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The young adult patient
Journal of Voice
Vol. 11, No. 2, pp. 144-152 © 1997 Lippincon-Raven Publishers. Philadelphia
The Three Ages of Voice
The Young Adult Patient Pamela Lynn Harvey Voice and Speech Services, Beth Israel Hospital, Boston, Massachusetts 02115, U.S.A.
Summary: The purpose of this paper is to 1) describe the unique issues of voice patients, ages 21-55; 2) outline the knowledge and clinical skills that speechlanguage pathologists should possess to deal with those issues; and 3) provide suggestions for promoting vocal longevity. Key Words: Young adult-Midlife--Professional voice user--Evaluation--Therapy--Longevity-General health.
The 1987 inaugural issue of the Journal of Voice focused on vocal aging with papers discussing connective tissue changes in the larynx, acoustic measures of the aging voice, vocal reaction time in the elderly, and vocal characteristics of biological age (1-6). Now, we revisit vocal aging from a clinically focused perspective. This paper describes the unique issues of voice patients, ages 21-55, and the knowledge and clinical skills that speech-language pathologists should possess to deal with those is-
What we know about vocal aging is an apparent overlay of general information about the aging process and specific information about the aging larynx. Generally, physiologic adaptations expected in aging include changes in cardiovascular characteristics, pulmonary function, hormonal balance, immune response, musculoskeletal integrity, and central nervous system function (2). Specific to laryngeal function, age-related degenerative changes include muscle atrophy, ligament deterioration, ossification of the hyaline cartilages, and slowing of neural transmission and nerve conduction velocity (3,4). Although not perceptually or acoustically apparent, some of these changes may begin in our 30s. Given the early onset of these declining functions and their insidious progression, it may be that lifestyle choices and vocal use patterns either accelerate or retard these age-related changes. Although chronological aging is unalterable, some current theories suggest that an individual can slow physiologic aging and advance the long-term health needed for a sustained career in vocal performance. This paper provides some suggestions to promote vocal longevity.
SUES.
OVERVIEW OF RESEARCH FINDINGS Most of the empirical studies describing the aging process of the larynx have not been focused on this age group. This is probably attributable to the relative stability of the voice in a normal, healthy person over the four decades from approximately age 20 to 60. Repeatedly, studies have demonstrated that intensity, fundamental frequency ranges, and vocal quality are sustained into a person's 60s (712). Accepted February 14, 1996. Address correspondence and reprint requests to Pamela Lynn Harvey, Voice Clinic Coordinator, Voice and Speech Services, Beth Israel Hospital, Suite 460, 333 Longwood Avenue, Boston, MA 02115, U.S.A. Portions of this paper were presented at The Voice Foundation's 24th Symposium: Care of the Professional Voice, Philadelphia, June 5-10, 1995.
YOUNG ADULT PROFESSIONAL VOICE USER Regardless of age, the "professional voice user" is a designation describing countless variations of phonatory abilities and demands. The conversational demands of the telemarketer and secretary, 144
THE YOUNG A D U L T P A T I E N T
the presentational voice use of the attorney and school teacher, and the performance demands of the singer or actor may all be appropriately labeled "professional voice use." However, viewing these vocal demands along a continuum as presented in Fig. 1 indicates performance as a more demanding task that requires greater vocal flexibility and endurance. Singers, particularly operatic singers, have requirements for precise respiratory control and extensive pitch range. Actors face the vocal calisthenics of the "character" voice that may be markedly different from their individual vocal persona--and potentially neither aesthetically pleasing nor physiologically healthy. For most professional voice users, the broad age span of 21-55, represents the period of greatest professional productivity. This is the time when careers are made or dreams are shattered. These years actually represents two life stages: young adulthood from ages 21 to about 35 and mature adulthood from around 35 to 55 years of age. A term that seems illustrative of this latter group, which is wedged between adolescence and senescence, is "middlescence" (13). The middlescent population includes the " B a b y Boomers"--76 million Americans born between 1946 and 1964. United States Census statistics reveal that slightly more than 7,000 people are turning 50 each day and that this will continue every day for the next 20 years. The Baby Boomers are a youth-oriented culture that is striving not only to add years to life, but also add life to those years (13). Baby Boomers want to maintain their health and remain professionally capable, vital, and energetic well into their 60s and 70s. To provide meaningful services to these patients we must understand their desires, their abilities, their lives, their vocal demands, and the disorders with which they present. CONTINUUM OF PHONATORY DEMANDS
r I \
PROFESSIONAL VOICE
J
CONVERSATION => PRESENTATION => PERFORMANCE Secretaries Telemarketers
Clergy Teachers Business
Singers Actors Executives
FIG. 1. Professional voice use may have many different types o f phonatory demands. This continuum progresses from least taxing voice use at the left to most difficult at the right. From: Fried MP. The larynx: a rnultidisciplinary approach. St Louis: 1996:254; with permission.
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The early years of young adulthood represent a vocal "coming of age." What was an acceptable vocal persona in a teenager or college student may need altering to reflect a more professional one. Professional voice users of this age frequently suffer from the excesses of nicotine and alcohol intake or battle gastroesophageal reflux, due to eating late in the evening (14,15). In these early adult years, performers often struggle with separating their vocal abilities from their talent. The singer or actor may believe that recognizing any voice problem will somehow diminish their talent. In this instance, objective assessment is quite beneficial. Instrumental measures can assist in moving the discussion from the clinician's perception of the voice problem, which may be regarded as opinion, to the documentable parameters functioning outside normal limits, which is often less emotionally threatening to the performer. Singers tend to reach their greatest ability in their 30s and maintain this plateau of performance for years. In contrast, most premier sports athletes reach their peak performance level in their teens or early 20s. Titze has attributed this difference in achieving peak performance to two factors. First is that singing, unlike other sports, is not strength related but rather dependent on skills of efficiency, coordination, and precision. Additionally, Titze speculates that the beginning of the aging process, which debuts in one's 30s, may actually work to the vocalist's advantage. When the larynx is composed of partially ossified cartilages it may provide a more stable framework for the vibrating vocal folds; by providing more fixed anchors at the end point of the tissue fibers, the resultant vibratory patterns would be more periodic and smooth (12). Although voices may reach some degree of stability as professional voice users enter middlescence, lives do not. Grueling work schedules, simultaneously caring for both growing children and aging parents, intense professional competition, and self-imposed demands to "do it all" combine to make the lives of these patients extremely stressful. The young adult and middlescent professional voice user is often overworked, overtired, and overextended. They often say, "I don't have time for this voice problem--I don't have time to be sick." Frequently, the onset of voice problems coincides with an upper respiratory infection. When the laryngitis sets in, these professional voice users continued to push their voices through their usual unrelenting, not-a-moment-to-spare schedules. Journal of Voice, Vol. 11o No. 2, 1997
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Any discussion of this age group would be incomplete without mention of the impact of their insurance coverage. Increasing numbers of young adult and middlescent patients are opting for managed care systems, such as Health Maintenance Organizations and Preferred Provider Organizations. HMOs and PPOs usually regard speech-language pathology services as a short-term benefit, meaning that all treatment must be provided within the allowed time frame, usually 60-90 days. Extension of therapy is very seldom approved and there is no coverage for follow-up. Interestingly, these insurance restrictions have expanded, not restricted, the speech-language pathologist's responsibilities as a health care provider. Now, the voice clinician functions exhaustively as a patient advocate, verifying referral status, requesting referrals from a patient's primary care physician, integrating interdisciplinary documentation, and making telephone calls to justify recommendations to an insurance reviewer to maximize coverage.
