Voice overuse: staying in fine voice

Teachers often consider voice problems such as throat discomfort, vocal fatigue and hoarseness an occupational hazard. With demanding work-schedules, lack of support from management and a culture which continues to embrace the mantra ‘keep calm and carry on’, many disregard their voice problems, never considering seeking specialist medical advice until the issue becomes severe.

According to one study (Morrow & Connor, 2011), teachers are eight times more likely to suffer from voice-related health conditions than the general public, with the prevalence of voice problems among music teachers being up to four times that of classroom teachers.

Voice overuse, misuse and ‘new use’ are the greatest risk factors for developing a voice problem. Speaking too loudly or for long periods without adequate rest can strain the vocal cords, leading to inflammation and injury. Ineffective speaking or singing technique can exacerbate problems further.

When we consider the working environment, vocal demands can be significantly higher for music teachers than their classroom teacher counterparts. There are long periods of high intensity voice-use, often singing and speaking against high levels of background noise, and poor room acoustics require increased vocal effort. Add to the mix other common risk factors for developing voice problems – such as being female, having allergies, respiratory infection, acid reflux, chronic cough or throat clearing, dehydration, stress, anxiety, having hearing problems or smoking – and the odds of developing a problem become even greater.

Voice problems can affect both work and social life, impacting mental health alongside interfering with job satisfaction, performance and attendance. According to another study (Kristiansen et al., 2014), approximately one-third of teachers miss work at least once during their careers due to voice problems.

The impact of voice problems among teachers creates significant financial costs to the sector, with the cost to schools calculated at around £15m a year (NEU, 2019). Other studies have shown that voice problems may even be detrimental to students’ learning and achievement.

How teachers can help themselves

Teachers need to be able to sustain their voice, energy and concentration for extended periods of time, which is both physically and mentally taxing. Stress and tiredness often contribute to increased susceptibility to illness, and this can lead to further fatigue, decreased vocal endurance, vocal power, and worsening voice quality. It’s common for teachers to become trapped in a downward health spiral, leaving them more susceptible to voice misuse and overuse as the term continues and they struggle to be heard.

Consider how common it is for music teachers to experience voice problems in the winter term, with the multitude of rehearsals and performances running up to Christmas. With winter coughs, colds and vomiting bugs, and the additional cover required on top of busy personal schedules, it’s no wonder voices begin to suffer.

Making small changes to daily habits can have a huge positive impact on how well your voice may fare during term time. We are not machines, and our bodies need opportunity to recover and reset. Implementing strategies to reduce volume, frequency and duration of voice-use can have immediate clinical benefits in vocal health.

So how does this look in practice?

You could begin by reflecting on your voice-use each day, prioritising which lessons or tasks will likely require more from your voice and dialling down the vocal effort and volume used on less important tasks. Plan for proximally closer interactions in smaller groups, and frequent opportunities for voice rest by considering teaching methods used, delegating tasks or seeking small periods of solitude throughout the day. Also consider alternative non-verbal strategies for gaining attention and requesting routine actions from your students – these can literally save your voice.

This diagram may be used in voice therapy to support discussion around practical approaches to managing behaviour change (adapted from George Engel’s ‘Biopsychosocial model’)

Simple daily voice exercises

• Warm-up stretches. Before you start singing or speaking, take time to warm up your body with some movement and gentle stretches, particularly of the neck and shoulders. Gentle chewing, tongue stretches and yawning are great for relaxing your jaw, tongue and throat.

• Abdominal breathing. Using appropriate breath support for speaking or singing tasks will help prevent straining your vocal cords and keep your voice healthy. Try 2–5 minutes of breathing exercises at the start of your day; for example, inhale for 4 counts through your nose and exhale on an ‘ss’ or ‘zz’ for 8 or more counts. Gradually increase the length of the outbreath, making sure no tension creeps into your face, throat, neck or shoulders.

• Warm up your voice. Vocal exercises can be used throughout the day to energise your voice production and ‘reset’ your voice. Examples include humming a few glides or a simple tune, or using some straw phonation, lip trills or tongue rolls. Tongue twisters can improve articulation. Reciting a poem or story using exaggerated intonation can improve the ‘musicality’ of your voice. Improved ‘musicality’ will help keep the voice healthy and flexible, while engaging your listeners more effectively.

• Cool down your voice. End each working day with a few cool-down exercises for body and voice; for example, gentle stretches and using descending pitch glides, lip trills or straw phonation.

Daily habits for a healthy voice

Alongside quitting smoking, tackling acid reflux, checking whether any medications cause dryness, and seeking support to manage stress and anxiety, the following six daily habits can help you maintain a healthy voice:

• Stay hydrated. Keeping your vocal cords hydrated is essential. Drinking eight glasses of water/herbal teas is recommended throughout the day. Use daily warm steam inhalations to lubricate and soothe your vocal tract and to thin secretions (so they’re easier to clear), before and after heavy voice use. Limit drinks that contain caffeine or alcohol as these can be dehydrating, cause irritation and prevent you from achieving quality sleep.

