Transcription:
Combatting Vocal Fatigue in a Virtual World

Melanie:  Welcome to Back To Health, your source for the latest in health, wellness and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family.

Back To Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I'm Melanie Cole. And I'm so happy to have you listen with us today as we discuss combating vocal fatigue in a virtual world. It's something that I think that not only those of us that talk for a living, but those of us that are now doing all these Zoom calls and conferences, and we didn't use to do it that way. So this is going to be a lively discussion about vocal therapy.

Joining me is Christine Murphy Estes and Scott Sussman. They're both speech-language pathologists, specializing in voice at the Sean Parker Institute for the Voice at Weill Cornell Medicine. I'm so glad to have you both with us today. Scott, I'd like to start with you. Tell us a little bit about your profession and this field of medicine, which many people don't know what it is. Tell us what a voice therapist does.

Scott Sussman: Sure. So you're absolutely correct. Most people when they meet me say, "What is it that you do exactly?" So like you said, we're speech-language pathologists, which covers communication throughout the entire lifespan, but we specialize in voice evaluation and rehabilitation. What does that mean? Basically, I tell my patients, "You can think of me like a physical therapist for the throat." And I provide rehabilitation for anything that affects the voice and upper airway and some of us even do swallowing rehabilitation. I also tell my patients, you can think of me as a voice detective.

So I meet my patients and I sort of put the pieces together of their backgrounds, their environment, their habits, how they take care of their voice, how they use their voice. And we put that all together to figure out what's going on and the best way to treat them.

Melanie: Such an interesting field that you're in. And as I said in my intro, I have a personal investment in this as my voice is what I do for a living. So, Christine, what types of patients do you usually see? Are they people like me? Do you see singers? Who do you see?

Christine Estes: Yeah, we certainly see lots of people like you. Really mostly people who use their voices a lot, and that can be either for their occupation or it can be social. And because it makes sense that people who use their voices more are more likely to experience voice injuries, just like how athletes are more likely to experience physical injuries because they're playing hard and they're playing often.

But also we work with people who have different types of voice or upper airway conditions that can result from surgeries or from illness, from different neurological conditions or even from just age-related changes to the larynx, which is another word for the voicebox.

So we see a variety of different people for all sorts of different reasons, but certainly the most common would be occupational and social voice use.

Melanie: It's such an interesting time we're in right now, because as we said, now we're all doing these Zoom meetings and conferences and things that we didn't use to do with our voices. You know, if you were in an office, you could turn around and talk to someone, get up and go talk to them. But now so much of it is virtual. So let's talk about who is most likely to encounter a voice issue. And singers and radio talk hosts aside, what are we doing? Tell us a little bit about our risk and how people are misusing their voice. Certainly, mothers and fathers that are screaming at their children can do damage to their voices. So Christine, tell us a little bit about risk factors for voice issues.

Christine Estes: Yeah, it's funny. I'm also not only a heavy voice user as a voice therapist, I'm also a singer and I also have two young children who are often at home with me when I'm trying to provide telehealth for my patients. So everything you're saying is resonating with me on every level.

Again, anyone who's using their voice as part of their profession is going to be likely to have a voice problem. And some of the people who experience them could be teachers who are doing incredible work during the pandemic. We're seeing school teachers who are teaching in person while wearing masks. We're seeing teachers who are teaching virtually and asking their students to turn on and off their microphones over and over. And we're seeing teachers who are doing both at the same time.

So school teachers are actually the highest represented population of individuals who experience voice injuries, even more than singers, even more than podcasters, and fitness instructors, dance teachers, lawyers, salespeople, worship leaders, all sorts of people who already use their voices a lot for what they do. And now, they're experiencing it even more through doing their job virtually, doing their jobs via video conferencing.

And the symptoms of voice problems can really manifest in a lot of different ways. You may notice that there's a change in the quality of your sound, so kind of a hoarseness, a raspiness in the voice. There could be a feeling of pain or tightness when talking feeling like it's suddenly more work to talk than it once was, noticing that your voice is much lower or higher than it used to be, feeling like people can't hear you the way that they used to, and you're having to repeat yourself over and over, losing your voice at the end of the day or losing your voice at the end of the week. And, you know, as you mentioned singers before, singers might notice more subtle changes in their voices, like it may take longer to warm up or they may lose some of their singing range, usually their high notes. So we're all experiencing all sorts of different types of voice issues, where there's a really great variety in the symptoms we experience.

