June 17, 2021
Why Voice Matters in Respiratory Health
Recently I was leading a voice skills class for Covid long-haulers. This particular cohort has been working with me for a number of months and they have progressed enough in their recovery to tolerate an hour of intensive speech work. After breath exercises, gentle stretching and general vocalizing, we began working on reading a limerick. I like to use limericks because they are short, predictable and rhythmical. They lend themselves to prosodic reading and it’s easy to remember where to breathe. In this case, we were working on keeping the breath support all the way to the end of the sentence and resonating the voice through vowels and consonants. I call this “flowing the air.” This way of speaking is more efficient, requiring less effort because the speech is in “flow” rather than out of focus, which is taxing and entails constant re-coordination of the components of the vocal machine: airflow, phonation, resonance and articulation.
Most of my participants were successful with their reading. They first practiced alone and then listened as each read aloud to me in a “masterclass” format. The nice thing about Zoom is they can work on the speech issues brought up with other students while they stay muted. Sometimes we do our best learning by watching each other.
The last participant read her first line at a very rapid pace. When I stopped her and asked her to slow down, she said “I can’t catch my breath. I think I need my inhaler.” After some minutes of guided quiet breathing, she was able to calm down a bit and eventually read aloud with control.
But this is not an uncommon occurrence in my work with lung disease patients and Covid long-haulers. This incident was probably a result of nerves…and the act of reading out loud.
When we speak, we control the breath and modulate breath pressure. Every utterance, whether it be a vowel, fricative, affricate, sonorant, glide, approximant or stop requires a different configuration of the vocal tract, which in turn changes the flow of air from the respiratory tract, single sound to single sound.
Healthy people inhale, set the vocal tract to the sound we need to make and as air flows up from the lungs and passes through the vocal folds in the larynx, sound is created. We speak entire sentences and paragraphs without thinking about this highly coordinated dance occurring in our thorax, head and neck (really the whole body is involved—I haven’t even mentioned the ear and brain, but I’ll leave that pedagogical discussion for another day!)
A healthy individual may not be using the speaking voice as efficiently as possible but this isn’t necessarily problematic. You might speak with a pressed tone, inappropriate loudness, monotone, mumble or vocal fry. You might over-breathe, taking in more air than you need for producing a sentence…but you can get away with these habits and live a fulfilling life. It doesn’t really matter.
Until it does.
And usually, that “matter”-ing happens when something compromises part of your vocal machine.
To steal a metaphor from a physiotherapist colleague, it’s not unlike body posture. You can walk around with poor posture for a long time, but then one day, you reach down and pick up a book the “wrong” way and suddenly, you can’t move anymore.
In the case of lung disease, the breath doesn’t cooperate. Typically, people with lung disease have difficulty either on the inhale and/or exhale, depending on the nature of the disease. Breath pattern can become compromised as the patient struggles to maintain airflow. Breaths can become higher and more panicky when experiencing shortness of breath, eventually causing gasping and gulping. While nasal breathing is resistive, slower and encourages a diaphragmatic pattern, mouth breathing triggers a larger, apical breath as it is easier to take in more air through the wider aperture. As we tend to inhale through our mouths when we speak or sing, voicing can cause breathlessness because of the tendency toward an inefficient breath pattern. The ribcage is heavy, requiring up to 30% of our energy to lift it and it can be difficult to control the outward flow of air because elastic recoil is high at large lung volumes and gravity will further cause it to rapidly collapse. It is no wonder that the shoulders and neck muscles become tight in people who use this high breath pattern. The vocal folds and extrinsic structures also have to squeeze harder to resist the large amount of air that comes from an overinflated ribcage. As the vocal folds and vocal tract are overtaxed by the excessive breath pressure, they too become fatigued or tight. Furthermore, the breath may not flow out enough, leading to hyperventilation and an imbalance in oxygen and carbon dioxide, which may trigger further panic and a sympathetic nervous response—“fight or flight.”
Combine the uncooperative breath with poor vocal habits and we have a problem. The two most common complaints I hear from people with lung disease are “I cough when I talk” and “I run out of breath when I speak.”