COMMON VOICE COMPLAINTS AND CONCOMITANT CONDITIONS Most of the voice disorders encountered in young adulthood and middlescence are hyperfunctional in nature: musculoskeletal tension dysphonias, true vocal fold nodules, or polyps and chronic laryngitis with edema and erythema. But each year, fewer patients seen in our voice clinic present with vocal fold pathology or vibratory dysfunction in isolation. Many patients have a concomitant disorder that may significantly complicate their treatment and recovery. Four of these recalcitrant conditions are endocrine dysfunction, asthma, multiple chemical sensitivity, and human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Endocrine concerns in this population are usually related to thyroid dysfunction or hormonal shifts within the female menstrual cycle or throughout her lifespan. Premenstrual symptoms include complaints of increased vocal fatigue and effort in singing and denigration of vocal control, pitch, range, intensity, and quality. Estrogen and progesterone secretion may cause shifts in the weight and shape of the vocal folds through water retention, edema of the interstitial tissue, and venous dilatation. Reports on the incidence and severity of vocal premenstrual symptoms are highly varied (16). InhibJournal of Voice, Vol. 11, No. 2, 1997
iting ovulation may be helpful to patients with pronounced vocal premenstrual syndrome, but oral contraceptives bring their own vocal implications (17). Clinicians must meticulously sort through these complaints and treat them as effectively as possible. Hormonally based vocal changes may also emerge as a woman approaches menopause (18). The cause of these complaints of vocal fatigue and reduced vocal control may come as a surprise to women who do not realize that cessation of menses may come at the later stages of menopause. By obtaining baseline estrogen levels in professional vocalists at around age 35, declining estrogen levels can be readily recognized and rectified. This practice allows the endocrinologist or gynecologist to tailor hormonal replacement therapy to the patient's past individual hormone profile. The incidence of asthma is growing in the United States. A recent audit of patient files over a 3-month period from our clinic indicates that 19% report a concomitant diagnosis of asthma as compared with 7% in a 3-month audit of patients seen in 1985. This dramatic increase is, in part, attributable to an escalation in the number of patients diagnosed with reversible obstructive pulmonary disease and, in part, a reflection of an expansion of the diagnosis to include pulmonary s y m p t o m s not previously termed asthma. The asthmatic vocally disordered patient is a challenge for several reasons. Even well-managed asthmatic patients often avoid breathing deeply in order to reduce coughing. Subsequently, these patients adopt as a protective mechanism very shallow respiratory cycles that may not provide adequate respiratory support. In patients whose disease is not well controlled, the vocal folds endure the abuse of chronic coughing with its sequela of cordal edema and irritation. Further complicating voice rehabilitation for the asthmatic patient is the use, often for many years, of inhaled steroids believed to have a deleterious effect on laryngeal musculature (19,20). Multiple chemical sensitivity (MCS) is a condition now reported with some regularity by patients in our urban setting (21-23). These patients report that the onset of MCS was precipitated by a single massive exposure or repeated low-dose exposure to an irritating chemical agent. Subsequently, the patient reportedly develops hypersensitivity with minimal exposure to molds, fragrances, fumes, cooking aromas, flowers, and so forth. Exposure results in abrupt onset of symptoms such as tingling or numb-
THE YOUNG A D U L T P A T I E N T
ness of the limbs, runny nose and eyes, changes in phonatory quality, and sensations of throat constriction and dyspnea. Paradoxical vocal fold movement is occasionally observed in these patients. The description and cause of MCS symptoms remains controversial as many physicians believe the condition has a psychogenic origin. As Sataloff notes in a previous report on vocal tract response to toxic injury: "The mechanism of these disorders remains obscure and treatment is currently guided by imagination, intuition and anecdote. To improve this uneasy situation, extensive collaborative research is essential" (24). The HIV/AIDS epidemic has taken a tragic toll on the performance community in the past decade. Recently, new combinations to medications seem to be having some impact on the disease with more HIV-positive patients maintaining their health longer before progression to an active AIDS status. As a result of this increased health span, an increasing number of these patients are being referred for voice therapy. These professional voice users are living with HIV, not dying of AIDS; they are working, productive, and concerned about their voices. AIDS-associated symptoms are most frequently infectious or neoplastic changes in laryngeal tissue (25). Although the voice pathologist cannot correct these problems, therapy designed to compensate for vocal deficits and maximize phonatory capabilities can be quite meaningful to the patient. KNOWLEDGE AND SKILLS OF THE VOICE PATHOLOGIST Patients in young adulthood and middlescence represent the largest percentage of professional voice users referred with vocal complaints. The speech-language pathologist must 1) accurately evaluate the full range of vocal dysfunction, from mild to severe; 2) design and implement effective treatment protocols; 3) understand the demands of the urgent need patient; 4) understand the special demands of performance, if working with singers and actors; and 5) know how and when to involve other disciplines in the patient's care and be able to effectively collaborate with other professionals. The general principles of evaluation, differential diagnosis, goal setting, and use of a hierarchical approach to voice rehabilitation apply to the management of voice disorders in the young adult and middlescent patient (26-28).
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Evaluation of young adult and middlescent professional voice users
Voice evaluation is essential to the differential diagnosis of a voice disorder. The first objective of the voice evaluation is to identify causal factors that may have precipitated the onset of the problem or be perpetuating its maintenance. Secondarily, the voice evaluation should provide information and education for the patient and establish a plan and direction for treatment (29). The voice evaluation is typically composed of a detailed patient history, objective voice measures, laryngeal videoendoscopy, auditory-perceptual judgments, visual observations, audiologic screening, and diagnostic therapy (30). Young adult and middlescent patients are usually quite intrigued, but not intimidated, by the use of instrumentation and technology during voice evaluation and therapy. For example, electroglottographic signals and aerodynamic measures may be used to identify hard glottal onset and contrast this potentially abusive phonatory pattern with aspirate onset of phonation (31-33). Interpretation of acoustic signals can be used to assess spectral characteristics for the presence or strength of the singer's formant (34,35). Flexible fiberoptic laryngoscopy coupled with video taping can be used as a visual feedback tool in describing the movements of the true vocal folds, supraglottic structures, larynx, palate, pharynx, and tongue during varying performance activities (36,37). Laryngeal videostroboscopy allows detailed, although subjective, description of the vibratory behavior of the vocal folds. When using laryngeal imaging, the speech-language pathologist does not diagnose laryngeal disease but rather describes the vibratory characteristics and muscle usage patterns that comprise the patient's phonatory style. It is difficult to realistically evaluate voice patients within the stark white walls and restricted spaces of the clinical cubicle. Professional voice users should be observed during actual presentations and performances, not just as they are simulating their usual voice use. Observation and discriminating listening may be needed to recognize issues of postural alignment, breath support, and microphone placement as well as faulty vocal habits and their pattern of occurrence, such as hard glottal attacks on vowel-initiated words, glottal fry at the termination of utterances, and throat clearing as a "vocal starting mechanism." Journal of Voice, Vol. 11, No. 2, 1997
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Designing voice therapy for young adult and middlescent patients Young adult and middlescent patients often need to understand the theoretical basis of voice treatment strategies in order to commit to compliance. This population grew up with modern medicine and frequently expects a pill to "fix" their maladies or to be done to rather than participate in voice therapy. It is essential to educate these patients on how the voice works through a simple lesson on anatomy and physiology. Analogies that compare the professional voice user to an athlete are usually well received. Viewing one's self as a vocal athlete helps patients realize that, like any other athlete, they are working with a muscle system that is governed by parameters of endurance, flexibility, and strength (38). Additionally, when patients have a basic understanding of the body-cover theory of phonation, they recognize that the health and pliancy of the overlying mucosa must also be established and maintained to achieve optimal results (39). Next, an individualized vocal hygiene regimen should be designed for each patient. Young adult and middlescent patients may regard vocal hygiene as a means of achieving "passive" progress. One patient may complete a program with emphasis on increasing laryngeal lubrication and decreasing throat clearing (40). Another patient may implement frequent timed periods of vocal rest throughout the day and begin a stress reduction program to supplement voice therapy. In subsequent sessions, the program is reviewed and modified. Vocal hygiene is not limited to reducing vocal abuse and misuse. Adherence to a vocal hygiene protocol may facilitate healing of laryngeal tissue and promote the maintenance of vocal health once that health is established (41,42). Description of numerous therapy techniques is beyond the scope of this article. One common goal in rehabilitation of hyperfunctional voice disorders is to reduce the force and laryngeal focus of voicing. Methods include breathy phonation, sometimes termed "confidential voice therapy" and forward focus, sometimes termed "resonant voice therapy" (43,44). Whereas both have been described as successful approaches to treating vocal pathologies, the breathy, confidential voice cannot be sufficiently amplified, thus limiting its usefulness in presentational speech and performance. Resonant voice therapy appears to have some advantages for working with professional voice users. This therapy often relies on the " Y buzz" described by Lessac to Journal of Voice, Vol. 11, No. 2, 1997
establish a kinesthetic " a n c h o r " of vibrational feedback in the orofacial structures (45). By maintaining this anchor, or referent sensation, the presentational speaker is able continuously to bring the vocal energy forward and thus maximize phonatory efficiency (46).
