Thursday, 24 March 2011 19:13


Written by
Rate this item
(0 votes)

The term singer applies to any person whose career, avocation or livelihood relies heavily on the use of his or her voice in a musical context rather than ordinary speech. Unlike percussionists, pianists or violinists, the singer is the instrument. Hence, the well-being of a singer depends not only on the health of his or her larynx (where the sound originates) or vocal tract (where the sound is modified), but also on proper functioning and maximal coordination of most mind and body systems.

Of the many styles of singing documented throughout the world, some reflect a unique liturgical, cultural, linguistic, ethnic or geo-political heritage, while others are more universal in nature. Among the common styles of singing in the United States and Western world are: traditional classical (including oratorio, opera, art songs and so on), barbershop, jazz, musical theatre (Broadway), choral, gospel, folk, country (and western), popular, rhythm and blues, rock ’n’ roll (including heavy metal, alternative rock and so on) and others. Each style of delivery has its typical settings, patterns, habits and associated risk factors.

Vocal Problems

Unlike non-singers, who may not be significantly hindered by vocal problems, for the classical singer, the effect of subtle vocal impairment can be devastating. Even within that category of trained singers, vocal impairment is much more debilitating for the higher voice classifications (sopranos and tenors) than for lower classifications (mezzo sopranos, altos, baritones and basses). On the other hand, some vocal performers (pop, gospel or rock, for example) go to great lengths to achieve a unique trademark and enhance their marketability by inducing vocal pathologies which often yield a breathy, husky, muffled diplophonic (simultaneous multiple pitches) quality. Owing, in part, to their impairment, they tend to sing with great effort, struggling particularly to produce the high notes. To many listeners, this struggle adds a dramatic effect, as if the singer is sacrificing his or her self while engaging in the artistic process.

The prevalence of occupation-related injuries in general, and voice disorders in particular, among singers is not well documented in the literature. This author estimates that on the average, between 10 and 20% of singers in the United States sustain some form of chronic voice disorder. However, the incidence of vocal injury varies significantly with many factors. Because many singers must adhere to specific artistic/aesthetic criteria, performance practices, popular (consumer) demands, financial constraints and social pressures, they often stretch their vocal capabilities and endurance to the limits. Furthermore, singers generally tend to deny, trivialize or ignore warning signs and even diagnoses of vocal injury (Bastian, Keidar and Verdolini-Marston 1990).

The most common problems among singers are benign mucosal disorders. The mucosa is the outer layer, or cover, of the vocal folds (commonly called vocal cords) (Zeitels 1995). Acute problems can include laryngitis and transient vocal fold swelling (oedema). Chronic mucosal lesions include vocal fold swellings, nodules (“calluses”), polyps, cysts, sub-mucosal haemorrhage (bleeding), capillary ectasia (widening), chronic laryngitis, leukoplakia (white spots or patches), mucosal tears and glottic sulci (deep furrows in the tissue). Although these disorders can be exacerbated by smoking and excessive alcohol consumption, it is important to note that these benign mucosal lesions are typically related to the amount and manner of voice use, and are the product of vibratory trauma (Bastian 1993).

Causes of Vocal Problems

In looking at the causes of vocal problems in singers, one should distinguish between intrinsic and extrinsic factors. Intrinsic factors are those related to personality, vocal behaviour (including speaking) on and off stage, vocal technique, and intake habits (primarily if substance abuse, improper medication, malnutrition and/or dehydration is involved). Extrinsic factors are related to environmental pollutants, allergies and so on. Based on clinical experience, intrinsic factors tend to be most important.

