Proposals to promote health and prevent voice disorders in occupational voice users: A scoping review

Martins, Glauciene Amaral; Saito, Isabele Tiemi; Viegas, Flávia; Simões-Zenari, Marcia; Nemr, Katia

doi:10.1590/1982-0216/202426111022

Glauciene Amaral Martins

Study conceptualization and project

Data collection, analysis, and interpretation

Manuscript writing

Critical review

Final approval of the version presented for publication

Participation in the necessary adjustments for publication

Universidade de São Paulo - USP, Faculdade de Medicina, Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, São Paulo, São Paulo, Brasil.

https://orcid.org/0000-0001-9435-8078

Isabele Tiemi Saito

Data collection

Analysis

Interpretation

Participation in manuscript writing

Critical review

Final approval of the version presented for publication

Universidade de São Paulo - USP, Faculdade de Medicina, Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, São Paulo, São Paulo, Brasil.

https://orcid.org/0000-0002-9290-954X

Flávia Viegas

Participation in manuscript writing

Critical review

Final approval of the version presented for publication

Participation in the necessary adjustments for publication

Universidade Federal Fluminense - UFF, Instituto de Saúde de Nova Friburgo, Departamento de Formação Específica em Fonoaudiologia, Nova Friburgo, Rio de Janeiro, Brasil.

https://orcid.org/0000-0003-1993-8288

Marcia Simões-Zenari

Participation in study conceptualization and project

Participation in manuscript writing

Critical review

Final approval of the version presented for publication

Support and participation in the necessary adjustments for publication

Submission to the journal and follow-up on the submission

Universidade de São Paulo - USP, Faculdade de Medicina, Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, São Paulo, São Paulo, Brasil.

https://orcid.org/0000-0003-0505-6655

Katia Nemr

Study conceptualization and project

Supervision of the development of the article

Critical review

Final approval of the version presented for publication

Distribution of tasks for the necessary adjustments for publication

Universidade de São Paulo - USP, Faculdade de Medicina, Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, São Paulo, São Paulo, Brasil.

https://orcid.org/0000-0002-8662-2702

Corresponding author: Marcia Simões-Zenari, Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina, Universidade de São Paulo - USP, Rua Cipotânea, 51, Cidade Universitária, CEP: 05360-000 - São Paulo, São Paulo, Brasil, E-mail: marciasz@usp.br

Conflict of interests: Nonexistent.

	Inclusion criteria
Population	Occupational voice users who were not undergoing treatment for vocal problems simultaneously with the prevention proposal.
Concept	Proposals for dysphonia prevention or health promotion focused on professional voices, carried out in groups or individually, directly or indirectly, with high or low technology resources.
Context	Studies that described the proposal and evaluated it using some tool - e.g., self-perception analysis, quality of life or voice before and after applying the proposal, and comparison of different groups.
Types of sources of evidence	Electronic databases containing peer-reviewed journals covering national and international publications published since 2010.

Sample number			Participants per sex*				Mean time of activity (years)**		Participants with vocal changes
Mean	Minimum	Maximum	Females		Males		Minimum	Maximum	No	Yes	Not specified
Mean	Minimum	Maximum	Mean	Mean %	Mean	Mean %	Minimum	Maximum	No	Yes	Not specified
90	4	286	60	62,48%	19	19,9%	8,7	20	11	2	5

