We are pleased to welcome Brian E. Petty, M.A., CCC-SLP, as our guest host
for the SLP chat tonight, Monday, April 7, 2003. He will be addressing the
topic of Voice Disorders and The Professional Singer.

Brian Petty, M.A., CCC-SLP, holds graduate degrees in Voice/Opera Pedagogy
and in Speech and Hearing Science from Ohio State University. He is happily
employed as Clinical Speech Pathologist and Singing Voice Specialist at the
University of Wisconsin Hospital and Clinics in Madison, Wisconsin.  Brian
maintains an active performance schedule as a lyric baritone, with recent
performances with the Dale Warland Singers, the Chicago Symphony's Ravinia
Festival, and the St. Paul Chamber Orchestra.  Recent recording projects have
been broadcast on National Public Radio.  Brian was also recently a panelist
at the National Opera Association national convention in Washington, DC.

<Robin> Welcome!  We are chatting tonight with Brian E. Petty, M.A., CCC-SLP, about the
          topic of Voice Disorders and The Professional Singer.
<Robin> Brian, please start us off with some general information about voice disorders
          and the professional singer.
<BrianPetty> Great idea Robin.  First, how many are already familiar with voice
<Krista> We don't have a voice disorders class until graduate school, but I have a basic
<casey> At a basic level
<Maura> I am in a graduate voice disorder class now.
<Adrienne> I have taken a voice disorders class.
<ajoh> Basic level
<Adrienne> Had 2 voice clients, neither were professional singers.
<GL> I worked for 15 years with singers cantors and dysphonias...in a different country.
<BrianPetty> GL, Excellent.  Thats a very difficult job for a singer.
<Maura> What is the most common voice disorder in professional singers?
<BrianPetty> I don't think that there is any one common voice disorder most common in
          professional singers, but hyperfunctional disorders and pathologies related to
          vocal hygiene and reflux are very common...
<Maura> Thank you for your answer.
<JLRP> Why reflux?
<BrianPetty> JLRP, acid reflux is quite a difficult thing for singers.  It causes edema
          and redness on the vocal folds, which makes them more stiff and less pliable.
          This causes problems with vocal range and flexibility, hoarseness, and breath
          management. The effects can be somewhat minor when approached from the perspective
          of the normal population, but can be debilitating in professional singers whose
          careers demand exceptional voice quality.
<Robin> What causes the reflux?
<BrianPetty> Reflux is often caused by a number of behaviors...
<BrianPetty> Diet is a big one, as is the time at which a singer eats...
<BrianPetty> Many MDs recommend not eating prior to a performance, however some singers
          claim that they need the extra energy.   Also, there have been some recent studies
          that show that prolonged singing is an exacerbating factor for reflux.
<Robin> Also, one should not eat right before going to sleep at night, true?
<BrianPetty> Yes exactly.  It's recommended to wait at least 3-4 hours before going to
<GL> Pillows are very useful...
<BrianPetty> GL, yes, pillows can be helpful.  However, it's best to raise the head of
          the bed from the frame, so that the body isn't bending at the waist.
<BrianPetty> Foods that can exacerbate reflux include fried/spicy food, tomatoes, citrus,
          chocolate, mints, nuts, caffeine, alcohol, and carbonation.
<Maura> When you talk about hyperfunctional voice disorders, are we talking mainly
          nodules and polyps?
<BrianPetty> Maura, yes nodules are common.
<BrianPetty> However cysts can also be common as well.  Any hyperfunctional etiology is
          quite common, mostly due to speaking technique rather than singing technique.
<Robin> So most of the hyperfunctional behaviors are with the speaking voice and not the
          singing voice?
<BrianPetty> Yes, it seems that the carefully cultivated singing technique is often not
          used during speaking behavior.  The front placement that is the goal of resonant
          voice therapy is often easily achieved by a singer, but difficult to carry over
          to unstructured everyday conversation.