Vocal injury is usually a cumulative process of misuse and/or overuse during the singer’s productive (performance-related) and/or non-productive (domestic, social) activities. It is difficult to ascertain how much of the damage is attributable directly to the former versus the latter. Performance risk factors can include unreasonably long dress rehearsals requiring full-voice singing, performing with an upper-respiratory infection in the absence of a replacement and excessive singing. Most vocalists are advised not to sing for more than about 1.5 hours (net) per day. Unfortunately, many singers do not respect the limitations of their apparatus. Some tend to get caught up in the exploratory excitement of new technical skills, new means of artistic expression, new repertoire and so on, and practice 4, 5 or 6 hours daily. Even worse is the beating of the voice into shape when distress signals of injury (such as loss of high notes, inability to sing softly, breathy delay in sound initiation, unstable vibrato and increased phonatory effort) are manifested. The culpability of vocal overtaxing is shared with other taskmasters such as the booking agent who squeezes multiple performances into an impossible time frame, and the recording agent who leases the studio for 12 consecutive hours during which the singer is expected to record a complete CD sound track from start to finish.

Although every singer may encounter acute episodes of voice problems at some point in his or her career, it is generally believed that those singers who are musically literate and can adjust the musical score to their voice limitations, and those who have had proper voice training, are less likely to encounter severe problems of a chronic nature than their untrained peers, who often learn their repertoire by rote, repeatedly imitating or singing along with demo tapes or recordings of other performers. In doing so, they frequently sing in a key, range or style unsuitable for their voices. Singers who lend themselves to periodic tutelage and maintenance by proficient voice experts are less likely to resort to faulty compensatory vocal manoeuvres if confronted by physical impairment, and are more inclined to establish a reasonable balance between artistic demands and vocal longevity. A good teacher is aware of the normal (expected) capabilities of each instrument, can usually distinguish between technical and physical limitations, and often is the first to detect warning signs of vocal impairment.

Sound amplification can also create problems for singers. Many rock groups, for example, amplify not only the singer, but the entire band. When the noise level interferes with auditory feedback, the singer is often unaware that he or she is singing too loudly and using faulty technique. This may contribute significantly to the development and exacerbation of vocal pathology.

Non-performance factors can also be important. Singers must realize that they do not have separate laryngeal mechanisms for singing and speaking. Although most professional singers spend much more time talking than singing, speaking technique is commonly discarded or rejected, which can adversely affect their singing.

Many of today’s singers must travel regularly from one performance venue to another, on trains, tour buses or airplanes. Ongoing touring requires not only psychological adaptation, but also physical adjustments on many levels. In order for singers to function optimally, they must receive adequate quality and quantity of sleep. Radical rapid changes in time zones causes jet lag, which forces singers to remain awake and alert when their internal clock is cueing various body systems to shut down for sleep, and conversely, to sleep when their brain systems are aroused to plan and execute normal daytime activities. Such interruption may result in a host of debilitating symptoms, including chronic insomnia, headaches, sluggishness, dizziness, irritability and forgetfulness (Monk 1994). Aberrant sleep patterns are also a common problem among those singers who perform late at night. These abnormal sleep patterns are all too often mismanaged with alcohol or recreational, prescription or over-the-counter (OTC) drugs (most of which adversely affect the voice). Frequent and/or prolonged confinement to a closed cabin of a motor vehicle, train or aircraft may create additional problems. Inhalation of poorly filtered (often recycled), contaminated, dehumidified (dry) air (Feder 1984), according to many singers, can cause respiratory discomfort, tracheitis, bronchitis or laryngitis that may linger on for hours or even days following a trip.

Owing to environmental instability and hectic scheduling, many singers develop erratic, unhealthful eating habits. In addition to reliance on restaurant food and unpredictable changes in meal times, many singers eat the main meal of the day after their performance, usually late at night. Particularly for the overweight singer, and especially if spicy, greasy or acidic foods, alcohol or coffee were consumed, lying down soon after having filled the stomach is likely to result in gastroesophageal reflux. Reflux is the retrograde flow of acids from the stomach up the oesophagus and into the throat and larynx. The resulting symptoms can be devastating to the singer. Eating disorders are quite common among singers. In the operatic and classical realm, overeating and obesity are quite common. In the musical theatre and pop domain, particularly among young females, reportedly one-fifth of all singers have encountered some form of eating disorder, such as anorexia or bulimia. The latter involves various purging methods, of which vomiting is thought to be particularly hazardous to the voice.