Working with the urgent need patient Young adult and middlescent professional voice users often fit into the category of the urgent need patient--the vocally injured individual who for legitimate reasons cannot participate in the more traditional course of voice therapy (47). Most frequently, urgent need patients are performers or high-level presentational speakers with an imminent, important performance or presentation. The urgent need patient is identified typically through the case history and falls into two categories: l) the local patient with marked vocal dysfunction currently performing or participating in excessive voice use or 2) the out-of-town patient who has very limited time in our setting. Examples would be the touring singer with a reputation and big money riding on tonight's sold-out concert or the local lead actor in who has no understudy. Most frequently, the urgent need patient is a performer who has a sense of responsibility to a larger group. Urgent need therapy revolves around "vocal Band-Aids"--techniques and suggestions to get the actor through tonight's performance, the business executive through tomorrow's annual sales presentation, or the singer through this weekend's important audition. A parsimonious approach is taken to vocal testing, choosing only those tests specifically indicated through visual or auditory observations, the case history, and laryngeal stroboscopy. The goal of urgent need therapy is not to perfect the voice, but to preserve it so that the professional voice user does not have to confront a markedly worse voice problem when "true" therapy can begin. Although all the suggestions made to the urgent need patient would be considered therapeutic, they may not fall into the more ideal pragmatic, hierarchically organized program that would be described as therapy.
Understanding the unique needs of performers Evaluation of performers is always more complex than evaluation of the nonperforming patient because vocal function must be assessed across a broader spectrum of activities. Additionally, the interpretation of results may differ if the patient is a
THE YOUNG
performer. Although there are data that suggest standards of vocal production for the normal, nonperforming voice within this age span (48-53), the literature lacks normative data for performers. Normative data derived from nonperforming populations may not provide a sound basis of comparison for performers. Preliminary studies suggest that, even in the presence of laryngeal pathology, voicedisordered performers may demonstrate some vocal capabilities that are commensurate with or exceed generally accepted normative values (56,57). Developing the confidence and expertise necessary to work with performers requires more than a clinical interest in voice disorders. The speechlanguage pathologist must seek out information and experiences that provide insight and familiarity with the performer's vocal needs. A performer's vocal requirements will always extend beyond typical conversational speech. Taking singing lessons or studying vocal pedagogy enables the speechlanguage pathologist to develop an appreciation and understanding of the mechanics of singing; studying acting may reinforce the vocal flexibility required for stage speech and character portrayal. Collaborating with other professionals One skill that is extremely beneficial in working with young adult and middlescent patients is knowing how and when to involve other disciplines in the plan of care. The speech-language pathologist must understand the skills and capabilities of other professionals and must be a good team player. The young adult and middlescent professional voice user usually is very focused on career and typically wants to complete voice therapy without disrupting work schedules or taking time off. The most efficacious route to rapid recovery is often through intensive interdisciplinary intervention. The voice care team, listed in Fig. 2, may provide a simultaneous interdisciplinary assessment as advocated by Morrison and Rammage (56) or a sequential examination as described by Sataloff (57). The voice care team works collaboratively to help the singer or actor restore laryngeal health and resume full vocal function. Young adult and middlescent voice patients are frequently interested in alternative medicine and its potential to impact on their vocal difficulties. A record of patient inquiries at our clinic revealed that 41% of patients made inquiries about the application of alternative or unconventional approaches to voice rehabilitation. Although predominately un-
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THE PERFORMING VOICE CARE TEAM Primary Care Physician Laryngologist Speech-Language (Voice) Pathologist Singing Voice Teacher Voice and Speech Trainer Vocal/Singing Coach
Adjunct
members:
Psychologist/Psychiatrist/Social Worker Nutritionist Pulmonologist Neurologist Gastroenterologist FIG. 2. Members of the voice care team may work simultaneously or sequentiallywith the voice disordered patient. From Fried MP: The larynx: a multidisciplinary approach. St. Louis: 1996:254; modifiedwith permission.
