Voice
26(1):e1–e10
4. Laukkanen AM, Järvinen K, Artkoski M, Waaramaa-Mäki-Kul-
mala T, Kankare E, Sippola S, Syrjä T, Salo A (2004) Changes
in voice and subjective sensations during a 45-min vocal loading
European Archives of Oto-Rhino-Laryngology (2021) 278:159–165
test in female subjects with vocal training. Folia Phoniatr Logop
56(6):335–346
5. Franca MC, Wagner JF (2015) Effects of vocal demands on voice
performance of student singers. J Voice 29(3):324–332
6. Jilek C, Marienhagen J, Hacki T (2004) Vocal stability in func-
tional dysphonic versus healthy voices at different times of voice
loading. J Voice 18(4):443–453
7. Vintturi J, Alku P, Sala E, Sihvo M, Vilkman E (2003) Loading-
related subjective symptoms during a vocal loading test with
special reference to gender and some ergonomic factors. Folia
Phoniatr Logop 55(2):55–69
8. Hunter EJ, Titze IR (2009) Quantifying vocal fatigue recovery:
dynamic vocal recovery trajectories after a vocal loading exercise.
Ann Otol Rhinol Laryngol 118(6):449–460
9. Solomon NP, DiMattia MS (2000) Effects of a vocally fatiguing
task and systemic hydration on phonation threshold pressure. J
Voice 14(3):341–362
10. Chang A, Karnell MP (2004) Perceived phonatory effort and pho-
nation threshold pressure across a prolonged voice loading task: a
study of vocal fatigue. J Voice 18:454–466
11. McHenry M, Evans J, Powitzky E (2016) Vocal assessment before,
after and the day after opera performance. J Voice 30(2):186–191
12. Onofre F, Prado YA, Rojas GVE, Garcia DM, Aguiar-Ricz LN
(2017) Measurements of the acoustic speaking voice after vocal
warm-up and cooldown in choir singers. J Voice 31(1):129.
e9–129.e14
13. - Aguiar-Ricz LN, Pellicani AD (2011) Psychometric instrument
for the measurement and evaluation of auditory perception and
tactile–kinesthetic vocal resistance. In: 1st Congress of the Con-
federation of European Otorhinolaryngology and Head and Neck
Surgery. July; Barcelona, Spain, 2011, p. 448.
14. Pellicani AD, Ricz H, Iqueda APD, Aguiar-Ricz L (2017) Effect
of the tracheoesophageal voice resistance test in total laryngecto-
mees. Laryngoscope 127:405–410
15. Sander EK, Ripich DE (1983) Vocal fatigue. Ann Otol Rhinol
Laryngol 92(2):141–145
16. Rantala L, Vilkman E, Bloigu R (2002) Voice changes dur-
ing work: subjective complaints and objective measurements
for female primary and secondary schoolteachers. J Voice
16(3):344–355
17. Pellicani AD, Ricz HM, Ricz LN (2015) Phonatory function after
prolonged voice use in Brazilian women. Codas 27(4):392–399
18. Hunter EJ, Titze IR (2010) Variations in intensity, fundamental
frequency, and voicing for teachers in occupational versus non-
occupational settings. J Speech Lang Hear Res 53(4):862–875
19. Yiu EML et al (2011) Quantitative high-speed laryngoscopic
analysis of vocal fold vibration in fatigued voice of young karaokê
singers. J Voice 25(3):e115–e121
165
20. Schneider B, Bigenzahn W (2003) Influence of glottal closure
configuration on vocal efficacy in young normal speaking woman.
J Voice 14(4):468–480
21. Welham N, Maclagan MA (2004) Vocal fatigue in young trained
singers across a solo performance: a preliminary study. Logoped
Phoniatr Vocol 29(1):3–12
22. Buder EH, Wolf T (2003) Instrumental and perceptual evaluations
of two related singers. J Voice 17(2):228–244
23. Whitling S, Rydell R, LybergÅhlander V (2015) Design of a clini-
cal vocal loading test with long-time measurement of voice. J
Voice 29(2):261.e13–27
24. Laukkanen AM, Kankare E (2006) Vocal loading-related changes
in male teachers’ voices investigated before and after a working
day. Folia Phoniatr Logop 58(4):229–239
25. Amir O, Amor N, Michaeli O (2005) Evaluating the influence of
warm up on singing voice quality using acoustic measures. J Voice
19(2):252–260
26. Boucher VJ, Ayad T (2010) Physiological attributes of vocal
fatigue and their acoustic effects: a synthesis of findings for a
criterion-based prevention of acquired voice disorders. J Voice
24(3):324–336
27. Vogel AP, Fletcher J, Maruff P (2010) Acoustic analysis of the
effects of sustained wakefulness on speech. J Acoust Soc Am
128(6):3747–3756
28. Kwak PE, Stasney CR, Hathway JR, Guffey D, Minard CG, Ong-
kasuwan J (2017) Physiologic and acoustic effects of opera per-
formance. J Voice 31(1):117.e11–117.e16
29. Boucher VJ (2008) Acoustic correlates of fatigue in laryngeal
muscles: findings for a criterion-based prevention of acquired
voice pathologies. J Speech Lang Hear Res 51(5):1161–1170
30. Carroll T, Nix J, Hunter E, Emerich K, Titze I, Abaza M (2006)
Objective measurement of vocal fatigue in classically trained sing-
ers: a pilot study of vocal dosimetry data. Otolaryngol Head Neck
Surg 135(4):595–602
31. Rantala L, Vilkman E (1999) Relationship between subjective
voice complaints and acoustic parameters in female teachers’
voices. J Voice 13(4):484–495
32. Laukkanen A-M, Ilomaki I, Leppanen K, Vilkman E (2008)
Acoustic measures and self-reports of vocal fatigue by female
teachers. J Voice 22:283–289
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13