The ability to speak effectively is a quality of life issue that we tend to take for granted. For someone who cannot breathe well, the other parts of the vocal machine have to work harder to compensate. I observe tension in the neck, face, jaw and tongue. I work hard with my clients and students to undo these compensatory behaviours. I teach them to make sounds without over-engaging the articulators. I teach them about resonance and well-formed vowels (is that [u] vowel rounded enough?) I teach them to allow the air to flow outward like a garden hose rather than holding the air back during voicing. I teach them to raise the pitch at the end of a sentence and to speak with intention. Importantly, I teach them to maintain a low breath pattern even when they breathe through the mouth, which is key to avoiding over-breathing while speaking.
While pulmonary rehab may include some instruction on breathing pattern, we ought to include voice skills in working with patients with lung disease. Voicing is a physiological event that requires agile coordination of the air, laryngeal valve, and pharyngeal and oral tracts. It does not “just happen.”
Singing is a good way to introduce efficient voicing, but its use in the lung disease population needs to be intentional and include skills that can translate into speech. I love using voiceless fricatives such as “s” “sh” “f” and “th” to encourage airflow with different pressures. Once those efficient flow patterns are established, voicing can easily be added through glides on “z” “zsh” “v” and voiced “th.” We do tongue exercises to encourage a larger range of articulator motion and practice pure vowel sounds. I often incorporate large body movements such as arm circles and squats to better connect the body, breath and voice. Singing songs reinforces the work of vocal exercises and prepares the voice for speech. (For what it’s worth, I often cue my high-level professional singing students to “talk on pitch” and “stop singing” because I believe the singing voice and speaking voice are one and the same, and the exercises I teach reflect this.) Yet it is important to remember singing requires a higher volume of air than speech. At the end of a singing class, we must also practice quiet breaths at lower volumes as this is an important skill to master.
Singing classes for people with lung disease should be times to work on breath technique, socialize with other patients and enjoy the psychological aspects of making music together. However, they are also opportunities to learn voice skills that will benefit breath management outside of the singing class. Lung disease, dyspnea and other breath disorders can inherently cause social isolation and communication skills should be prioritized in this population. Singing is a low cost, low resource way to help people struggling to breathe and if worked well, can address both physical and quality of life issues.
March 27, 2021
Singing and Long-COVID Part 2
Tuesdays are my day at Breathe Well Physio where I typically teach “Breathe, Sing, Move!” and work with individuals who need voice work, but in the last few weeks they’ve turned into my “long-COVID day.” I now spend the morning working with individual singers looking for voice help following their acute COVID, and the afternoons are for classes. I have worked with long-COVID patients on an individual basis now for several months. This Tuesday was my first time working with this population in a group.
Here is how things played out:
My first singer canceled due to a potential relapse while my second singer slept through two alarms and was late for her lesson. When this singer eventually connected with me, we made it through one minute of breathing and humming exercises before she burst into tears due to the emotional gravity of making sounds that actually felt good.
In the afternoon, I taught three classes, two for long-COVID patients, and one for people with other lung diseases such as COPD, asthma, pulmonary fibrosis or general breathlessness— “Breathe, Sing, Move!” (or BSM for short).
BSM has been in operation for over four years and the program has been tweaked more times than I can count. It is meant to be an extension of pulmonary rehab, combining exercise and education with voice skills. Participants learn to inhale efficiently and extend the exhale through movement and singing. The outcome is better breath management, better vocal communication skills and an improved overall quality of life. By obtaining these skills we find our participants gain in domains of disease mastery (the ability to function and manage one’s condition) and emotional functioning, and reduce their breathlessness and fatigue.
In Tuesdays’ BSM class, we did basic breathing, small and large scale stretches, vocalizing, balance work, squats…and four minutes of the “Macarena” including an option for a plyometric jump and clap following the characteristic “Heeeeyyyyyy Macarena!” We sang folksongs, Cole Porter and the Beatles. This class is ACTIVE. We are working on reconditioning through progressive exercise on a vocal and whole-body level. Our participants were dancing, singing and moving despite their compromised respiratory systems and physical impediments such as oxygen tanks and wheel chairs. Above all, it is FUN! It is nearly impossible for me to leave without a renewed energy and a smile on my face. The number of “regulars” and those who rotate in on an ongoing basis as their schedules allow is a testament to the program’s efficacy.
