Voice Health in Pre-Service Physical Education Majors: A Pilot Study

Authors: Marty Marra, Ed. D., Kellyn Hall, Ph. D., and Fred J. Cromartie, Ed. D.

Corresponding Author:
Dr. Marty Marra
Longwood University
201 High Street
Farmville, VA 23909
marraml@longwood.edu
434-395-2935

Dr. Marty Marra is an Assistant Professor of Health and Physical Education at Longwood University in Farmville, VA. Dr. Marra has been involved in education for 33 years and continues to research and study in the areas of pedagogy, professionalism, current trends and gender equity issues in health, physical education and athletics.

Kellyn Hall, Ph.D. CCC/SLP is a clinician, researcher, teacher, and author with over 30 years’ experience working in a variety of medical settings.  She is currently an Associate Professor in the Communication Sciences and Disorders program at North Carolina Central University where she teaches medical speech-language pathology courses. Her clinical interests are in adult and pediatric voice disorders.

Dr. Fred J. Cromartie, is the Director of Doctoral Studies at the United States Sports Academy.

Voice Health in Pre-Service Physical Education Majors: A Pilot Study

ABSTRACT

Teachers are at a higher risk for phono-traumatic voice disorders due to increased vocal demands of their profession. Previous studies suggest that training modules may be effective in educating practicing teachers about vocal hygiene and vocally abusive behaviors.

The purpose of this study was to pilot an online training module targeting student teachers before they entered their teaching professions. The goals were to provide instruction about vocal hygiene, strategies for optimal voice production, and determine the effectiveness of the training in their vocal practices in their future careers. It was hypothesized that an online educational module will increase undergraduate students’ knowledge of vocal hygiene, thereby reducing their risk of developing voice disorders in the future.

Key words:  vocal hygiene, pre-service teachers, physical education teachers, voice health, Phono-traumatic voice disorders, vocal abusive behaviors

INTRODUCTION

The prevalence of voice disorders is high among professions where vocal use is demanding (14).  Teachers are professional voice users; they depend on a consistent and effective voice quality for their work. If voice problems develop, then the ability to perform their job is threatened (13, 15). Vocal dysfunction may lead to periods of sick leave and the need for vocal rehabilitation involving great financial costs (17, 18). The etiology of the voice problems in teachers is linked not only to the high demands for vocal use, but also for the environment in which the voice (19). Teachers, especially physical education teachers, need to speak loudly for prolonged periods of time often against competing background noise such as in the gymnasium or an outside space.  It is not surprising that the incidence of voice disorders among teachers and student teachers is estimated to be as high as 38% with more than half of teachers reporting that they have experienced voice problems during their careers (14). These problems range from mild throat discomfort, vocal fatigue, hoarseness, to the complete loss of voice (10).  Voice problems ultimately can affect the ability to work. More than 40% of teachers report that they reduce or alter their teaching activities and were absent from work for at least one day in the previous year due to their voice problem (13).

The consequences of voice problems for teachers vary depending on the etiology, severity, and frequency of the voice problems (10).  For example, teachers who suffer vocal inflammation due to repeated vocal trauma associated with loud talking (e.g. phono-trauma), may recover after a period of vocal rest. However, repeated phono-trauma can lead to lasting vocal cord tissue changes resulting in persistent hoarseness, vocal weakness, and reduced loudness (7). One common type of vocal tissue change is vocal nodules or “singer’s nodes”. These are benign growths, similar to callouses, that develop on the vocal cords as a result of vocal abuse, misuse, and overuse (12). Chronic or fibrotic vocal nodules often require surgical removal and thus threaten the professional voice users’ livelihood. The impact of voice disorders is most often seen in professional singers. For example, Julie Andrews, who is world famous for vocal performances in movies and theatre, lost her singing voice after surgery on her vocal cords to remove nodules. Following surgery in 1997, Andrews was no longer able to perform and her professional career as a singer was over (12).  In the same vain, a teacher who has chronic voice problems will eventually suffer a loss in the ability to effectively perform his/her job and may need to consider leaving the field (8). This was true for the first author, who chronically battled vocal hoarseness and periods of aphonia (complete loss of voice) throughout her career as a physical education teacher in the schools.