A detrimental factor to voice production is exposure to pollutants, such as formaldehyde, solvents, paints and dusts, and allergens, such as tree, grass or weed pollens, dust, mould spores, animal danders and perfumes (Sataloff 1996). Such exposure may occur on and off stage. In their work milieu, singers can be exposed to these and other pollutants associated with vocal symptoms, including cigarette smoke and theatrical smoke and fog effects. Singers use a greater percentage of their vital capacity than ordinary speakers. Furthermore, during intense aerobic activity (such as dancing), the number of breathing cycles per minute increases, and mouth breathing prevails. This results in the inhalation of larger amounts of cigarette smoke and fogs during performances.

Treatment of Vocal Problems

Two major issues in the treatment of vocal problems of singers are self-medication and improper treatment by physicians who are not knowledgeable about the voice and its problems. Sataloff (1991, 1995) surveyed the potential side effects associated with medications commonly used by singers. Whether recreational, prescription, over the counter or food supplements, most drugs are likely to have some effect on phonatory function. In an attempt to control “allergies”, “phlegm” or “sinus congestion”, the self-medicating singer will ultimately ingest something that will damage the vocal system. Likewise, the physician who keeps prescribing steroids to reduce chronic inflammation caused by abusive vocal habits and ignores the underlying causes will eventually hurt the singer. Vocal dysfunction resulting from poorly indicated or ill-performed phonosurgery has been documented (Bastian 1996). To avoid injuries secondary to treatment, singers are advised to know their instruments, and consult only with health care professionals who understand and have experience and expertise managing the vocal problems of singers, and who possess the patience to educate and empower singers.



Read 1822 times Last modified on Wednesday, 29 June 2011 10:56
More in this category: « Musicians Performance Anxiety »

" DISCLAIMER: The ILO does not take responsibility for content presented on this web portal that is presented in any language other than English, which is the language used for the initial production and peer-review of original content. Certain statistics have not been updated since the production of the 4th edition of the Encyclopaedia (1998)."


Part I. The Body
Part II. Health Care
Part III. Management & Policy
Part IV. Tools and Approaches
Part V. Psychosocial and Organizational Factors
Part VI. General Hazards
Part VII. The Environment
Part VIII. Accidents and Safety Management
Part IX. Chemicals
Part X. Industries Based on Biological Resources
Part XI. Industries Based on Natural Resources
Part XII. Chemical Industries
Part XIII. Manufacturing Industries
Part XIV. Textile and Apparel Industries
Part XV. Transport Industries
Part XVI. Construction
Part XVII. Services and Trade
Education and Training Services
Emergency and Security Services
Entertainment and the Arts
Arts and Crafts
Performing and Media Arts
Entertainment and the Arts Resources
Health Care Facilities and Services
Hotels and Restaurants
Office and Retail Trades
Personal and Community Services
Public and Government Services
Transport Industry and Warehousing
Part XVIII. Guides

Entertainment and the Arts References

American Academy of Orthopedic Surgeons. 1991. Protective equipment. In Athletic Training and Sports Medicine. Park Ridge, IL: APOS.

Arheim, DD. 1986. Dance Injuries: Their Prevention and Care. St. Louis, MO: CV Mosby Co.

Armstrong, RA, P Neill, and R Mossop. 1988. Asthma induced by ivory dust: A new occupational cause. Thorax 43(9):737-738.

Axelsson, A and F Lindgren. 1981. Hearing in classical musicians. Acta Oto-Larynogologica 92 Suppl. 377:3-74.

Babin, A 1996. Orchestra pit sound level measurements in Broadway shows. Presented at the 26th Annual Meeting of the American Public Health Association. New York, 20 November.

Baker, EL, WA Peterson, JL Holtz, C Coleman, and PJ Landrigan. 1979. Subacute cadmium intoxication in jewellery workers: an evaluation of diagnostic procedures. Arch Environ Health 34:173-177.

Balafrej, A, J Bellakhdar, M El Haitem, and H Khadri. 1984. Paralysis due to glue in young apprentice shoemakers in the medina of Fez. Rev Pediatrie 20(1):43-47.

Ballesteros, M, CMA Zuniga, and OA Cardenas. 1983. Lead concentrations in the blood of children from pottery-making families exposed to lead salts in a Mexican village. B Pan Am Health Organ 17(1):35-41.