Let’s contrast this fast-paced, high-energy class that builds on typical community music and choral programs with “Breathe, Speak, Pace”…
(Notice the change in title that reflects the emphasis on PACING rather than MOVING. Pacing is a strategy to help people avoid worsening of symptoms such as severe fatigue and “brain fog” in response to physical or mental exertion. Furthermore, speaking well replaces singing, which will likely be too athletic for most participants.)
“Breathe, Speak, Pace” (BSP) is a twice weekly class attended by people recovering from long-COVID. One class is led by my physiotherapist partner, Jessica, and Rosie, a researcher/exercise physiologist who specializes in chronic fatigue. The goal in the class I lead is better management skills for both breath and voice in order to perform functional tasks like speaking during work.
My long-COVID group classes were a completely different scene from BSM. Here, the majority of participants were on couches or their beds. There were few smiles and the energy was low. From my prior work with post-COVID patients, I knew to cut down on my activities and reduce the load as much as possible. I had planned on simple breathing exercises, stretches, vocalizations, vocal health information and an easy vocal improv activity. However, it took all of 30 seconds for me to throw my lesson plan out the window when I realized that even such a simple plan would be too much. In fact, after we did four breath cycles using the fricative /s/ on the exhale, I received the comment that it was too much and they were having trouble keeping up—and that was after 10-15 minutes of meditation and body scanning. Granted, my class is a mixed bag in terms of where people are in their recovery, the severity of their symptoms and overall long-COVID experience. But this is a reminder that this is new territory and we are very much in a “trial-and-error” situation.
I left the classes on Tuesday worrying I had done more damage than good. Indeed, one participant wrote and said she felt breathless and couldn’t talk after the class. (This participant has since informed me she is doing much better and is following up with her pulmonologist.) I had set the pace based on my knowledge from working with individual COVID long-haulers but that was too much for a group class. The spectrum of those in recovery is very wide. It’s worth reiterating that each person in those classes is being treated for breathlessness in tandem by my physio who specializes in breathing pattern disorders either on an individual basis or in the other arm of Breathe, Speak, Pace. It may be that these classes are not for everyone, which means we may have to change our screening practices.
I will also state we received plenty of POSITIVE feedback, lest it appear I am solely focused on the negative, artist that I am! There is no doubt there are people that can really benefit from this type of instruction.
After much debriefing via email and phone calls with Jessica, I have spent the last few days rethinking, re-evaluating, reworking and redoing. I have re-filmed ALL of my practice videos. I have reformatted my classes to include multiple “exit” points for anyone who feels they have had too much. I will lower my voice even more and slow down the pace. I will adjust my lighting and cueing to make sure it’s not too cognitively challenging. The wellbeing of everyone in the class is my top priority, and I will continue adjusting the program as needed. We may come to a time when we offer those who are more functional a separate faster-paced class and have a more educational class for those who are really struggling.
I am reminded of my first experiences working with cystic fibrosis patients just over a decade ago. Those early days were tough as I figured out what worked and what didn’t. One day, one of my dissertation study participants came to my studio for her lesson and coughed so hard she threw up all over the room. I felt awful because the singing had triggered the cough. She was fine, but I never forgot it. Incidentally, I found that the CF clinic staff’s demeanor toward me changed after I had that healthy and humbling dose of reality.
What I perceive as “slow” and “easy” based on my experience as a vocal pedagogue who has worked with multiple ages in multiple settings isn’t enough or even relevant. I caution the multitude of well-meaning singing teachers and choir directors out there who are eager to welcome this population into their programs. This isn’t as easy as it looks. I have learned in my time working with people living with chronic illness, that they are always looking for answers– and I DO NOT have them. I only have tools that may or may not be useful. Be careful of making false promises to those who are drawn to the glamour of learning breathing from “artists.”