proved, alternative medicine practices represent an emerging force in health care. Eisenberg et al surveyed the prevalence, cost, and pattern of the use of unconventional therapies in the United States (58). Reports indicated that 34% of American adults interviewed used at least one alternative therapy in the preceding year. Those between the ages of 2549 were most likely to use unconventional approaches. Interestingly, 72% of respondents did not inform their physician or "conventional" practitioner that they were using alternative treatment. Speech-language pathologists and other voice clinicians may want to inquire specifically about the patient's participation in other therapies and educate themselves about the principles and applicability of such practices as acupuncture, chiropractic, massage therapy, and meditation (59). All of the skills described are necessary to be an effective voice pathologist. But to go beyond being effective, the exceptional clinician will provide information to the patient that extends beyond specific clinical interaction. For example, the speechlanguage pathologist can share information about Journal of Voice, Vol. 11, No. 2, 1997
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The Voice Foundation (1721 Pine Street, Philadelphia, PA 19103, U.S.A.) with each patient. Most professional voice users find a great deal of comfort in knowing that there is an organization of professionals concerned about their needs and devoted to voice care and voice rehabilitation. PROMOTING VOCAL LONGEVITY Today's young adult and middlescent professional voice users will be the next century's senescent population. By taking a few proactive steps, these patients can promote the vocal longevity necessary to maintain active, professional lives. A simple notecard listing the general principles of vocal longevity, as shown in Fig. 3, can be provided to professional voice users with the speech-language pathologist explaining the details of each suggestion. By placing these notecards in a frequently viewed spot, such as a mirror or door frame, the professional voice user will be reminded of their commitment to the principles of vocal longevity. Eventually, these practices will become healthy habitual routines. At its best, voice therapy can serve as the catalyst for making broad lifestyle changes as professional voice users realize they must stand up on their own behalf and begin to take care of themselves. This means taking care of both voice issues and general health. Attend to the process of healthy voicing Young adult and middlescent professional voice users are busy, goal oriented people who may be so product-oriented that they lose site of the process of healthy voicing. For example, singers may be determined to have the voice sound beautiful, regardless of technique. By overt attention to the process of healthy voice production, the product takes care of itself. Follow a vocal hygiene program As previously mentioned, adhering to a vocal hygiene program can facilitate recovery from voice disorders and assist in maintaining vocal health. VOCAL
LONGEVITY
ATTEND TO THE PROCESS OF HEALTHY VOICING FOLLOW A VOCAL HYGIENE PROTOCOL WARM UP ADEQUATELY/EXERCISE THE VOICE STRIVE FOR OPTIMUM HEALTH FIG. 3. Simple suggestions for vocal longevity can be included on a notecard to be placed in a frequently viewed location. Journal of Voice, Vol. I1, No. 2, 1997
Vocal hygiene suggestions may also maximize the endurance and flexibility required by many professional voice users. Young adult and middlescent voice users should understand and be able to actively implement suggestions such as increasing vocal fold lubrication, identifying and reducing vocal misuse, avoiding laryngeal irritants, using vocal pacing, and so forth. Warm up adequately/exercise the voice To maintain vocal agility and health, Saxon suggests that vocalists should structure practice sessions to contain a warm-up, conditioning phase, and a cool down (38). Although the exact effects of warm-up are unknown, most singers and actors find that appropriate warm-up prevents vocal injury and enhances vocal abilities. It is no secret that careers can be maintained if injuries can be avoided. Warm-up should include exercises in alignment, breathing, laryngeal relaxation, gentle initiation of voicing, and "releasing" the voice (building resonance or pitch range extension). Warm-up should be completed prior to rehearsals, presentations, and performances and is helpful in channeling performance anxiety into performance energy. The warmup should meet the technical demands of the specific performance. Following performance, there should be a complete vocal "cool down" to relax the system. The conditioning phase will be highly individualized and dependent on the professional voice user's needs and goals. For presentational speakers, the conditioning phase might consist of vocal function exercises (60). Actors and singers may collaborate with their voice teachers and vocal coaches to devise a personalized vocal work-out that addresses the components of frequency, intensity, and duration of exercise; type of voicing; and progression of voice skills or tasks (38). Strive for optimal health Laryngeal health and aging cannot be separated from general health and chronological and physiological aging. Increasingly, health status has been linked with lifestyle choices such as diet, smoking, and exercise (61--64). Broad suggestions such as "Get some rest, get some exercise and eat a balanced diet" should be honed to carry greater meaning and increased specificity. Setting and working toward specific lifestyle goals allows the professional voice user to begin to define personal health, not just as the absence of disease, but as the optimal functioning of the body's intricate systems.
THE YOUNG ADULT PATIENT
As previously mentioned, young adult and middlescent professional voice users are often overworked and overtired. These patients need to understand that sleep deprivation can have a deleterious effect on their overall health and their ability to withstand stress and resist illness. Irwin et al. (65) demonstrated that even a modest loss of sleep during a single night reduces cellular immune function. This example may be provoking to voice patients who begin to understand that they may be inviting some larger health problems on an ongoing basis if they do not begin to take care of themselves. Studies have shown that adequate exercise helps maintain cardiovascular health, respiratory function, muscular systems, and insulin function and protects against cancer (66-69). Young adult and middlescent professional voice users, being youth oriented and concerned about physical appearance, may claim vanity as the sole motivation to exercise. To drive the health benefits of exercise, activity must do more than burn calories. A complete program will include exercises addressing cardiorespiratory endurance, muscular strength (resistance training), flexibility, and muscular coordination (38). Nutritional status is extremely important in defining the professional voice user's health span. Current antiaging and disease prevention research focuses heavily on the role of free radical oxidation, which has been linked to the aging process in general and 62 disease processes, including cancer, heart disease, diabetes, atherosclerosis, infectious diseases, arthritis, cerebrovascular disease, macular degeneration, and cataracts (70--76). The body's defense in fighting free radical pathology appears to rest with proper micronutrition (77-83). Informed nutrition--combined with exercise and adequate sleelr---encourages good overall health and subsequently vocal longevity.
26.
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source waveform characteristics. J Speech Hear Res 1989; 32(3):556-65. Miller D, Shutte H. Feedback from spectrum analysis applied to the singing voice. Journal o f Voice 1990;4(4):329. Sundberg J. What's so special about singers? Journal o f Voice 1990;4(2):107-19. Sataloff RT, Spiegel JR, Carroll LM, Schiebel BR, Darby KS, Rulnick R. Strobovideolaryngoscopy in professional voice users: results and clinical value. Journal o f Voice 1988;1(4):359--64. Bless DM, Swift E. Stroboscopy: new diagnostic techniques and applied physiology. In: Fried MP, ed. The larynx: a multidisciplinary approach, 2nd ed. St. Louis: MosbyYearbook, 1996:81-101. Saxon K, Schneider C. Vocal exercise physiology. San Diego: Singular Publishing, 1994. Hirano M, et al. Structure and mechanical properties o f the vocal fold in speech and language: advances in basic research and practice. In: Loss M, ed. New York: Academic Press, 1982. Verdolini-Martson K, Titze I, Druker D. Changes in phonation threshold pressure with induced conditions of hydration. Journal o f Voice 1990;4(2): 142-51. Verdolini-Marston K, Sandage M, Titze I. Effects of hydration treatments on laryngeal nodules and polyps and related voice measures. Journal o f Voice 1994;8(1):30--47. Chan RWK. Does voice improve with vocal hygiene education? A study of some instrumental voice measures in a group of kindergarten teachers. Journal o f Voice 1994;8(3): 279-91. Verdolini K, Druker D, Palmer P. Physiological study of "resonant voice" ]unpublished manuscript]. Verdolini-Marston K, Burke M, Lessac A, et al. A preliminary study on two methods of treatment for laryngeal nodules. Journal o f Voice (in press). Lessac A. The use and training o f the human voice: a practical approach to speech and voice dynamics. New York: Drama Book Specialists, 1967. Titze I. Control of vocal intensity and efficiency. Principles o f Voice Production Englewood Cliffs, N J: Prentice-Hall, Inc., 1994. Harvey PL. Speaking and singing with an injured voice. Presentation, The First World Voice Congress, Oporto, Portugal, 1995. Eckel F, Boone DR. The S/Z ratio as an indicator of vocal pathology. J Speech Hearing Res 1981;46:147-9. Hollien H, Dew D, Philips P. Phonation frequency ranges of adults. J Speech Hear Res 1971;14:755--60. Stoichel ML. Speaking fundamental frequency characteristics and phonational frequency ranges of non-smoking female adults. J Speech Hear Res 1981;24:437-41. Coleman RF, Mabis JH, Hinson JK. Fundamental frequency-sound pressure level profiles of adult male and female voices. J Speech Hear Res 1977;20:197-204. Horii Y. Fundamental frequency perturbation observed in sustained phonation. J Speech Hear Res 1979;22:5-19. Kent R, Kent J, Rosenbek J. Maximum performance tests of speech production. J Speech Hearing Res 1987;52:367-87. Harvey P, et al. Objective analysis of actors' voices: an initial report. Journal o f Voice 1989;3(2): 143-7. Harvey P, Coleman R, Aronson D. Objective evaluation o f actors' voices: normative data on the trained theatrical voice. Presentation, The Voice Foundation, 22rid Annual Symposium- Care of the Professional Voice, Philadelphia, 1993. Morrison M, et al. The management o f voice disorders. San Diego: Singular Publishing Group, Inc., 1994. Sataloff RT. Professional voice: the science and art o f clinical care. New York: Raven Press, 1991.