Reference	Objective	Application	Topics approached
13	To investigate the effectiveness of a preventive vocal health training program for German student teachers.	In person, in groups (10 to 12 people), and educational institutions. They were carried out in eight 90-minute sessions.	VH, voice functioning, posture, breathing, appropriate tone of voice during speech, vocal intensity, resonance, articulation, and prosodic elements.
14	To evaluate the usefulness of a targeted VH program compared to VH + VT for the prevention and treatment of voice problems in student teachers.	In-person with online monitoring; in groups (2-hour seminar on VH) and individually (10 to 15-minute meeting with each participant). The VT took place in 8 sessions.	VH: hydrating, controlling exogenous inflammation, and avoiding screaming. VT: aimed at an abducted laryngeal configuration.
15	To present an action to promote the vocal health of teachers within the scope of primary healthcare.	In person, in groups, at the workplace. Six fortnightly workshops (from 40 minutes to 1 hour).	Guidance on VH, vocal production, and vocal techniques.
16	To investigate the effects of a vocal education program on primary school teachers in the Persian education system.	In person, in groups, at the workplace. They were carried out in 8 weekly sessions of 1 hour each.	VH program, monitoring the application of learned practices.
18	To investigate the perception of the use of voice as a work tool and instrument of artistic expression, in a choir of preschool teachers.	In person, in groups, and at the places where the rehearsals and presentations took place. Duration of 6 months.	Reflection on the artistic and occupational voice use, the influence of work organization on vocal health, vocal health, and time management.
19	To investigate the immediate effects of a VW and VC program as a strategy to protect teachers' voices in the teaching context.	In person, in groups, at the workplace. 13-minute session with VW and 7-minute VC exercises.	VW: stretching, speech articulation exercises, breathing, mucosal relaxation, and resonance. VC: stretching, resonance, and glottal source.
20	To investigate the impact of a group vocal health promotion program for popular singers without vocal impairment.	In person, in groups, at the workplace. Seven meetings were held.	Guidance on the physiological anatomy of the vocal tract, VH care, and vocal exercises.
21	To longitudinally assess the impact of voice-based educational activities on teachers’ quality of life.	In person, in groups, at the workplace. A lecture on VH and 4 meetings every 15 days for vocal exercises.	Guidance on VH and vocal improvement exercises.
22	To test an online telepractice model for the prevention of voice disorders in healthy student teachers through measurements acquired with a mobile application.	Online, individually, on a smartphone application. Twice a day for 5 days a week, over 4 weeks. The voice was recorded with the application.	Guidance on VH and self-monitoring measures.
23	To determine the effectiveness of a voice care program among Malaysian teachers.	In person, in groups, at the workplace. Four 30-minute sessions.	Individual voice amplification, VH instructions, and voice amplifier journal.
24	To examine the effects of a short-term VT program for teachers.	In person, in groups; 25-hour course (in total), delivered over 8 weeks.	Lecture, posture education workshop, mindfulness, and traditional VT and VH techniques.
25	To explore the effectiveness and applicability of the Lax Vox method as a preventive voice program for healthy teachers.	In-person, individual. Three weekly sessions of 60 minutes each and practice 3 times a day for 12 minutes.	VW and VC using Lax Vox.
26	To investigate the effectiveness of a holistic VT program designed for theater students.	In person, in groups; 12 weekly sessions of 30 to 45 minutes.	Basic vocal anatomy, physiology, and VH education. VT: breathing, posture, relaxation, VW, resonance, and voice projection.
27	To define and implement a preventive vocal health program for university professors.	In person, in groups, or individually. Different actions were carried out for each level of prevention (primary - 1, secondary - 2, and tertiary - 3).	1 - personal habits and VH. 2 - vocal techniques for tone and volume control plus primary prevention guidelines. 3 - vocal re-education (relaxation exercises and breathing techniques) plus guidance on levels 1 and 2.
28	To determine the effect of an online vocal health and stress reduction program implemented at a Colombian university during the COVID-19 pandemic.	Online synchronously, individually. Four 45-minute weekly virtual sessions were held. Upon completion of the program, professors had access to all course material.	Improvement of working conditions, stress management, recommendations for voice care and vocal training (VW, VC, laryngeal relaxation, and breathing exercises), and promotion of healthy lifestyle habits.
29	To determine the effect of a Vocal Health Promotion Program at the Workplace and working conditions on the vocal functioning of university professors.	Blended, individual, with 4 sessions lasting 45 minutes each (2 remote and 2 in-person sessions) over 4 weeks. Participants should practice VT exercises at home.	VH, VT, and modifications in teaching-learning strategies in classrooms.
30	To evaluate the usability and acceptability of the "Health and Voice" application in promoting the vocal health of elementary school teachers.	Online, individual. Participants used the application and immediately answered the questionnaires.	General knowledge about voice, myths and truths, game associating acquired knowledge, guidelines for reducing the environmental impact on the voice, and basic vocal anatomy and physiology.
31	To evaluate the long-term effectiveness of a vocal training program for teachers in Lower Saxony, Germany.	In person, in groups, at the workplace. Each training session lasted 2 days, including 8 classes of 1.5 hours each.	Vocal techniques and individualized guidance for each teacher (aimed at modifying behaviors related to the professional use of the voice). The teachers’ specific working conditions were discussed, such as vocal stress, room acoustics, and noise reduction.