Bastian, RW. 1993. Benign mucosal and saccular disorders; benign laryngeal tumors. In Otolaryngology-Head and Neck Surgery, edited by CW Cumming. St. Louis, MO: CV Mosby Co.

—. 1996. Vocal fold microsurgery in singers. Journal of Voice 10(4):389-404

Bastian, R, A Keidar, and K Verdolini-Marston. 1990. Simple vocal tasks for detecting vocal fold swelling. Journal of Voice 4(2):172-183.

Bowling, A. 1989. Injuries to dancers: Prevalence, treatment and perception of causes. British Medical Journal 6675:731-734.

Bruno, PJ, WN Scott, and G Huie. 1995. Basketball. In The Team Physicians’s Handbook, edited by MB Mellion, WM Walsh and GL Shelton. Philadelphia, PA: Mosby Yearbook.

Burr, GA, TJ Van Gilder, DB Trout, TG Wilcox, and R Friscoll. 1994. Health Hazard Evaluation Report: Actors’ Equity Association/The League of American Theaters and Producers, Inc. Doc. HETA 90-355-2449. Cincinnati, OH: US National Institute for Occupational Safety and Health.

Calabrese, LH, DT Kirkendal, and M Floyd. 1983. Menstrual abnormalities, nutritional patterns and body composition in female classical ballet dancers. Phys Sports Med 11:86-98.

Cardullo, AC, AM Ruszkowski, and VA DeLeo. 1989. Allergic contact dermatitis resulting from sensitivity to citrus peel, geriniol, and citral. J Am Acad Dermatol 21(2):395-397.

Carlson, T. 1989. Lights! Camera! Tragedy. TV Guide (26 August):8-11.

Chasin, M and JP Chong. 1992. A clinically efficient hearing protection program for musicians. Med Prob Perform Artists 7(2):40-43.

—. 1995. Four environmental techniques to reduce the effect of music exposure on hearing. Med Prob Perform Artists 10(2):66-69.

Chaterjee, M. 1990. Ready-made garment workers in Ahmedabad. B Occup Health Safety 19:2-5.

Clare, PR. 1990. Football. In The Team Physicians’s Handbook, edited by MB Mellion, WM Walsh, and GL Shelton. St. Louis, MO: CV Mosby Co.

Cornell, C. 1988. Potters, lead and health—Occupational safety in a Mexican village (meeting abstract). Abstr Pap Am Chem S 196:14.

Council on Scientific Affairs of the American Medical Association. 1983. Brain injury in boxing. JAMA 249:254-257.

Das, PK, KP Shukla, and FG Ory. 1992. An occupational health programme for adults and children in the carpet weaving industry, Mirzapur, India: A case study in the informal sector. Soc Sci Med 35(10):1293-1302.

Delacoste, F and P Alexander. 1987. Sex Work: Writings by Women in the Sex Industry. San Francisco, CA: Cleis Press.

Depue, RH and BT Kagey. 1985. A proportionate mortality study of the acting profession. Am J Ind Med 8:57-66.

Dominguez, R, JR DeJuanes Paardo, M Garcia Padros, and F Rodriguez Artalejo. 1987. Antitetanic vaccination in a high-risk population. Med Segur Trab 34:50-56.

Driscoll, RJ, WJ Mulligan, D Schultz, and A Candelaria. 1988. Malignant mesothelioma: a cluster in a Native American population. New Engl J Med 318:1437-1438.

Estébanez, P, K Fitch, and Nájera 1993. HIV and female sex workers. Bull WHO 71(3/4):397-412.

Evans, RW, RI Evans, S Carjaval, and S Perry. 1996. A survey of injuries among Broadway performers. Am J Public Health 86:77-80.

Feder, RJ. 1984. The professional voice and airline flight. Otolaryngology-Head and Neck Surgery, 92(3):251-254.

Feldman, R and T Sedman. 1975. Hobbyists working with lead. New Engl J Med 292:929.

Fishbein, M. 1988. Medical problems among ICSOM musicians. Med Prob Perform Artists 3:1-14.

Fisher, AA. 1976. “Blackjack disease” and other chromate puzzles. Cutis 18(1):21-22.

Frye, HJH. 1986. Incidence of overuse syndrome in the symphony orchestra. Med Prob Perform Artists 1:51-55.

Garrick, JM. 1977. The frequency of injury, mechanism of injury and epidemiology of ankle sprains. Am J Sports Med 5:241-242.

Griffin, R, KD Peterson, J Halseth, and B Reynolds. 1989. Radiographic study of elbow injuries in professional rodeo cowboys. Phys Sports Med 17:85-96.

Hamilton, LH and WG Hamilton. 1991. Classical ballet: Balancing the costs of artistry and athleticism. Med Prob Perform Artists 6:39-44.

Hamilton, WG. 1988. Foot and ankle injuries in dancers. In Sports Clinics of North America, edited by L Yokum. Philadelphia, PA: Williams and Wilkins.

Hardaker, WTJ. 1987. Medical considerations in dance training for children. Am Fam Phys 35(5):93-99.

Henao, S. 1994. Health Conditions of Latin American Workers. Washington, DC: American Public Health Association.

Huie, G and EB Hershman. 1994. The team clinician’s bag. Am Acad Phys Asst 7:403-405.

Huie, G and WN Scott. 1995. Assessment of ankle sprains in athletes. Phys Assist J 19(10):23-24.

Kipen, HM and Y Lerman. 1986. Respiratory abnormalities among photographic developers: A report of 3 cases. Am J Ind Med 9:341-347.

Knishkowy, B and EL Baker. 1986. Transmission of occupational disease to family contacts. Am J Ind Med 9:543-550.

Koplan, JP, AV Wells, HJP Diggory, EL Baker, and J Liddle. 1977. Lead absorption in a community of potters in Barbados. Int J Epidemiol 6:225-229.

Malhotra, HL. 1984. Fire safety in assembly buildings. Fire Safety J 7(3):285-291.

Maloy, E. 1978. Projection booth safety: New findings and new dangers. Int Assoc Electr Inspect News 50(4):20-21.

McCann, M. 1989. 5 dead in movie heliocopter crash. Art Hazards News 12:1.

—. 1991. Lights! Camera! Safety! A Health and Safety Manual for Motion Picture and Television Production. New York: Center for Safety in the Arts.

—. 1992a. Artist Beware. New York: Lyons and Burford.

—. 1992b. Art Safety Procedures: A Health and Safety Manual for Art Schools and Art Departments. New York: Center for Safety in the Arts.

—. 1996. Hazards in cottage industries in developing countries. Am J Ind Med 30:125-129.

McCann, M, N Hall, R Klarnet, and PA Peltz. 1986. Reproductive hazards in the arts and crafts. Presented at the Annual Conference of the Society for Occupational and Environmental Health Conference on Reproductive Hazards in the Environment and Workplace, Bethesda, MD, 26 April.

Miller, AB, DT Silverman, and A Blair. 1986. Cancer risk among artistic painters. Am J Ind Med 9:281-287.

MMWR. 1982. Chromium sensitization in an artist’s workshop. Morb Mort Weekly Rep 31:111.

—. 1996. Bull riding-related brain and spinal cord injuries—Louisiana, 1994-1995. Morb and Mort Weekly Rep 45:3-5.

Monk, TH. 1994. Circadian rhythms in subjective activation, mood, and performance efficiency. In Principles and Practice of Sleep Medicine, 2nd edition, edited by M. Kryger and WC. Roth. Philadelphia, PA: WB Saunders.

National Institute for Occupational Safety and Health (NIOSH). 1991. Environmental Tobacco Smoke in the Workplace: NIOSH Current Intelligence Bulletin 54. Cincinnati, OH: NIOSH.

Norris, RN. 1990. Physical disorders of visual artists. Art Hazards News 13(2):1.

Nubé, J. 1995. Beta Blockers and Performing Musicians. Doctoral thesis. Amsterdam: University of Amsterdam.

O’Donoghue, DH. 1950. Surgical treatment of fresh injuries to major ligaments of the knee. J Bone Joint Surg 32:721-738.