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58. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence costs, and patterns. N Eng J Med 1993;328:246--52. 59. D'antoni ML, Harvey PL, Fried MP. Alternative medicine: does it play a role in the management of voice disorder. Journal o f Voice 1995;9(3):308-I I. 60. Stemple JD, Lee L, D'amico B, Pickup B. Efficacy of vocal function as a method of improving voice production. Journal o f Voice 1994;8(1): 1--8. 61. Beasley J, Swift J. The Kellogg Report: the impact of nutrition, environment and lifestyle on the health of Americans. Institute of Health Policy and Practice. Bard College Center, Annandale-on-Hudson, 1989. 62. National Research Council. Diet and health; implication for reducing chronic disease risk. Washington, DC: National Academy Press, 1989. 63. Shils M, Olson B, Shike M, eds. Modern nutrition in health and disease, 4th ed. Philadelphia: Lea and Febiger, 1994. 64. Koop CE. The Surgeon General's report on nutrition and health. Washington, DC: National Academy Press, 1988. 65. Irwin M, Mascovich A, Gillin C, Willoughby R, Pike J, Smith T. Partial sleep deprivation reduces natural killer cell activity in humans. Psychiatr Med 1994;56:493-8. 66. Wenger HA, Bell GJ. The interaction of intensity, frequency and duration of exercise training in altering cardiorespiratory fitness. Sports Med 1986;3(4):346--56. 67. Bortz W. Disuse and aging. JAMA 1982;248:1203-8. 68. Blair S, Kohl H, Paffenbarger M. Physical fitness and allcause mortality: a prospective study of health men and women. JAMA 1989;262:2395--401. 69. Ballor DL, Poehlman ET. Resting metabolic rate and coronary risk factors in aerobically and resistance trained women. A m J Clin Nutr 1992;56:968-73. 70. Scandalios J. Molecular biology of free radical scavenging systems. Free Radic Biol M e d 1993;14(4):227-335. 71. Sies H. Oxidative stress: from basic research to clinical application. Am J Med 1991;91(suppl 3C):3-31. 72. Halliwell B. Reactive oxygen species in living systems: source, biochemistry, and role in human disease. A m J Med 1991 ;91(suppi 3C):9C-13C. 73. Sohal R. The free radical hypothesis of aging: an appraisal of the current status. Aging (Milano) Clinical Exp Res 1993;5 (1):3-17. 74. McCord J. Human disease, free radicals and the oxidant/ antioxidant balance. Clin Biochem 1993;26(5):351-8. 75. Adams J. Oxygen free radicals and Parkinson's disease. Free Radic Biol Med 1991 ;10(1): 161--69. 76. Ames B, Shigenaga M, Hagen T. Oxidants, antioxidants and the degenerative diseases of aging. Proc Natl Acad Sci USA 1993;90:7915-22. 77. Antioxidants: What are they? Can they help keep you healthy? Mayo Clinic Health Letter 1993;11(8):1. 78. Diplock AT. Antioxidant nutrients and disease prevention: an overview. A m J Clin Nutr 1991 ;53(suppl !):189S-93S. 79. Blumberg J. Dietary antioxidants and aging. Contemporary Nutrition 1992; 17(3): 1-7. 80. Hennekens C. Antioxidant vitamins and cancer. A m J Med 1994;97(3):22S-8S. 81. Garewal H. Emerging role of beta-carotene and antioxidant nutrients in prevention of oral cancer. Arch Otolaryngol Head Neck Surg 1995;121(2):115-21. 82. Hodis H, Mack W, LaBree L, et al. Serial coronary anglographic evidence that antioxidant vitamin intake reduces progression of coronary artery atherosclerosis. J A M A 1995; 273(23): 1849-54. 83. Schmidt K. Antioxidant vitamins and beta-carotene: effects on immunocompetence. A m J Clin Nutr 1991,53(suppl 1): 383S-5S.
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The Three Ages of Voice
The Young Adult Patient Pamela Lynn Harvey Voice and Speech Services, Beth Israel Hospital, Boston, Massachusetts 02115, U.S.A.
Summary: The purpose of this paper is to 1) describe the unique issues of voice patients, ages 21-55; 2) outline the knowledge and clinical skills that speechlanguage pathologists should possess to deal with those issues; and 3) provide suggestions for promoting vocal longevity. Key Words: Young adult-Midlife--Professional voice user--Evaluation--Therapy--Longevity-General health.
The 1987 inaugural issue of the Journal of Voice focused on vocal aging with papers discussing connective tissue changes in the larynx, acoustic measures of the aging voice, vocal reaction time in the elderly, and vocal characteristics of biological age (1-6). Now, we revisit vocal aging from a clinically focused perspective. This paper describes the unique issues of voice patients, ages 21-55, and the knowledge and clinical skills that speech-language pathologists should possess to deal with those is-
What we know about vocal aging is an apparent overlay of general information about the aging process and specific information about the aging larynx. Generally, physiologic adaptations expected in aging include changes in cardiovascular characteristics, pulmonary function, hormonal balance, immune response, musculoskeletal integrity, and central nervous system function (2). Specific to laryngeal function, age-related degenerative changes include muscle atrophy, ligament deterioration, ossification of the hyaline cartilages, and slowing of neural transmission and nerve conduction velocity (3,4). Although not perceptually or acoustically apparent, some of these changes may begin in our 30s. Given the early onset of these declining functions and their insidious progression, it may be that lifestyle choices and vocal use patterns either accelerate or retard these age-related changes. Although chronological aging is unalterable, some current theories suggest that an individual can slow physiologic aging and advance the long-term health needed for a sustained career in vocal performance. This paper provides some suggestions to promote vocal longevity.
SUES.
OVERVIEW OF RESEARCH FINDINGS Most of the empirical studies describing the aging process of the larynx have not been focused on this age group. This is probably attributable to the relative stability of the voice in a normal, healthy person over the four decades from approximately age 20 to 60. Repeatedly, studies have demonstrated that intensity, fundamental frequency ranges, and vocal quality are sustained into a person's 60s (712). Accepted February 14, 1996. Address correspondence and reprint requests to Pamela Lynn Harvey, Voice Clinic Coordinator, Voice and Speech Services, Beth Israel Hospital, Suite 460, 333 Longwood Avenue, Boston, MA 02115, U.S.A. Portions of this paper were presented at The Voice Foundation's 24th Symposium: Care of the Professional Voice, Philadelphia, June 5-10, 1995.
YOUNG ADULT PROFESSIONAL VOICE USER Regardless of age, the "professional voice user" is a designation describing countless variations of phonatory abilities and demands. The conversational demands of the telemarketer and secretary, 144
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the presentational voice use of the attorney and school teacher, and the performance demands of the singer or actor may all be appropriately labeled "professional voice use." However, viewing these vocal demands along a continuum as presented in Fig. 1 indicates performance as a more demanding task that requires greater vocal flexibility and endurance. Singers, particularly operatic singers, have requirements for precise respiratory control and extensive pitch range. Actors face the vocal calisthenics of the "character" voice that may be markedly different from their individual vocal persona--and potentially neither aesthetically pleasing nor physiologically healthy. For most professional voice users, the broad age span of 21-55, represents the period of greatest professional productivity. This is the time when careers are made or dreams are shattered. These years actually represents two life stages: young adulthood from ages 21 to about 35 and mature adulthood from around 35 to 55 years of age. A term that seems illustrative of this latter group, which is wedged between adolescence and senescence, is "middlescence" (13). The middlescent population includes the " B a b y Boomers"--76 million Americans born between 1946 and 1964. United States Census statistics reveal that slightly more than 7,000 people are turning 50 each day and that this will continue every day for the next 20 years. The Baby Boomers are a youth-oriented culture that is striving not only to add years to life, but also add life to those years (13). Baby Boomers want to maintain their health and remain professionally capable, vital, and energetic well into their 60s and 70s. To provide meaningful services to these patients we must understand their desires, their abilities, their lives, their vocal demands, and the disorders with which they present. CONTINUUM OF PHONATORY DEMANDS
r I \
PROFESSIONAL VOICE
J
CONVERSATION => PRESENTATION => PERFORMANCE Secretaries Telemarketers
Clergy Teachers Business
Singers Actors Executives
FIG. 1. Professional voice use may have many different types o f phonatory demands. This continuum progresses from least taxing voice use at the left to most difficult at the right. From: Fried MP. The larynx: a rnultidisciplinary approach. St Louis: 1996:254; with permission.