<casey> What is "front placement" ?
<BrianPetty> Casey, good question.  "Front placement" is another term for balanced oral
          and nasal resonance.  You can feel it while you're humming... the buzzy feeling in
          the nose, cheekbones, and mouth.  It facilitates more power with less effort...
<Adrienne> Sometimes it's called "forward focus"?
<BrianPetty> Yes, it's the same concept Adrienne.
<casey> So, how do you teach a singer to carryover front placement while speaking and
          in turn reduce the voice disorder?
<BrianPetty> It's interesting, it's the same as with other clients.  Progressively
          longer periods of connected speech.  It's just that the singer is often more
          motivated and progresses faster.
<GL> By my experience, singers are very good with drills...but they want to understand
<GL> You know, many singers tend to put scarfs on their throats to keep their vocal-cords
          warm...what's your opinion?
<BrianPetty> GL, scarves are good for keeping the neck warm, but that shouldn't be
          considered a substitute for vocal warmup and cooldown. It's very important to keep
          in mind the difference between a "warm neck" and a "warmed-up voice".  They're
          totally different concepts.  Vocal warmups are exercises designed to increase
          circulation and pliability of the vocal folds, as well as "calibrate" the instrument.
          It's not just "warm", it's "warmed up".
<phatmom> Do you see a great number of voice problems with professional singers? I always
          felt that they would have a trained voice and know how not to abuse it.
<BrianPetty> Phatmom, you'd think that would be true.  Even the operatic singer can have
          habits in their speaking voice that can prove detrimental.  It's about making
          them aware.  They often don't make the connection that it's all the same
<Robin> Tell us about the vocal warm ups and cooldown and their importance.
<ajoh> Yes, I'd always heard about the importance of warmups, but never cooldowns.
<BrianPetty> About warmups and cooldowns...
<BrianPetty> We've heard of warmups, to get blood flow going and stretch and condition
<BrianPetty> but cooldowns are just as important.  They help to dissipate lactic acid,
          which can cause a sensation of vocal fatigue.
<ajoh> Are cooldowns similar to warmups, or a different technique?
<BrianPetty> Ajoh, cooldowns are often similar to warmups... easy glides, tongue/lip
          trills, humming.  But it's important not to use vocal warmups and cooldowns as a
          cookbook technique.  They are used in specific individuals for specific reasons.
          Before assigning an exercise, you need to know why you've chosen that specific
          exercise and what its goals/effects are.  Dr. Ingo Titze wrote a great short
          article for The Journal of Singing that outlines his favorite vocal warmups.
          I agree with him wholeheartedly.  You can see that article at the website,
<ajoh> Thanks.
<phatmom> I thought if they used their diaphram and projected their voice properly they
          would be ok. Do you see many professional singers getting voice problems due to
          trying to change the pitch of their voice? I have often felt many SLPs are very
          afraid to try and change the pitch of voice even if it is inappropriate for age,
          sex and size.
<BrianPetty> Phatmom, I don't see a lot of singers trying to change their voice in
          that way... sometimes I see a tenor trying to sing bass, or other issues to that
          effect.  Occasionally you'll see an amateur choral singer who will sing parts that
          are not suited for him/her.  It's important to encourage them to sing the part that
          fits their voice naturally and let the director worry about the fact that the choir
          "has no tenors".
<phatmom> I think many otolaryngologists are also leary of having patients pitch changed.
<GL> BY THE WAY ....who is sending you singers for treatments???  ENT???
<BrianPetty> ENT does generally refer the singers.  Singers generally know to go to
          their ENT first.
<GL> What about nutrition??  drinks???
<BrianPetty> Nutrition is important as it is for everyone, but perhaps more for the
          travelling performer.  It's easy to get sucked into the fast-food cycle, but to
          keep the stamina needed for a tour it's important to eat in a healthy way.
<ajoh> I remember hearing about orange juice and honey.  Any comments on that, Brian?