Olkinuora, M. 1984. Alcoholism and occupation. Scand J Work Environ Health 10(6):511-515.

—. 1976. Injuries to the knee. In Treatment of Injuries to Athletes, edited by DH O’Donoghue. Philadelphia, PA: WB Saunders.

Pan American Health Organization, (PAHO). 1994. Health Conditions in the Americas. Vol. 1. Washington, DC: PAHO.

Pheterson, G. 1989. The Vindication of the Rights of Whores. Seattle, WA: Seal Press.

Prockup, L. 1978. Neuropathy in an artist. Hosp Pract (November):89.

Qualley, CA. 1986. Safety in the Artroom. Worcester, MA: Davis Publications.

Ramakrishna, RS, P Muthuthamby, RR Brooks, and DE Ryan. 1982. Blood lead levels in Sri Lankan families recovering gold and silver from jewellers’ waste. Arch Environ Health 37(2):118-120.

Ramazzini, B. 1713. De morbis artificum (Diseases of Workers). Chicago, IL: University of Chicago Press.

Rastogi, SK, BN Gupta, H Chandra, N Mathur, PN Mahendra, and T Husain. 1991. A study of the prevalence of respiratory morbidity among agate workers. Int Arch Occup Environ Health 63(1):21-26.

Rossol, M. 1994. The Artist’s Complete Health and Safety Guide. New York: Allworth Press.

Sachare, A.(ed.). 1994a. Rule #2. Section IIC. In The Official NBA Basketball Encyclopedia. New York: Villard Books.

—. 1994b. Basic Principle P: Guidelines for infection control. In The Official NBA Basketball Encyclopedia. New York: Villard Books.

Sammarco, GJ. 1982. The foot and ankle in classical ballet and modern dance. In Disorders of the Foot, edited by MH Jahss. Philadelphia, PA: WB Saunders.

Sataloff, RT. 1991. Professional Voice: The Science and Art of Clinical Care. New York: Raven Press.

—. 1995. Medications and their effect on the voice. Journal of Singing 52(1):47-52.

—. 1996. Pollution: Consequences for singers. Journal of Singing 52(3):59-64.

Schall, EL, CH Powell, GA Gellin, and MM Key. 1969. Hazards to go-go dancers to exposures to “black” light from fluorescent bulbs. Am Ind Hyg Assoc J 30:413-416.

Schnitt, JM and D Schnitt. 1987. Psychological aspects of dance. In The Science of Dance Training, edited by P Clarkson and M Skrinar. Champaign, IL: Human Kinetics Press.

Seals, J. 1987. Dance surfaces. In Dance Medicine: A Comprehensive Guide, edited by A Ryan and RE Stephens. Chicago, IL: Pluribus Press.

Sofue, I, Y Yamamura, K Ando, M Iida, and T Takayanagi. 1968. N-hexane polyneuropathy. Clin Neurol 8:393-403.

Stewart, R and C Hake. 1976. Paint remover hazard. JAMA 235:398.

Tan, TC, HC Tsang, and LL Wong. 1990. Noise surveys in discotheques in Hong Kong. Ind Health 28(1):37-40.

Teitz, C, RM Harrington, and H Wiley. 1985. Pressure on the foot in point shoes. Foot Ankle 5:216-221.

VanderGriend, RA, FH Savoie, and JL Hughes. 1991. Fracture of the ankle. In Rockwood and Green’s Fractures in Adults, edited by CA Rockwood, DP Green, and RW Bucholz. Philadelphia, PA: JB Lippincott Co.

Warren, M, J Brooks-Gunn, and L Hamilton. 1986. Scoliosis and fracture in young ballet dancers: Relationship to delayed menarcheal age and amenorrhea. New Engl J Med 314:1338-1353.

World Health Organization (WHO). 1976. Meeting on Organization of Health Care in Small Industries. Geneva: WHO.

Zeitels, S. 1995. Premalignant epithelium and microinvasive cancer of the vocal fold: the evolution of phonomicrosurgical management. Laryngoscope 105(3):1-51.