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The early years of young adulthood represent a vocal "coming of age." What was an acceptable vocal persona in a teenager or college student may need altering to reflect a more professional one. Professional voice users of this age frequently suffer from the excesses of nicotine and alcohol intake or battle gastroesophageal reflux, due to eating late in the evening (14,15). In these early adult years, performers often struggle with separating their vocal abilities from their talent. The singer or actor may believe that recognizing any voice problem will somehow diminish their talent. In this instance, objective assessment is quite beneficial. Instrumental measures can assist in moving the discussion from the clinician's perception of the voice problem, which may be regarded as opinion, to the documentable parameters functioning outside normal limits, which is often less emotionally threatening to the performer. Singers tend to reach their greatest ability in their 30s and maintain this plateau of performance for years. In contrast, most premier sports athletes reach their peak performance level in their teens or early 20s. Titze has attributed this difference in achieving peak performance to two factors. First is that singing, unlike other sports, is not strength related but rather dependent on skills of efficiency, coordination, and precision. Additionally, Titze speculates that the beginning of the aging process, which debuts in one's 30s, may actually work to the vocalist's advantage. When the larynx is composed of partially ossified cartilages it may provide a more stable framework for the vibrating vocal folds; by providing more fixed anchors at the end point of the tissue fibers, the resultant vibratory patterns would be more periodic and smooth (12). Although voices may reach some degree of stability as professional voice users enter middlescence, lives do not. Grueling work schedules, simultaneously caring for both growing children and aging parents, intense professional competition, and self-imposed demands to "do it all" combine to make the lives of these patients extremely stressful. The young adult and middlescent professional voice user is often overworked, overtired, and overextended. They often say, "I don't have time for this voice problem--I don't have time to be sick." Frequently, the onset of voice problems coincides with an upper respiratory infection. When the laryngitis sets in, these professional voice users continued to push their voices through their usual unrelenting, not-a-moment-to-spare schedules. Journal of Voice, Vol. 11o No. 2, 1997
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Any discussion of this age group would be incomplete without mention of the impact of their insurance coverage. Increasing numbers of young adult and middlescent patients are opting for managed care systems, such as Health Maintenance Organizations and Preferred Provider Organizations. HMOs and PPOs usually regard speech-language pathology services as a short-term benefit, meaning that all treatment must be provided within the allowed time frame, usually 60-90 days. Extension of therapy is very seldom approved and there is no coverage for follow-up. Interestingly, these insurance restrictions have expanded, not restricted, the speech-language pathologist's responsibilities as a health care provider. Now, the voice clinician functions exhaustively as a patient advocate, verifying referral status, requesting referrals from a patient's primary care physician, integrating interdisciplinary documentation, and making telephone calls to justify recommendations to an insurance reviewer to maximize coverage.
COMMON VOICE COMPLAINTS AND CONCOMITANT CONDITIONS Most of the voice disorders encountered in young adulthood and middlescence are hyperfunctional in nature: musculoskeletal tension dysphonias, true vocal fold nodules, or polyps and chronic laryngitis with edema and erythema. But each year, fewer patients seen in our voice clinic present with vocal fold pathology or vibratory dysfunction in isolation. Many patients have a concomitant disorder that may significantly complicate their treatment and recovery. Four of these recalcitrant conditions are endocrine dysfunction, asthma, multiple chemical sensitivity, and human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Endocrine concerns in this population are usually related to thyroid dysfunction or hormonal shifts within the female menstrual cycle or throughout her lifespan. Premenstrual symptoms include complaints of increased vocal fatigue and effort in singing and denigration of vocal control, pitch, range, intensity, and quality. Estrogen and progesterone secretion may cause shifts in the weight and shape of the vocal folds through water retention, edema of the interstitial tissue, and venous dilatation. Reports on the incidence and severity of vocal premenstrual symptoms are highly varied (16). InhibJournal of Voice, Vol. 11, No. 2, 1997
iting ovulation may be helpful to patients with pronounced vocal premenstrual syndrome, but oral contraceptives bring their own vocal implications (17). Clinicians must meticulously sort through these complaints and treat them as effectively as possible. Hormonally based vocal changes may also emerge as a woman approaches menopause (18). The cause of these complaints of vocal fatigue and reduced vocal control may come as a surprise to women who do not realize that cessation of menses may come at the later stages of menopause. By obtaining baseline estrogen levels in professional vocalists at around age 35, declining estrogen levels can be readily recognized and rectified. This practice allows the endocrinologist or gynecologist to tailor hormonal replacement therapy to the patient's past individual hormone profile. The incidence of asthma is growing in the United States. A recent audit of patient files over a 3-month period from our clinic indicates that 19% report a concomitant diagnosis of asthma as compared with 7% in a 3-month audit of patients seen in 1985. This dramatic increase is, in part, attributable to an escalation in the number of patients diagnosed with reversible obstructive pulmonary disease and, in part, a reflection of an expansion of the diagnosis to include pulmonary s y m p t o m s not previously termed asthma. The asthmatic vocally disordered patient is a challenge for several reasons. Even well-managed asthmatic patients often avoid breathing deeply in order to reduce coughing. Subsequently, these patients adopt as a protective mechanism very shallow respiratory cycles that may not provide adequate respiratory support. In patients whose disease is not well controlled, the vocal folds endure the abuse of chronic coughing with its sequela of cordal edema and irritation. Further complicating voice rehabilitation for the asthmatic patient is the use, often for many years, of inhaled steroids believed to have a deleterious effect on laryngeal musculature (19,20). Multiple chemical sensitivity (MCS) is a condition now reported with some regularity by patients in our urban setting (21-23). These patients report that the onset of MCS was precipitated by a single massive exposure or repeated low-dose exposure to an irritating chemical agent. Subsequently, the patient reportedly develops hypersensitivity with minimal exposure to molds, fragrances, fumes, cooking aromas, flowers, and so forth. Exposure results in abrupt onset of symptoms such as tingling or numb-
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ness of the limbs, runny nose and eyes, changes in phonatory quality, and sensations of throat constriction and dyspnea. Paradoxical vocal fold movement is occasionally observed in these patients. The description and cause of MCS symptoms remains controversial as many physicians believe the condition has a psychogenic origin. As Sataloff notes in a previous report on vocal tract response to toxic injury: "The mechanism of these disorders remains obscure and treatment is currently guided by imagination, intuition and anecdote. To improve this uneasy situation, extensive collaborative research is essential" (24). The HIV/AIDS epidemic has taken a tragic toll on the performance community in the past decade. Recently, new combinations to medications seem to be having some impact on the disease with more HIV-positive patients maintaining their health longer before progression to an active AIDS status. As a result of this increased health span, an increasing number of these patients are being referred for voice therapy. These professional voice users are living with HIV, not dying of AIDS; they are working, productive, and concerned about their voices. AIDS-associated symptoms are most frequently infectious or neoplastic changes in laryngeal tissue (25). Although the voice pathologist cannot correct these problems, therapy designed to compensate for vocal deficits and maximize phonatory capabilities can be quite meaningful to the patient. KNOWLEDGE AND SKILLS OF THE VOICE PATHOLOGIST Patients in young adulthood and middlescence represent the largest percentage of professional voice users referred with vocal complaints. The speech-language pathologist must 1) accurately evaluate the full range of vocal dysfunction, from mild to severe; 2) design and implement effective treatment protocols; 3) understand the demands of the urgent need patient; 4) understand the special demands of performance, if working with singers and actors; and 5) know how and when to involve other disciplines in the patient's care and be able to effectively collaborate with other professionals. The general principles of evaluation, differential diagnosis, goal setting, and use of a hierarchical approach to voice rehabilitation apply to the management of voice disorders in the young adult and middlescent patient (26-28).