<BrianPetty> I would advise against lots of orange juice, in that it can exacerbate acid
          reflux.  Honey is soothing to the oropharynx, but does little to affect the vocal
          folds.  I would recommend increased hydration (both systemic and topical hydration)
          over honey supplements.  You might check with your allergist about honey, though,
          because I seem to recall that people with allergies sometimes benefit from taking
          honey that is produced in their immediate area.  I can't say that's the gospel truth
          or give you a reference, but it might be worth a quick question to your allergist
          on that.
<gayle> Brian, which disorders are more prevalent among opera singers?  pop singers? 
          gospel singers?
<BrianPetty> Opera, pop, and gospel are distinct types of singing, but the instrument is the
          same.  Any type of hyperfunction can cause the hyperfunctional voice disorders that
          we talked about earlier.  Opera singers tend to be more trained than pop or gospel
          artists, and have the skills to adjust their technique to varying health and                     
          environmental conditions.  Pop and gospel artists don't often have that training,
          and develop hyperfunctional disorders as a result.  Also, gospel in particular has
          a tendency to facilitate supraglottic hyperfunction.  The question is how does a
          gospel or pop artist decrease hyperfunction while still maintaining the performance
          practices and vocal qualities that distinguish their art form from classical singing?
          It's frequently a balancing act, and requires dedication and excellent monitoring by
          the speech pathologist and by the singer him/herself.
<phatmom> What are common speech complaints of singers?
<BrianPetty> There are no specific "common complaints", as the patient's complaint is related
          closely to his/her disorder.  There are as many different presentations of the
          complaint as there are singers in the world.  The key is not to expect a rote list
          of complaints, but to listen carefully to the singer's description of what is going
          on with his/her voice.  The singer is a patient who is exquisitely sensitive to
          his/her own body and voice, and will describe the sensation in great detail.  Our
          job is to help the singer interpret these symptoms.
<Robin> Which voice disorders due you usually seen in singers?
<BrianPetty> I do see that singers suffer from nodules and cysts, as well as edema and
          irritation from reflux.  Those seem to be the most common maladies at least in
          our clinic.
<gayle> Brian, what's the typical treatment term?
<BrianPetty> Gayle, for most trained singers, I would give treatment duration between
          4-6 sessions if they are in the area.
<BrianPetty> It's different for touring singers, though.
<Robin> How can there be effective treatment for someone who is touring?
<BrianPetty> Robin, that's a tough issue.  Many touring performers, particularly rock
          singers or untrained vocalists, just want to know if they can sing that night.
          It's important to schedule enough time to be able to do some therapy, create a
          home practice program, and do some education while they are there.  Some singers
          benefit greatly from the speech pathologist being on-site in rehearsal or
          performance, and this certainly is helpful when the goal is to carry over skills
          to functional use.  If the performer is touring, the time is very limited. 
          Sometimes a singer will be able to attend a "vocal boot camp" concept, with 2-4
          sessions daily.  This "crash course" is great for increasing awareness and allowing
          for focused practice and treatment.  It's particularly effective when used in a
          team-treatment approach, assuming that there are 2-3 voice specialists on your staff.
<phatmom> What is the current tx for vocal nodules? I remember it used to be to do
          nothing for the school-aged child.
<phatmom> In 1982 tx was recommended for school-aged children and many programs could
          be used, however in 1985 tx changed and it was felt that the tx of choice was
          to do nothing.
<BrianPetty> Phatmom, I don't believe in doing nothing for the school age child... but
          for singers the treatment for nodules lies in identifying the behavior that
          caused them.
<Robin> Brian, what types of things do you do in therapy with the singers?
<BrianPetty> Robin, I start by doing some basic warmup exercises, and seeing what their
          current protocol is like...
<BrianPetty> Some singers warm up FAR too much, and some not at all... some others sing
          exercises but don't know what they do.  The goal is to create a protocol they
          can use that makes best use of their limited time.
<BrianPetty> Then, assuming that there is a misuse behavior in their speaking voice,
          I use either structured or unstructured therapy tasks to increase self-awareness
          of that pattern.
<BrianPetty> This is easier in patients who have had voice training... with untrained
          singers I'll take time to focus on the front focus aspect a little more.
<phatmom> Can you ever see tense neck/laryngeal muscles and give relaxation exercises
          that can be performed while the singer is touring?
<casey> How about relaxation exercises?
<BrianPetty> Casey and Phatmom, yes, relaxation exercises, yoga-based stretches for the
          neck/back/shoulders... all are great for releasing tension and helping to
          maximize performance.
<phatmom> How about the effects of drug and alcohol on the voice? Do you advise to
          limit intake of these substances?
<BrianPetty> Alcohol has a demonstrated drying effect on the voice and should be
          avoided if possible....Its also a significant exacerbator of reflux.
          I'm assuming that you mean prescription drugs.
<BrianPetty> There is a wonderful resource at www.ncvs.org that lists common prescribed
          drugs and their vocal effects... I'd recommend printing it out.  I did!
<uwaj> Thanks for the link
<GL> I worked a great deal with religious singers....cantors...they seem to have much
          more problems than the usual singer...what's your opinion?
BrianPetty> GL, regarding your question about cantors, I'm not sure.  I don't think
          that the literature is so different from other sacred or classical lit, but
          perhaps the training for cantors focuses less on the vocal aspect and more on
          the spiritual side.
<BrianPetty> They also have a very tough schedule, so fatigue could play a factor too.
<GL> Do you recommend treatment as well as Botox for singers???
<BrianPetty> GL, I have not seen a professional singer with Spastic Dysphonia (SD), but
          botox may be indicated.  It would be a balancing act between the hypofunction
          caused by the toxin and the hyperfunction caused by the SD.
<BrianPetty> just a guess...
<phatmom> Do you ever see voice quality problems such as a hoarse voice? If you see a
          singer consistently getting hoarse due to vocal abuse, this sounds bad but if
          they had an untrained voice would it be a good recommendation to prescribe
          singing/voice lessons?
<phatmom> Professional singing lessons which teach a singer how to use their voice,
          projection, breathing etc...
<BrianPetty> Phatmom brings up a good point...
<BrianPetty> Singing lessons.
<BrianPetty> Singing teachers are not regulated, and there are no set guidelines for
          training.  That said, there are many wonderfully knowledgeable teachers out
          there who would love to work in conjunction with the SLP.  I would be sure that
          you know and are comfortable with their pedagogical technique before referring. 
          Also, be careful that the teacher isn't working on things that are in the SLP
          realm and vice versa.
<BrianPetty> It takes a lot of knowledge and collaboration to make that partnership
          work for the patient.
<GL> I was surprised to hear that in the USA today you don't tend to do Pushing
          exercises for an open glottis...why is that???
<BrianPetty> GL, do you mean vocal folds that are paralyzed?
<casey> GL, what are you referring to?
<GL> Vocal cords that are weak...paresis...
<BrianPetty> GL, are you referring specifically to singers with bialteral vocal fold
          paresis?  In that instance I would refer to laryngology and perhaps to
          neurology.  It's very rare to see that bilaterally.
<GL> What about unilateral???
<casey> Brian, do you know of any literature that is against vocal adduction exercises?
<BrianPetty> Pushing drills in and of themselves are of benefit in some cases, but
          should be used carefully.  Singers, particularly less trained, may develop
          hyperfunctional patterns which may be difficult to deal with.
<phatmom> I think it would be a very rare thing to have a paralyzed vocal cord bilateral
          or unilateral in a singer.
<BrianPetty> Phatmom, it's not so rare.  Some singers, who may have had cardiac surgery
          for example, could easily experience damage to the Recurrent Laryngeal Nerve
          (RLN) which would result in paresis or paralysis.
<Robin> Brian, an SLP in the middle east wrote to us with a question about choral singers.
<BrianPetty> Yes, Robin?
<Robin> She would like to share voice tips for care of the singing voice with her fellow
          singers.  She also wondered why in her trainings in the choir most of the singers
          get a headache during the warm up exercises.
<gayle> Please elaborate on the choral singer.  I have heard of people getting lightheaded.
<BrianPetty> Okay let's talk about choral singers for a moment...
<BrianPetty> Think of the singer as a vocal athlete...
<BrianPetty> Other than a few quick calisthenics, can you think of other athletes that warm
          up by everyone doing the exact same drill at the same time?
<BrianPetty> Most athletes warm up individually for a while... as do symphony musicians for
<gayle> Good point, Brian
<phatmom> Football players have gruelling workouts!
<GL> The warm-up headache is due to exessive abdominal breathing....
<BrianPetty> GL that's a possibility, but I wouldn't state that as THE cause until I knew
          what exactly what was happening... "headache" means different things to different
          people.  We also don't know what warmups are being used.  Because there are no                    
          regulatory standards for choral conductors, he/she could be using inappropriate
          warmup patterns that cause excess tension and/or a "forced" voice quality that
          could cause discomfort.  We just don't know.  This is a good illustration of why
          it is rarely appropriate to provide speech pathology services, particularly voice
          services, from a remote location.
<BrianPetty> The choral warm up by its nature cannot address individual variation in need...
          that's why choral singers benefit so much from individual attention to establish
          self-warmup procedures as well as self-monitoring and mindfulness.
<GL> Brian do you recommend Appoggio technique to choir singers???
<BrianPetty> GL, yes yes yes!  Appoggio, a great product of Italianate vocal pedagogy, is
          I think the best way to teach breath support.  Refer to the work of Richard Miller
          for more information and a description of Appoggio.
<BrianPetty> Appoggio is the sensation of resistance during effective singing support, felt
          at the base of the sternum......
<BrianPetty> I liken it to the feeling you get when you release the clutch and press the gas
          on a standard transmission... that resistance... it's a great way to think of breath
          support during singing...
<GL> Appoggio is abdominal breath support with a lot of air in the upper chest...the singer
          then releases the air GRADUALLY by using his chest muscles WHILE holding the
          abdominal support......
<GL> It is very useful when you have to sing a long line without breathing again....
<BrianPetty> I think it's very important to be careful when discussing Appoggio in a group
          of SLPs.  It's a technique used in vocal pedagogy, and should only be taught by a
          trained voice teacher.  GL's description of Appoggio, focusing on using the chest
          muscles, can easily result in a hyperfunctional clavicular breathing pattern if not
          taught carefully and with expertise.  There are very few SLPs with the background
          to teach singing.  If you're not a trained singing teacher, I would allow the
          patient's current singing teacher to address it.
<Robin> Thank you for bring up that point, Brian.
<BrianPetty> Wow, we could go on and on.... for hours... great discussion!!!
<Robin> Brian, we really appreciate you sharing your expertise with us. Do you have any
          other references to share with us?
<BrianPetty> A useful reference is Dr. Robert Sataloff's wonderful text, "Professional
          Voice: The Science and Art of Clinical Care". 
<BrianPetty> Thanks so much for having me tonight.
<Robin> Thanks everyone for being here.
<BrianPetty> Thanks everybody!!!
<Adrienne> You've been so helpful tonight Brian!  Thanks for coming!
<BrianPetty> Thanks Adrienne!
<phatmom> Thanks Brian for the chat!
<BrianPetty> Thanks phatmom!
<uwaj> Thank you
<gayle> Thank you again, Brian.
<GL> Thank you very much Brian...a pleasure
<BrianPetty> Good night all.... happy singing. 

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