Summary of the results of the articles included in the review		Level of evidence*
Reference	Results
13	There was an improvement in VQ and vocal capacity, despite an increase in subjective voice strain, which suggests an increase in self-perception.	2
14	For initially healthy participants, the VH program prevented VHI scores from worsening. For participants with low initial VHI scores, the VH program failed to produce benefits, and VT was needed to optimize results.	2
15	Eighty percent of teachers reported an improvement in their professional performance, and 93.3% said they would continue performing the exercises, but pointed out the lack of time as the main difficulty in performing them routinely.	6
16	There was a significant improvement in EG’s VHI scores, while CG’s worsened.	5
18	Choir and drama (art and music) can be an efficient strategy to promote vocal health and adopt lifestyles that allow for self-care.	3
19	EG and CG did not differ in the intragroup analysis. However, in the intergroup analysis, VW improved QoL and reduced the degree of body discomfort; VC decreased both f0 and the degree of discomfort. The results indicate potential protection for teachers’ voices.	5
20	It was effective according to the singers' perception of their vocal production and there was a greater reduction in the percentage of complaints from EG than from CG.	5
21	Teachers had greater mastery and overall V-RQOL scores in both CGs and EGs. However, there was no statistical difference in scores between groups.	2
22	In the preliminary analysis, f0 and jitter (%) demonstrated changes in the voice comparing before and after applying the prevention model, in face-to-face and remote practice.	2
23	After the intervention, a significant effect was observed on the Malay-VHI-10 total scores, which supports the use of voice amplifiers along with VH as a prevention and treatment modality.	2
24	Teachers' voice performance improved after 25 hours of training in acoustic level, f0, and frequency disturbance measures, as well as subjective voice assessment using the VHI.	5
25	The results suggest improvement in selected measures of QoL, MPT, vocal function, self-assessment, and perceived applicability, with good adherence to routine.	7
26	There was an increase in EG participants' knowledge about VH. QoL in CG worsened, while no changes were found in EG. The auditory-perceptual evaluation showed improvements in EG’s grade of hoarseness and roughness.	2
27	The authors comment positively on their results, despite the focus of the study remaining on the division of groups into primary, secondary, and tertiary prevention, pointing out that the method used in the study can be applied to other occupational voice users.	4
28	The results demonstrate a reduction in the perception of vocal fatigue and an improvement in pneumo-phono-articulatory coordination, measured with the Vocal Fatigue Index and MPT.	5
29	EG showed an increase in V-RQOL scores compared to CG, but the effect was not statistically significant. After the program, the shimmer decreased and MPT and HNR increased in EG.	2
30	The authors concluded that the application is effective in promoting vocal health for teachers, as it has high acceptability and usability, in addition to increasing knowledge about VH.	6
31	Ninety-three percent of teachers implemented VT into their daily professional lives, and these behavioral changes led to better vocal capacity and performance. However, teachers at higher risk of voice disorders still had high rates of impact of self-reported voice problems after VT.	5

[1] Corresponding author: Marcia Simões-Zenari, Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina, Universidade de São Paulo - USP, Rua Cipotânea, 51, Cidade Universitária, CEP: 05360-000 - São Paulo, São Paulo, Brasil, E-mail: marciasz@usp.br

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Proposals to promote health and prevent voice disorders in occupational voice users: A scoping review

ABSTRACT

Purpose:

Methods:

Literature Review:

Conclusion: