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Treating the Disordered Professional Voice as a Repetitive Strain Injury

Treating the Disordered Professional Voice as a Repetitive Strain Injury
George Charpied
September 2, 2010



There is an increasing demand for treatment of the professional voice, which is the voice of professionals such as teachers, presenters, singers, actors, etc. The dysphonic professional voice, typically labeled vocal fatigue, might be referred to as a repetitive strain injury of the voice (RSIV). As defined by the World Health Organization, repetitive strain injury (RSI) occurs from doing the same demanding tasks day after day. RSI is the term:

Used to describe a set of musculoskeletal symptoms affecting a large number of people...who perform repetitive tasks over a prolonged period, [it occurs] most commonly in the hands, wrists, and arms although other areas may be affected depending on the type of work performed. RSI causes considerable pain and discomfort in the affected area....Over time [the] disability can become so severe that temporary or permanent cessation of employment results. (World Health Organization, 1994, p. 23)

RSIV has many similarities to injuries of other musculoskeletal injuries, but instead of the injury affecting the back, knee, wrist, or hearing, the strain affects the vocal foldsand perhaps articulationsof the larynx and its surrounding muscular suspensory framework. Professional voice dysphoniaor RSIVis no less real than repetitive strain injury derived from other work-related injuries. A patient's complaints of increasing effort to voice, change in pitch, pain or discomfort and vocal fatigue amounts to a repetitive strain injury of the voice. Speech-language-pathologists (SLPs) in the hospital setting are increasingly receiving referrals of patients who have vocal impairments of their professional voices. Regardless of the cause, these patients have a genuine disorder and need treatment (Colton and Casper, 1996; Gotaas and Starr, 1993; Stemple, Glaze, & Klaben, 2000).

The treatment needed is often simple, though sometimes complex, but always necessary as the voice of the professional affects their livelihood. SLPs have an obligation to care for these professionals who can be teachers in their prime who have developed severe vocal fatigue or hoarseness, or actors unable to perform at their highest level (Fritzell, 1996; Jones et al., 2002; Mann et al., 1999; McHenry and Carlson, 2004; Roy, Merrill, Thibeault, Gray, & Smith, 2004; Russell, Oates, & Greenwood 1998; Sala, Laine, Simberg, Pentti, & Suonpaa, 2001; Smith, Kirchner, Taylor, Hoffman, & Lemke 1998).

Unfortunately, there are barriers to the provision of high-quality treatment for the professional voice with RSIV. One barrier to intervention is that most graduate programs give short shrift to training vocal therapists. Graduate students coming out of academic and clinical fellowship training are typically left to their own devices to find their way to competencies in a chosen specialty. SLPs with only an introduction to voice disorders will be ill-prepared to recognize RSIV, much less treat it.

Another barrier is associated with the rise of otolaryngologists specializing in laryngopathology (i.e., laryngologists) and its treatment. SLPs are increasingly being asked to work with these medical partners at high levels of expertise. But the medical profession is also unclear on just what they are treating. Hence, SLPs must be prepared to provide explanations and definitions of RSIVwhat it is and what it is not.

Defining professional dysphonia as RSIV is a also major shift in thinkinga shift away from an array of classifications and typologies (Gotaas and Starr, 1993; National Institute on Deafness and Other Communication Disorders, 2008; Stemple et al., 2000), which seek to find commonalities without comprehending the nature of the disordered professional voice (Solomon and DiMattia, 2000). Although defining professional dysphonia as RSIV does not exclude the role of organic causes (Solomon and DiMattia), it places the origins of RSIV as a work environment that exposes the professional voice to risk (Vilkman, 2004). It places disabling musculoskeletal symptoms among the symptomatic triad of elevated phonation threshold pressure (PTP; Titze, 1988, 1992), irregular fundamental frequency often with associated glottal fry (McHenry and Carlson, 2004), and reports of increased effort (Jones et al., 2002; Roy et al., 2004; Russell et al., 1998). SLPs need to have a clear cut understanding of disorder entities to explain what they are working with and what they are treating. RSIV is no different. In the case of professional voice disorders, there isn't a clear-cut disease entity. Until now.

George Charpied

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