• Eat well. Fuelling your body with the essential vitamins and minerals it needs to meet the demands you put on it is key to staying healthy. If your immune system is working optimally, you will be more likely to avoid the coughs and colds which will keep you and your voice out of action. If you do become ill, a healthy body will likely recover faster. If you don’t manage to eat your five-a-day regularly, a daily vitamin supplement may be a good investment.

• Take breaks. Many voice problems are caused by inflammation and tension building up from misuse and overuse of the voice. Take regular ‘absolute voice rest’ breaks from speaking or singing to give your vocal cords time to rest. This could be 10 minutes total silence during lunchbreak, going for a walk on your own or quietly practising some meditation, gentle breathing exercises or stretches during your day. Setting vocal boundaries for yourself, such as ‘I will only speak during class time and will rest my voice and hydrate during breaks’ can be key to maintaining a healthy voice.

• Avoid excessive talking. It’s important in the classroom to frequently check in with yourself as to whether you have tension in your neck, face or jaw, whether you are raising your volume or pushing your voice unnecessarily. Try to limit excessive talking and shouting, as this can strain your vocal cords, putting you at greater risk of vocal injury.

• Be mindful of your environment. If the acoustics are not ideal, using a portable voice amplification system has been shown to reduce voice overuse as it reduces the intensity and effort required. To reduce atmospheric dryness, try having a bowl of water in the room to improve humidity, or open the windows, and keep sipping water.

• Smile! Smiling, laughing, and spending time relaxing really is the best medicine when it comes to the voice. Feel good hormones dopamine and serotonin are released when you smile, helping you stay calm and perform tasks better.

Myths vs facts

Teachers who use singing or deliver singing as part of the curriculum can be well-placed to offer vocal health advice to colleagues, based on pre-existing knowledge and an interest in vocal health. However, it’s important to stay up to date with what is fact, and what is anecdotal.

Colleagues within the staffroom have been known to share well-meaning advice and discuss various remedies as a means of improving voice issues. Drinking honey, lemon and ginger or herbal teas tastes nice and can provide comfort and hydration, but what you swallow doesn’t go anywhere near your vocal cords and so will not affect your voice directly.

Gargling salt water or apple cider vinegar may provide relief for your throat but it isn’t ‘washing off your vocal cords’. Anything which numbs sensation such as antiseptic throat sprays or throat lozenges may do more harm than good as you may feel you’re able to carry on talking or singing, exacerbating inflammation, and causing further damage.

Avoiding dairy or coffee is generally a myth, and individuals should judge whether to reduce these based on how they personally affect their own digestive system, energy levels and mucus secretions. Everybody needs adequate rest, however, so considering the switch to decaffeinated drinks beyond midday may improve your ability to switch off come bedtime. Boosting your water intake should allow the body to release energy more effectively if you need an afternoon pep-up. Combine this with a healthy snack and some movement and stretching and you should be feeling good to go!

When and how to seek specialist medical help

You are not alone, and help is out there! Prolonged and recurring hoarseness in the absence of a cold or throat infection and a persistent change in pitch or quality of voice should be investigated.

If any of the symptoms listed in this article persist for longer than two weeks, it is recommended you seek expert medical advice. Speak with your GP and ask for them to refer you to ENT.

The British Voice Association (BVA) has a list of voice clinics across the UK, and the British Association of Performing Arts Medicine (BAPAM) has recommendations for professional health practitioners who work with performing artists.

Links and references

• Morrow, S.L., and Connor, N.P., 2011. Comparison of voice-use profiles between Elementary classroom and music teachers. Journal of Voice, 25(3), pp.367-72.

• Morrow, S.L., and Connor, N.P., 2011. Voice Amplification as a means of reducing vocal load for Elementary music teachers. Journal of Voice, 25(4), pp.441-6.

• Kristiansen, J., Lund, S.P., Persson, R., et al., 2014. A study of classroom acoustics and school teachers’ noise exposure, voice load and speaking time. International Archives of Occupational and Environmental Health, 87, pp.851-60.

• Byeon, H., 2019. The risk factors related to voice disorder in teachers. International Journal of Environmental Research and Public Health. 16(19), Sep 30.

• National Education Union, Voice Care for Teachers, 2019: neu.org.uk/advice/voice-care-teachersneu.org.uk/advice/voice-care-teachers

  britishvoiceassociation.org.uk

  bapam.org.uk

Carrie Garrett is co-founder of VitaVoice: vitavoice.co.uk

The daily vitamin supplement Optimise is formulated with professional voice users in mind.