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Evaluation of young adult and middlescent professional voice users
Voice evaluation is essential to the differential diagnosis of a voice disorder. The first objective of the voice evaluation is to identify causal factors that may have precipitated the onset of the problem or be perpetuating its maintenance. Secondarily, the voice evaluation should provide information and education for the patient and establish a plan and direction for treatment (29). The voice evaluation is typically composed of a detailed patient history, objective voice measures, laryngeal videoendoscopy, auditory-perceptual judgments, visual observations, audiologic screening, and diagnostic therapy (30). Young adult and middlescent patients are usually quite intrigued, but not intimidated, by the use of instrumentation and technology during voice evaluation and therapy. For example, electroglottographic signals and aerodynamic measures may be used to identify hard glottal onset and contrast this potentially abusive phonatory pattern with aspirate onset of phonation (31-33). Interpretation of acoustic signals can be used to assess spectral characteristics for the presence or strength of the singer's formant (34,35). Flexible fiberoptic laryngoscopy coupled with video taping can be used as a visual feedback tool in describing the movements of the true vocal folds, supraglottic structures, larynx, palate, pharynx, and tongue during varying performance activities (36,37). Laryngeal videostroboscopy allows detailed, although subjective, description of the vibratory behavior of the vocal folds. When using laryngeal imaging, the speech-language pathologist does not diagnose laryngeal disease but rather describes the vibratory characteristics and muscle usage patterns that comprise the patient's phonatory style. It is difficult to realistically evaluate voice patients within the stark white walls and restricted spaces of the clinical cubicle. Professional voice users should be observed during actual presentations and performances, not just as they are simulating their usual voice use. Observation and discriminating listening may be needed to recognize issues of postural alignment, breath support, and microphone placement as well as faulty vocal habits and their pattern of occurrence, such as hard glottal attacks on vowel-initiated words, glottal fry at the termination of utterances, and throat clearing as a "vocal starting mechanism." Journal of Voice, Vol. 11, No. 2, 1997
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Designing voice therapy for young adult and middlescent patients Young adult and middlescent patients often need to understand the theoretical basis of voice treatment strategies in order to commit to compliance. This population grew up with modern medicine and frequently expects a pill to "fix" their maladies or to be done to rather than participate in voice therapy. It is essential to educate these patients on how the voice works through a simple lesson on anatomy and physiology. Analogies that compare the professional voice user to an athlete are usually well received. Viewing one's self as a vocal athlete helps patients realize that, like any other athlete, they are working with a muscle system that is governed by parameters of endurance, flexibility, and strength (38). Additionally, when patients have a basic understanding of the body-cover theory of phonation, they recognize that the health and pliancy of the overlying mucosa must also be established and maintained to achieve optimal results (39). Next, an individualized vocal hygiene regimen should be designed for each patient. Young adult and middlescent patients may regard vocal hygiene as a means of achieving "passive" progress. One patient may complete a program with emphasis on increasing laryngeal lubrication and decreasing throat clearing (40). Another patient may implement frequent timed periods of vocal rest throughout the day and begin a stress reduction program to supplement voice therapy. In subsequent sessions, the program is reviewed and modified. Vocal hygiene is not limited to reducing vocal abuse and misuse. Adherence to a vocal hygiene protocol may facilitate healing of laryngeal tissue and promote the maintenance of vocal health once that health is established (41,42). Description of numerous therapy techniques is beyond the scope of this article. One common goal in rehabilitation of hyperfunctional voice disorders is to reduce the force and laryngeal focus of voicing. Methods include breathy phonation, sometimes termed "confidential voice therapy" and forward focus, sometimes termed "resonant voice therapy" (43,44). Whereas both have been described as successful approaches to treating vocal pathologies, the breathy, confidential voice cannot be sufficiently amplified, thus limiting its usefulness in presentational speech and performance. Resonant voice therapy appears to have some advantages for working with professional voice users. This therapy often relies on the " Y buzz" described by Lessac to Journal of Voice, Vol. 11, No. 2, 1997
establish a kinesthetic " a n c h o r " of vibrational feedback in the orofacial structures (45). By maintaining this anchor, or referent sensation, the presentational speaker is able continuously to bring the vocal energy forward and thus maximize phonatory efficiency (46).
Working with the urgent need patient Young adult and middlescent professional voice users often fit into the category of the urgent need patient--the vocally injured individual who for legitimate reasons cannot participate in the more traditional course of voice therapy (47). Most frequently, urgent need patients are performers or high-level presentational speakers with an imminent, important performance or presentation. The urgent need patient is identified typically through the case history and falls into two categories: l) the local patient with marked vocal dysfunction currently performing or participating in excessive voice use or 2) the out-of-town patient who has very limited time in our setting. Examples would be the touring singer with a reputation and big money riding on tonight's sold-out concert or the local lead actor in who has no understudy. Most frequently, the urgent need patient is a performer who has a sense of responsibility to a larger group. Urgent need therapy revolves around "vocal Band-Aids"--techniques and suggestions to get the actor through tonight's performance, the business executive through tomorrow's annual sales presentation, or the singer through this weekend's important audition. A parsimonious approach is taken to vocal testing, choosing only those tests specifically indicated through visual or auditory observations, the case history, and laryngeal stroboscopy. The goal of urgent need therapy is not to perfect the voice, but to preserve it so that the professional voice user does not have to confront a markedly worse voice problem when "true" therapy can begin. Although all the suggestions made to the urgent need patient would be considered therapeutic, they may not fall into the more ideal pragmatic, hierarchically organized program that would be described as therapy.