Given that not all teachers suffer voice problems, individual factors associated with the development of voice disorders have been researched to help determine who is at greatest risk (5).   Poor ‘vocal hygiene’ habits are etiologically linked with voice disorders (3).  Specifically, reduced water consumption (hydration), lack of sleep, over use of caffeine, exposure to vocal irritants (i.e. smoking, inhaling chemicals etc.), and engaging in other vocally traumatic behaviors (i.e. excessive throat clearing and coughing) have also been found to contribute to voice problems in teachers (7). Gender differences exist as well. Female teachers are more likely than men to suffer voice problems (5). The gender differences are believed to be related to hormonal and anatomical differences in the underlying vocal cord tissue in males compared to females (4, 5). Other variables associated with voice problems are age, and years of work in the field. Roy and colleagues (13) found that female teachers between 40-59 years of age who had been teaching 16 or more years were at risk for developing voice problems.

In light of these findings, and given the vocal demands of physical education teachers, it is not surprising female physical education teachers tend to have voice changes sooner than classroom teacher (11). Roy and colleagues found an increase in voice issues among female physical education teacher after teaching for as few as five years (13). Voice changes included difficulty reaching high and low notes when singing, lower voice tones in general conversation and a tendency to speak loudly in other, non-teaching environments. Many females who have taught more than 16 years tended to have male characteristics in their voice tones because of excessive use, overuse, or improper use of their voices due to teaching (14).

Teaching may be viewed as an occupational hazard for the development of voice disorders, particularly in female physical education majors.  Simberg et al. (16) stated that voice disorders in teachers are preventable and advocated for vocal disorder prevention programs need to be developed. Unfortunately, training in vocal hygiene and techniques for voice use are often missing from teacher training (16). Physical education teachers report limited exposure to proper vocal hygiene training or specific instruction on how to prevent voice problems (2). Previous research suggests that vocal hygiene training has a positive effect in high risk populations such as teachers (20). However, Roy et al. (13) found that teachers are reluctant to take time off work for medical appointments and they also show concern that doctors may advise them to reduce voice use at work, switch occupations, or stop teaching altogether. Vilkman (19) interpreted these findings to mean that teachers accept voice disorders as an occupational hazard and may be unaware of available resources to treat or eliminate them. Aiken and Rumbach (2) found that when physical education instructors were exposed to vocal training, it was often described as brief, uninteresting, and irrelevant to their specialized profession. Much of the lack of vocal education was attributed to apathetic attitudes toward voice use and vocal hygiene from management staff. As a result, physical education instructors often felt pressured to work despite vocal problems because vocal hygiene practices were not prioritized in the industry (2).

With adequate training and instruction, it is possible for voice problems in teachers, especially physical education teachers, to be avoided. Voice therapy programs typically target individual and group therapy of current teachers (20). Voice disorders prevention training geared toward the student physical education teacher population may help future teachers avoid voice problems prior to the start of their careers. It would be difficult, however, to provide weekly individual and/or group face-to-face training for student teachers who are scattered among different placement sites. An online training program may be an efficient and effective way to achieve the same goals. The training program would need to be geared toward teachers’ interests, easy to access, brief, and interesting. A multifaceted controlled study is needed to determine the effectiveness of online education/training in voice disorders prevention and the long-term effects of the training on voice disorders prevention.

The purpose of this pilot study was to determine the effectiveness of an online vocal hygiene training module for physical education majors at high risk for developing voice disorders. The goals were to provide instruction about vocal hygiene, strategies for optimal voice production, and determine the effectiveness of the training in promoting healthy vocal practices. This study is part of a longitudinal investigation of an online vocal training program for the prevention of voice disorders in physical education teachers who are at high risk for developing voice problems. Results may lend support to the need and benefit of early voice education and training in the physical education major curriculum.

METHODS

Participants

Undergraduate physical education majors were invited to participate in this study through announcements made in classes and a mass email sent to all physical education student teachers at Longwood University.  Five participants met the following inclusion criteria: held senior status, enrolled in intern teaching experience (HPEP 482), reported no history of smoking, respiratory allergies or asthma, reported voice problems in the past, and provided informed consent. The participants consisted of 3 male students and 2 female students. The participants mean age was 23.5 (range: 22 – 25 years of age).