I know for me personally, just beginning in teletherapy, prior to April of last year, I had never really used video conferencing. And so I noticed in my very first week of working with my patients, that my voice was getting tired and hoarse and it was feeling like a lot of work just at the end of a week. And I'm trained to do this. I'm a classical opera singer. I'm a voice therapist. I know what to do. But the way we're using our voices on these video conferencing platforms is very different from in-person interactions and I think so many of us are feeling that.

Scott Sussman: Excuse me. I'll add that same thing that Christine was just saying, I actually got into the field because I was the patient. I was a professional singer and went through a lot of voice therapy. And since going into the pandemic and working on Zoom, I'm actually busier now than I was pre-pandemic. And my voice use is through the roof. And I have been navigating how to take care of myself and how to do this as well.

Melanie: Well, thank you both. And I guess we're all kind of in the same boat here. But I do have a question about the symptoms. Christine, you were mentioning all these symptoms, fatigue and all of that. that. Right now, and at various times of the year, people suffer from allergies. There's all kinds of external factors. How do we know if we're hoarse, if we've got that fatigue, that it's not something like allergies that's causing people to clear their throats more often causing-- because you hear it in those Zoom meetings where people are like--

Scott Sussman: "Are you listening to me? Are you listening to me as I clear my throat?"

Melanie: Well, yes. And I do the same. So could that be affecting our voice as well? Instead of it being improper voice usage or overuse, can it be things like allergies or the environment?

Christine Estes: Oh, absolutely. It can be. I think, many of us notice chronic problems annually from allergies or from illness. And we noticed the other things associated with that. It's often not just specific to the voice, so certainly there can be other factors involved. And if we're mindful of our environment, keeping our homes clean and free from dust, if we're potentially using an air purifier, if that's helpful, if we're controlling our allergies, some people find benefit from over-the-counter medications or from immunotherapy, or if we're controlling and resting our voices when we're ill, if we're hydrating well, there are lots of ways to kind of control some of the voice symptoms of that.

However, I think about three major categories, where it may be a voice problem that goes beyond just typical allergy and illness. And the first is if the change is really very sudden, like you were singing or yelling or coughing, and then your voice suddenly acutely disappeared. And it didn't really come back. That's one condition where it would be very wise to seek an evaluation with an ENT, preferably a laryngologist. And a laryngologist is an ENT, an ear nose and throat doctor who specializes in the T of that, the throat, the voice specifically.

The second situation that you really should be monitoring is if you've had a voice change for about two weeks and you've taken care of all of those things. So if you've taken care of your allergies and you're controlling them to the best of your ability, if you're recovering from the cold that maybe you caught, or if you're hydrating really well to counter some of the dryness that we're feeling when we're indoors in the heat or outdoors in the dry cold, but your voice isn't really getting better. After that two week point, it might be wise to seek an evaluation, even if you are having voice problems because of illness and allergies. After a while, it might be wise to seek an evaluation.

The third thing that I like to think about, where I would recommend coming in for a voice evaluation, is if you notice chronic voice problems that happen year after year or they periodically just come and go, maybe they're even getting worse. Like for instance, with school teachers. I'm bringing them up because I feel like they have been such heroes during the pandemic. They're doing so much for our kids. You know, we noticed that school teachers, they seem to start off the school year generally pretty well. And then around October and November, every year, they might be feeling a change in their voices for the worse and feeling like their voices are giving out by the end of the week. Well, if this is happening year after year, you don't have to go through all of those ups and downs. Why not get an evaluation and see how things are and learn how to take care of it? So that you're really maintaining your voice rather than always going through a decline in recovery.

Melanie: Scott, what happens in voice therapy? As Christine just went over all of these great bits of advice and ways that we can identify problems when they arise, tell us what a session is like with you. And while you're telling us that, then give us some really good advice about maintaining really good vocal health.

Scott Sussman: Sure. So as I clear my throat, excuse me/ I'm having my own allergy things today.

Christine Estes: Scott, do you need some voice therapy? I'm happy to help to you.

Scott Sussman: Thank you. Christine. I'll come over to your office. So a typical treatment session, like I was saying, we're the voice detective. So our job is to design a treatment plan for our patients that the textbook answer would be to balance the systems of the voice. You know, how you use your air, how you're using your voice, how you're allowing the voice to travel through your mouth and nasal passages, how you're articulating your sounds.

And we can do that through several different approaches. There are typical exercise approaches to voice therapy where we're guiding our patients through vocal scales or glides, or all different types of exercises. There are approaches to voice therapy where we're really working at the conversational level. And it's very much talking to our patients, providing adjustments for how they're saying it or how they feel their voice.

And then there are other approaches. For example, one of my favorite ones is laryngeal massage where I actually can massage and manipulate the throat, almost like how you think a chiropractor would adjust someone's back. So there are lots of different approaches in voice therapy, but I always tell my patients, you get out of it what you put into it. So it's much more than what they do in that 45-minute to an hour session. It's very much what they do on their own time and how they practice.

Vocal hygiene is the foundation of what we do. It's not always enough to get the patient to where they want to be, but it's certainly, you have to create the right environment for the voice. I often tell the patients you want to think about your voice sort of like how you think about calories or cash spending. How much vocal cash do you want to spend on something?

So thinking about how much am I talking? How does it feel when I speak, do I actually need to even speak right now? You want to save your cash. You can save your cash by limiting background noise. You can save your cash by not talking over people in conversation and kind of fighting for the attention. You can save your cash by using amplification.

We'll get to Zoom in a moment, but your headset and your microphone is so important. Can the other person see you? We get a lot of visual cues, which is something that's happening that's hard with our mask-wearing at the moment, which sometimes patients have a lot of trouble dealing with. We see a lot of that yelling across our homes. Whispering, whispering is actually not great for the voice. Throat clearing and coughing, like you are hearing me do a little while ago.

And then self-care like Christine already spoke about. Hydration is so important. Looking at your medications, what's drying, the caffeine intake. Are you drinking alcohol? Which many of my patients were doing during the pandemic and how that affects the voice, the drying effects of that. How much sleep are we getting? How much physical exercise are we getting? And I certainly have patients saying, you know, "I'm not exercising quite like I was before," which can certainly take it's effects of the voice too. So looking at the overall self-care of my patients is very important and provides the right foundation for them.

Melanie: How interesting people don't always assume that many of the things that you've mentioned would affect our voice. But what a great analogy, spend your cash wisely. If you don't have to talk, don't talk, right? So before we wrap up here, as we're returning to work in communal work environments, Christine, first last word to you.

Do you feel that workplaces should consider voice training for employees to limit potential difficulties and really what you would like us to know about voice therapy? And as an opera singer, you know, when you're done giving us all this great advice, you can maybe give us a little note that we can hear, but if you would tell us what you would like workplaces to think about as they're setting up Zooms, as many of them are going to continue to do televisits and Zoom meetings. So kind of wrap that part of it up for us.

Christine Estes: Yeah, I agree with you. I think that Zoom and other video conferencing platforms, I think this is here to stay to some degree. And I think it's very wise that people are taking the time to learn about how to use their voices most effectively, because it's not going anywhere. That's for sure.

In terms of workplaces considering voice training for their employees, personally I think that any investment into the health of your employees is a worthwhile endeavor. And the voice is so important to so many different professions. You know, we use our voices for the basics, delivering information and educating, but we're also motivating people and we're giving music to the world and our voices are so important throughout everything that we do. If a teacher has a major voice problem, they're going to have to call out of work. And it's much more costly to bring in substitutes because of those missed work days.

And we have research to show us that voice problems can lead to a decreased quality of life. We have research showing that voice problems lead to job dissatisfaction and social dissatisfaction and personal dissatisfaction. So with education and with preventive training, it's less likely that people are going to experience voice problems and those who still do are probably going to have less severe voice problems and not require extensive treatment.

Because treatment isn't just limited to voice therapy, as much as we'd like it to be. Sometimes it requires medical treatment. Sometimes people require surgical treatment and a prolonged period of recovery from that surgery. So I'm a big believer in that Benjamin Franklin proverb, that an ounce of prevention is worth a pound of cure. And I think that's true for so many things in life, but certainly when it comes to the voice.