Understanding the unique needs of performers Evaluation of performers is always more complex than evaluation of the nonperforming patient because vocal function must be assessed across a broader spectrum of activities. Additionally, the interpretation of results may differ if the patient is a
THE YOUNG
performer. Although there are data that suggest standards of vocal production for the normal, nonperforming voice within this age span (48-53), the literature lacks normative data for performers. Normative data derived from nonperforming populations may not provide a sound basis of comparison for performers. Preliminary studies suggest that, even in the presence of laryngeal pathology, voicedisordered performers may demonstrate some vocal capabilities that are commensurate with or exceed generally accepted normative values (56,57). Developing the confidence and expertise necessary to work with performers requires more than a clinical interest in voice disorders. The speechlanguage pathologist must seek out information and experiences that provide insight and familiarity with the performer's vocal needs. A performer's vocal requirements will always extend beyond typical conversational speech. Taking singing lessons or studying vocal pedagogy enables the speechlanguage pathologist to develop an appreciation and understanding of the mechanics of singing; studying acting may reinforce the vocal flexibility required for stage speech and character portrayal. Collaborating with other professionals One skill that is extremely beneficial in working with young adult and middlescent patients is knowing how and when to involve other disciplines in the plan of care. The speech-language pathologist must understand the skills and capabilities of other professionals and must be a good team player. The young adult and middlescent professional voice user usually is very focused on career and typically wants to complete voice therapy without disrupting work schedules or taking time off. The most efficacious route to rapid recovery is often through intensive interdisciplinary intervention. The voice care team, listed in Fig. 2, may provide a simultaneous interdisciplinary assessment as advocated by Morrison and Rammage (56) or a sequential examination as described by Sataloff (57). The voice care team works collaboratively to help the singer or actor restore laryngeal health and resume full vocal function. Young adult and middlescent voice patients are frequently interested in alternative medicine and its potential to impact on their vocal difficulties. A record of patient inquiries at our clinic revealed that 41% of patients made inquiries about the application of alternative or unconventional approaches to voice rehabilitation. Although predominately un-
ADULT
PATIENT
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THE PERFORMING VOICE CARE TEAM Primary Care Physician Laryngologist Speech-Language (Voice) Pathologist Singing Voice Teacher Voice and Speech Trainer Vocal/Singing Coach
Adjunct
members:
Psychologist/Psychiatrist/Social Worker Nutritionist Pulmonologist Neurologist Gastroenterologist FIG. 2. Members of the voice care team may work simultaneously or sequentiallywith the voice disordered patient. From Fried MP: The larynx: a multidisciplinary approach. St. Louis: 1996:254; modifiedwith permission.
proved, alternative medicine practices represent an emerging force in health care. Eisenberg et al surveyed the prevalence, cost, and pattern of the use of unconventional therapies in the United States (58). Reports indicated that 34% of American adults interviewed used at least one alternative therapy in the preceding year. Those between the ages of 2549 were most likely to use unconventional approaches. Interestingly, 72% of respondents did not inform their physician or "conventional" practitioner that they were using alternative treatment. Speech-language pathologists and other voice clinicians may want to inquire specifically about the patient's participation in other therapies and educate themselves about the principles and applicability of such practices as acupuncture, chiropractic, massage therapy, and meditation (59). All of the skills described are necessary to be an effective voice pathologist. But to go beyond being effective, the exceptional clinician will provide information to the patient that extends beyond specific clinical interaction. For example, the speechlanguage pathologist can share information about Journal of Voice, Vol. 11, No. 2, 1997
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The Voice Foundation (1721 Pine Street, Philadelphia, PA 19103, U.S.A.) with each patient. Most professional voice users find a great deal of comfort in knowing that there is an organization of professionals concerned about their needs and devoted to voice care and voice rehabilitation. PROMOTING VOCAL LONGEVITY Today's young adult and middlescent professional voice users will be the next century's senescent population. By taking a few proactive steps, these patients can promote the vocal longevity necessary to maintain active, professional lives. A simple notecard listing the general principles of vocal longevity, as shown in Fig. 3, can be provided to professional voice users with the speech-language pathologist explaining the details of each suggestion. By placing these notecards in a frequently viewed spot, such as a mirror or door frame, the professional voice user will be reminded of their commitment to the principles of vocal longevity. Eventually, these practices will become healthy habitual routines. At its best, voice therapy can serve as the catalyst for making broad lifestyle changes as professional voice users realize they must stand up on their own behalf and begin to take care of themselves. This means taking care of both voice issues and general health. Attend to the process of healthy voicing Young adult and middlescent professional voice users are busy, goal oriented people who may be so product-oriented that they lose site of the process of healthy voicing. For example, singers may be determined to have the voice sound beautiful, regardless of technique. By overt attention to the process of healthy voice production, the product takes care of itself. Follow a vocal hygiene program As previously mentioned, adhering to a vocal hygiene program can facilitate recovery from voice disorders and assist in maintaining vocal health. VOCAL
LONGEVITY
ATTEND TO THE PROCESS OF HEALTHY VOICING FOLLOW A VOCAL HYGIENE PROTOCOL WARM UP ADEQUATELY/EXERCISE THE VOICE STRIVE FOR OPTIMUM HEALTH FIG. 3. Simple suggestions for vocal longevity can be included on a notecard to be placed in a frequently viewed location. Journal of Voice, Vol. I1, No. 2, 1997
Vocal hygiene suggestions may also maximize the endurance and flexibility required by many professional voice users. Young adult and middlescent voice users should understand and be able to actively implement suggestions such as increasing vocal fold lubrication, identifying and reducing vocal misuse, avoiding laryngeal irritants, using vocal pacing, and so forth. Warm up adequately/exercise the voice To maintain vocal agility and health, Saxon suggests that vocalists should structure practice sessions to contain a warm-up, conditioning phase, and a cool down (38). Although the exact effects of warm-up are unknown, most singers and actors find that appropriate warm-up prevents vocal injury and enhances vocal abilities. It is no secret that careers can be maintained if injuries can be avoided. Warm-up should include exercises in alignment, breathing, laryngeal relaxation, gentle initiation of voicing, and "releasing" the voice (building resonance or pitch range extension). Warm-up should be completed prior to rehearsals, presentations, and performances and is helpful in channeling performance anxiety into performance energy. The warmup should meet the technical demands of the specific performance. Following performance, there should be a complete vocal "cool down" to relax the system. The conditioning phase will be highly individualized and dependent on the professional voice user's needs and goals. For presentational speakers, the conditioning phase might consist of vocal function exercises (60). Actors and singers may collaborate with their voice teachers and vocal coaches to devise a personalized vocal work-out that addresses the components of frequency, intensity, and duration of exercise; type of voicing; and progression of voice skills or tasks (38). Strive for optimal health Laryngeal health and aging cannot be separated from general health and chronological and physiological aging. Increasingly, health status has been linked with lifestyle choices such as diet, smoking, and exercise (61--64). Broad suggestions such as "Get some rest, get some exercise and eat a balanced diet" should be honed to carry greater meaning and increased specificity. Setting and working toward specific lifestyle goals allows the professional voice user to begin to define personal health, not just as the absence of disease, but as the optimal functioning of the body's intricate systems.
THE YOUNG ADULT PATIENT
As previously mentioned, young adult and middlescent professional voice users are often overworked and overtired. These patients need to understand that sleep deprivation can have a deleterious effect on their overall health and their ability to withstand stress and resist illness. Irwin et al. (65) demonstrated that even a modest loss of sleep during a single night reduces cellular immune function. This example may be provoking to voice patients who begin to understand that they may be inviting some larger health problems on an ongoing basis if they do not begin to take care of themselves. Studies have shown that adequate exercise helps maintain cardiovascular health, respiratory function, muscular systems, and insulin function and protects against cancer (66-69). Young adult and middlescent professional voice users, being youth oriented and concerned about physical appearance, may claim vanity as the sole motivation to exercise. To drive the health benefits of exercise, activity must do more than burn calories. A complete program will include exercises addressing cardiorespiratory endurance, muscular strength (resistance training), flexibility, and muscular coordination (38). Nutritional status is extremely important in defining the professional voice user's health span. Current antiaging and disease prevention research focuses heavily on the role of free radical oxidation, which has been linked to the aging process in general and 62 disease processes, including cancer, heart disease, diabetes, atherosclerosis, infectious diseases, arthritis, cerebrovascular disease, macular degeneration, and cataracts (70--76). The body's defense in fighting free radical pathology appears to rest with proper micronutrition (77-83). Informed nutrition--combined with exercise and adequate sleelr---encourages good overall health and subsequently vocal longevity.
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