Materials/Measurements:

Perceptual and instrumental measures of voice quality were obtained.  The perceptual evaluation was performed using the Consensus Auditory-Perceptual Evaluation of Voice (6). The CAPE-V uses a visual analog scale (VAS) for ratings of overall voice disorder from 0 (normal) to 100 (severe).  Acoustic measurements of voice were made using OperaVox^®, a software system used to analyze frequency, jitter, shimmer, and noise-to-harmonics ratio (NHR) by an iPad’s internal microphone with sampling rate of 45 kHz. Frequency is the number of times the vocal cords vibrate each second measured in Hertz (Hz). Shimmer (measured in decibels or dB%) and jitter (measured in dB%) are vocal perturbation measures of the cycle-to-cycle variability in amplitude (shimmer) the acoustic waveform. High perturbation measures (greater than 1%) are correlated with vocal hoarseness (9). A 5 second voice sample was recorded of each participation sustaining a mid-vowel /ɑ/ as in the word ‘hot’.  Recordings were made in a sound-reduced booth with the microphone-to-mouth distance held constant at 30 cm.  The middle 1-second of each sample was selected for acoustic analysis. 

A “Vocal Hygiene Training” module was embedded into the learning management system (Canvas) of the course HPEP 482. Within the module, written material and a 15-minute instructional video created for this study using PowToons^® were embedded. The written material addressed general knowledge about voice disorders in teachers and coaches as well as voice therapy/prevention strategies. The video provided general education on voice production, vocal hygiene strategies, and voice therapy and prevention strategies. Vocal hygiene and consequences of poor vocal health (i.e. smoking, vocal abuses, dehydration, alcohol, and caffeine effects on the voice) and environmental factors specific to physical educators (i.e. talking against background noise and/or in reverberating environments) were emphasized.  Vocal training education included breath support, reduced vocal tension, vocal warm up, and vocal projection strategies. Pre-training and post-training tests were also embedded in the module. The 15 item pre-training test assessed the prior knowledge regarding topics covered written material and the video. This test was repeated at the conclusion of the study (i.e. post-training test) as an estimate of post-training learning of the material presented in the module. Finally, pre- and post-training questionnaires surveyed participants daily vocal habits, vocal abuses, perceived changes in voice quality, use of vocal hygiene, and application of vocal techniques/vocal hygiene strategies.

Procedures

All participants were seen individually at the Longwood University Speech and Hearing clinic one week prior to the start of their spring semester student internship. After obtaining informed consent, the pre-training questionnaire and voice recordings were taken. Next, students accessed the online training module in Canvas during their first week of internship. The participants completed the pre-training test and then proceeded to view the modules materials and video. The first author made follow-up weekly contact with the students through announcements and email to encourage them to implement the strategies they learned in the vocal hygiene training module. After 10 weeks, participants returned to the clinic for the post-training voice recordings, CAPE-V, and to complete the post-training questionnaire. At this time they also completed the online post-training test. This study is ongoing; therefore statistical analysis of group data were not performed due to the low sample size. Descriptive statistics were used to provide a preliminary snapshot of the feasibility of using an online training module embedded in students’ internship course as an easy and effective method of improving vocal health of student teachers of physical education.

RESULTS AND DISCUSSION

The results of the pre- and post-training tests are presented in Table 1. Overall there was a 36% increase in identification of factors that negatively affect voice after participating the online training module (pre-test = 36%; post-test=100%). Knowledge of factors that negatively affect the voice increased 34% (pre-test=32%, post-test=92%). Awareness of strategies to improve the voice increased from 8% to 80%.  At the post training, the overall test score average improved from 10/15 (66%) to 14/15 (93%). These data show that participants’ knowledge regarding voice issues improved as a result of the training module suggesting that participants learned and retained the information.

Table 1: Percentage of Pre- and Post- Test Scores for Three Content Areas

	Pre-Training	Post-Training
Knowledge of Vocal Hygiene (5 items)	36 %	100%
Knowledge of Factors Negatively Affecting Voice (5 items)	32%	92%
Vocal Strategies (5 items)	8%	80%
Total Test Score	53%	80%

The results of the pre- and post-training acoustic measures are presented in Table 2. For all of the acoustic measures, the values decreased suggesting a positive trend in voice quality. At the pre-training testing, participants’ voices were ratings on the CAPE-V ranged from mildly to moderately dysphonic (scores between 10/100 – 30/100). Following the training and at the end of their student teaching experience, these ratings decreased to the normal to mild range (0/10 to 10/100). 

Table 2: Acoustic Measures for Fundamental Frequency (Fo), Jitter, Shimmer, and CAPE-V Ratings for Pre- and Post-Training

Participant		Fo Hz	Jitter %	Shimmer %	Cape-V Rating
1	Pre- Post-	212 218	1.40 0.89	8.18 4.19	27/100 10/100
2	Pre- Post-	195 210	2.49 0.78	8.59 4.44	15/100 10/100
3	Pre- Post-	222 225	1.59 .089	8.12 5.63	30/100 8/100
4	Pre- Post-	200 230	0.63 0.77	5.37 3.88	10/100 10/100
5*	Pre- Post-	126 130	2.01 1.74	8.52 3.88	10/100 10/100
Note: * denotes male participant.

Date from the pre-and post-test questionnaire suggest that at the time of the pre-test, 17.4% did not recognize teachers as being at risk for vocal problems and 78.2% of participants felt that they had less than average knowledge of vocal hygiene. However, at the time of the post-test, 100% of participants reported awareness of voice issues related to teaching and strategies to avoid these problems. Furthermore, the participants reported that they considered vocal hygiene factors more often when they were preparing for teaching in the gymnasium or outside.  Participants were asked to rate the likelihood of implementing the vocal hygiene strategies in the future on a 5 point scale (0 = not likely; 5 = extremely likely). The average rating was 3.7 which is “very likely”.

Anecdotally the participants commented on their experiences in voice changes that they have had since entering their intern teaching experiences. Participants initially experienced voice-related symptoms such as hoarseness of voice, sore throats, vocal fatigue, and frequent throat clearing during their intern teaching experiences. Four of the five participants described their intentional behavioral changes during their teaching such as decreasing or altering communication during classes, using non-verbal physical cues, altering their pitch, and less “throat” projection and more “diaphragm” projection. The participants reported that previously they had experienced voice changes that impacted their performance in the gymnasium which they were now intentionally monitoring.

CONCLUSION

Overall, the participants were more cognizant of their own personal voice health and therefore, made intentional choices to execute the information learned in the methods classes as well as the module shared prior to their vocal testing. These findings suggest that physical educators should advocate for services that address the specific needs and requirements of those entering the teaching profession. Using a microphone necklace in the gymnasium and a megaphone when outside, may help to preserve vocal health. However, when not available, correct vocal techniques and recognition of early vocal strain and ways to avoid are also a necessary part of the physical education curriculum. Clear directives for the content and delivery of proper intervention strategies tailored to this specific population and their vocal health should be explored.

APPLICATION IN SPORT

In the future, teaching prospective Physical Educators how to project their voices in a proper manner is imperative in the methods courses of all universities. Teaching how to blow the whistle appropriately and using the diaphragm to project when speaking are as important as learning how to teach skills properly to PK–12 students. Every methods course should include voice health practices and management techniques, including non-verbal actions. Methods courses must also teach future Physical Educators to utilize whistles, music, and other modes of management signals in an appropriate and effective way instead of only their voices. This profession is considered high risk for voice-related disorders. By increasing awareness about healthy voice behavior in the teaching profession, teachers will improve their quality of work and minimize any permanent impairments and/or disabilities to their voice which ultimately may impact their livelihood.

ACKNOWLEDGMENTS

The authors would like to thank the following Longwood University Communication Disorders graduate students in their assistance in this research project: Stephanie Fields, Lauren McGonagle, Anna Powers, Hunter Reese, Seraphina Chabinec, Leah Horton, and Jayln Taylor.

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