So if we can teach people strategies and teach them about things like not overspending their vocal budgets or wasting their vocal calories and teach them different ways they can use their voices more effectively, we're going to keep people happier and doing their jobs longer and socializing and enjoying their lives more.

And as for me as an opera singer, I don't sing professionally anymore. Obviously, being a voice therapist takes up a lot of my time and being a mom pretty much the rest of that time. But I still warm up my voice almost every day. I do all of the things I ask my patients to do, and that can include some lip trills or some gentle humming exercises. I still sing just to keep my voice in check and I think it helps me give good therapy to my singers. So I do all the things I was trained to do. I just don't have any aspirations to be back on the stage.

Scott Sussman: I know we're running out of time, but I will be remiss if I don't say just a few specific Zoom tips for your listeners. Is that all right?

Melanie: Well, absolutely because I was coming to you for your last words. So why don't you give us our healthy voice with Zoom, what you want all of the listeners to know about keeping that healthy voice?

Scott Sussman: Okay. So this is super important. One of the benefits of Zoom, we think of it as we're speaking so much on Zoom. We think it doesn't pick us up. We want to project our voice and kind of shout into the computer when we can actually use technology to help us. And that's how I've gotten through this,

The type of microphone and the headset you use is super important. I have played with many myself. It's not a one-size-fits-all. You have many different options. There are I think it's called binaural or mono headsets on one ear. The one ear sometimes lets you hear yourself better so that you can hear your voice in the other ear. I prefer the two ears, but I use a mic monitoring program so I can hear my own voice.

Some people prefer a boom mic, and you'll hear it as I do it on here. I actually lost my voice a few weeks ago and I didn't miss any of my patients because I was able to move the mic closer to my mouth. And even though I barely had a voice and if I pull the microphone away, you can hear that. But if I put it right up there, you hear me pretty clear. So I prefer a boom mic.

My colleague, Christine, likes a condenser mic and her sound is brilliant. I mean, her patients always say-- I mean, she has a beautiful voice anyway as you can hear. So the type of technology you use, play around with that. You have a lot of options. The other thing, your lighting is very important, so that anyone on the other end can see your mouth and see what you're doing. Sometimes we're sitting in the dark and it's harder to understand because some of voicing is actually visual or some of our comprehension of the sound.

Your Zoom settings are important. There are music and professional audio settings in Zoom that if you're singing or you're making sounds, Zoom may actually cut you out because it thinks it's background noise. So you want to make sure to look at those. And you also want to be cognizant of the other person's setup because I have patients who maybe they don't have their hearing aids in or whatnot, and then they can't hear either. And so educating them about getting headphones, getting a microphone is super important as well. And your internet connection also plays a role.

Christine Estes: Internet connection definitely plays a role. I find it's so much better to plug directly into my router, so that I'm not having delays. It minimizes frustration in a lot of ways. And if I can add a couple of extra things specific to video conferencing in Zoom, I would say also if you keep your own volume that is coming towards you on the lower side, you're going to be less likely to respond with excessive loudness. So I actually keep my volume on my laptop quite low, so I can still hear my patients very well. But I don't feel like they're barraging me with loud sound and then I'm not giving them back louder sound than necessary because we kind of lose track over that. It's kind of like when we're playing music in the car and it gets progressively louder and louder and louder. And we turn off the car and restart it and realize how loud it was. We kind of do that to our voices to some degree as well.

And I also tell my patients to keep a straw cup handy filled with water. So that they're just periodically compelled to go ahead and sip that water. It gives their voice a break. It gives them a little hydration. It gives their eyes a break as well. All good things when we're sitting in front of a screen all day long,

Melanie: What great advice this has been. You both are wonderful. And I can hear the passion in your jobs and in what you do for a living. And listeners, I keep my water and my teas and all of my liquids just to the left of me. And I use a great mic, so it's an RE20. And, you know, so all of their advice is so good. Take that to heart because it will help to save our precious voices.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back To Health. We'd like to thank our listeners and invite our audience to download, subscribe, rate, and review Back To Health on Apple podcasts, Spotify and Google podcast. For more health tips, please visit WeillCornell.org and search podcasts. And parents, don't forget to check out our Kids HealthCast. I'm Melanie Cole.  

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