Voice therapy for adults - Caroline Bowen

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Voice therapy for adults
WITH VOCAL NODULES AND VOICE STRAIN
Copyright © 1998 Caroline Bowen

Cite this article as:
Bowen, C. (1998). Voice therapy for adults with vocal nodules and voice strain. Downloaded on (date) from www.speech-language-therapy.com/adult-voice-strain.htm

Causes of nodules and vocal strain
Voice strain and nodules are caused by stress to the vocal mechanism, the larynx, within which are the delicate vocal cords. This stress is generally referred to as "vocal abuse". It can include overuse of the cords such as: excessive talking, singing, whispering, coughing, loud sneezing, crying, laughing, throat-clearing, shouting, screaming, grunting, making funny sound-effects, and assuming voices or accents (e.g. imitating a "Big Bad Wolf voice" when reading children stories).

Any of the above ways of using the voice are more likely to strain the vocal cords or cause nodules if the speaker is unwell, under significant emotional stress, overtired, grieving, working too hard, having too little recreational time, or undergoing a period of major change (separation/divorce, re-entering the workforce, "empty nest" syndrome, moving house, changing jobs, and hormonal changes). Inefficient breathing patterns, poor nutrition, poor level of fitness, unhappiness, inter-personal problems, depression and anxiety will all contribute to voice and nodule formation.

All of the above factors will assume greater significance if the speaker has difficult speaking-environments to deal with, in terms of the size of the venue/s (e.g., over-large lecture theatre or hall with poor acoustics or inadequate amplification, smoky or otherwise dusty or polluted environments (e.g. cigarette smoke, chalk dust, petrol fumes, house or road dust), or noisy locations (e.g. venues near busy roads, car parks or railway lines). Outside lecturers in rural settings have particular problems associated with having to speak in the open air, often in dusty situations. This can apply to physical education teachers and coaches also, including swimming coaches working in noisy indoor heated pool areas.

Listener behaviour
The behaviour of the listener has an important bearing on voice use and abuse. For example, teachers and coaches can "condition" students or athletes to be unresponsive unless they are actually being shouted at! Similarly, teachers sometimes get into a habit of using a forced "stern" or "macho" voice which can strain the mechanism if used to excess. Having to address an unruly, disruptive or hostile class or audience on a regular basis stresses the voice directly and indirectly.

Initial symptoms
Once voice symptoms begin (e.g., in the form of a dry, scratchy throat or lack of volume) there is often a tendency to take medicated lozenges, mouth washes and gargles, and drying medications such as antihistamines. This adds insult to injury. So too, does "battling on" when you have a cold, the flu or other viral illness, or severe asthma or sinusitis - taking a mixture of patent and prescription medications and forcing yourself to continue working (at "work" and at home). Many voice problems would not develop if people rested and recuperated from common winter ailments.

Voices have people attached to them!
Realistically, most people cannot take time off work to repair damaged voices. The best that most of us can do is to be aware of the causative factors, and try to adopt better voice use as a way of life, within reasonable limits.

Eliminating vocal nodules
Vocal nodules are products of voice abuse. Absolute voice rest (not using the voice at all) is generally not necessary in eliminating them. It is generally only prescribed for people who seem to find it impossible to practise moderation. Some people find it easier not to speak at all, than to speak infrequently or softly. However, relative voice rest, to avoid further injury and facilitate healing is always beneficial. Vocal nodules resolve (disappear) with proper voice use, and should be treated with voice modification and relative voice rest which involved avoidance of the abusive activities identified by the speaker and the Speech-Language Pathologist.

PHASE 1
Relative voice rest
At its most extreme, relative voice rest involves an initial period of between 4 and 7 days using the voice no more than 15 minutes in each 24 hour period. It is normally undertaken with Speech Pathology supervision, once its advantages and disadvantages have been explored with the speaker.

PHASE 2
Minimising voice use & building personal resources
There is a famous adage invoice therapy circles which goes: "Don’t say a single word for which you are not being paid." This is usually a little excessive in Phase 2 - but it does communicate the goal of speaking no more than is absolutely necessary. This means being succinct when speaking, avoiding any loud use of the voice, keeping phone calls brief and avoiding all non-speech voice use (throat clearing, coughing, "voiced" sneezing, crying, "voiced" laughing, and odd sound-effects).

Warming up
Before using the voice professionally for speaking or singing, engage in a short warm-up period of controlled, soft, vocal exercises. Using optimal posture (straight but not stiff, balanced, with each breathing) do five minuted of gentle scales, or hum a favourite tune (using quiet full voice - i.e. not breathy voice), or sing a favourite song that does not have high and low notes at the extremes of your register. Practise the art of getting "into voice" - feeling the relaxed use of effective, almost effortless, efficient voice production. Think about economy of effort while speaking. Some speakers and singers do this in the car on the way to work. Before work, mentally run through the ways you can reduce work/voice stresses for that day.

Avoiding abusive environments
Avoid or modify internal (bodily and psychological) and external (environmental) voice-damaging environments as far as possible. If you cannot avoid them altogether - take a break every now and then. If the space your voice has to work in is too large, try to figure out a way to create a smaller space within it. Remember, that a large space is difficult for the listener too, and try to enlist their support and co-operation in improving the overall speaking and listening situation. Keep a supply of drinking water handy, and massage under your chin if your mouth becomes dry.

Optimising general health
Don’t "push" yourself when you are sick or tied or emotionally upset. Dehydration, fatigue and other general medical conditions have an effect on the mucosa covering the vocal cords, potentially altering lubrication and vocal efficiency. A good general level of mental and physical health and fitness, with good balance between work and leisure, is a key component of optimal vocal well being. Try not to have a "the show must go on" philosophy.

Cancel non-essential commitments
This is particularly important if you have a cold, persistent post nasal drip, cough, allergy attack or other such condition. The risk of severe vocal injury to an already troublesome vocal mechanism is never justified.

Use good voice production techniques
Gain your listeners’ attention before speaking, and:

1. Maintain optimal breathing patterns.
2. Speak relatively slowly.
3. Articulate clearly.
4. Speak in at a comfortable pitch level.
5. Speak at a comfortable loudness level.
6. Use pitch change, rather than loud volume, for emphasis.
7. Monitor posture (no hunched shoulders or curved spine).
8. Avoid monotonous delivery.
9. Watch out for muscle tension.

More articles on this site about
the voice and voice care

Tummy Trouble! Conditions that may affect the voice
http://www.speech-language-therapy.com/tummy.htm
Voice care for tour guides
http://www.speech-language-therapy.com/tourguides.htm
Voice therapy for pre-adolescents - Voice strain / vocal nodules
http://www.speech-language-therapy.com/teen-nodules.htm
Voice therapy for children (1) Voice strain / vocal nodules
http://www.speech-language-therapy.com/kidsnodules.html
Voice therapy for children (2) Signs, symptoms, causes, risk-factors
http://www.speech-language-therapy.com/kidsnodules-2.html
Voice: Something out of the Box
http://www.speech-language-therapy.com/webwords8.htm
Voice and Speech Anatomy
http://www.speech-language-therapy.com/anatomy.htm

Page updated 04 Feb 2010

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