I hope in the coming months we can figure it out, but only time will tell. There is no precedent. As I said, we are very much in a trial-and-error stage.
p.s. I now ALWAYS have a barf bucket on hand.
February 24, 2021
Singing and Long-COVID…
I have been approached by many singing teachers interested in starting programs similar to the one from the English National Opera. I know there are many more out there, so I thought I’d publicly share some thoughts.
First, I am THRILLED at the level of excitement this has generated among my singing teacher colleagues. I have argued for years that singing teachers are underused resources in the community. Singing teachers are very knowledgeable about breath, body and voice. We provide a place for artistic expression, connection and psychological well-being. We help people understand the fundamental and technical aspects of communication and this carries over into multiple aspects of our students’ lives.
There are clear physical benefits to learning singing. We gain awareness of body and breath, and learn to coordinate that with the voice. Singers learn to control the breath and may even increase vital capacity and tidal volume by changing the efficiency of their breathing pattern.
But there are differences in breathing when it comes to lung disease and among different lung diseases of varying severity.
It is highly likely a teacher will encounter a student with asthma or COPD either in a private lesson, group lesson or choir. Those students’ goals may be to sing better, speak better or breathe better. A good teacher will honour those goals and choose exercises and repertoire that helps the student meet them.
I began teaching singing to cystic fibrosis patients during my doctoral studies. I had met a singer with CF whose doctors were encouraging her to keep up her singing to maintain her lung function. I was curious about the physiological mechanisms behind this and set off to study the intersections between respiratory physiotherapy and singing. In a nutshell, singing encourages deep inhalation followed by controlled exhalation that induces pressure oscillations within the vocal tract. Not only is the breathing pattern diaphragmatic and consistent with the patterns encouraged by respiratory physiotherapists, the high velocity airflow and pressure oscillations may change the properties of mucus and make it more easily cleared by a huff or cough. Indeed, over the past decade when I have taught singing lessons to people living with lung disease, many begin to cough productively, which is a good thing as it provides respiratory hygiene. It’s also an opportunity to talk about effective cough and cough management.
The goals of teaching singing to people with lung disease are different than the ones we set for those who come to us for singing. The goals in this case are more health focused and the student may or may not be aware that this is happening because they are having “fun” singing. Yesterday during our “Breathe, Sing, Move!” class I was asked how I choose our songs. First, they have to appeal as universally as possible to my participants. They have to be within a certain range and they have to be easily learned. But then they have to meet my pedagogical goals of coordinating the breath, voice, articulators and resonators so the skills learned in the class can carry over into regular life. Furthermore, the repertoire section is not where they receive the bulk of instruction. I must tailor the vocalizations and breathing exercises we do to prepare for the “practicum” of singing. This is something that I have practiced and refined over many years.
When I began “Breathe, Sing Move!” with my physiotherapist colleague, I had already written a dissertation about singing and lung disease, attended and presented at conferences, and published a review paper in a peer reviewed journal about singing and lung health. I had consulted with medical doctors and allied health professionals about my methods and spent time in medical clinics. I was an “expert.”
However, I will not forget Jessica pulling me aside one day early on and saying “You shouldn’t do breath holds with lung disease because they may desaturate.” The exercise she was referring to was a common one for voice teachers: the box breath where one inhales for four counts, suspends the air for four, exhales for four and suspends again. While this may work in some cases to teach control of the breath, after all that time I hadn’t come to a real understanding of how breathing is different for people whose gas exchange is compromised. In many cases, the alveoli are not able to efficiently exchange CO2 and O2 due to either blockage from mucus or damage to the tissues. In some people this will lead to O2 levels dropping off, which can ultimately have cascading consequences. We are better off encouraging people with lung disease to keep moving air in and out of the lungs rather than holding it.
This is just an example of how you may not know what you don’t know. It is why we must collaborate closely with our colleagues and understand that they may not have a sophisticated knowledge of our work either. We have to educate them about what we do, how we do it and why we make our choices. Then we must humble ourselves, be willing to recognize the holes in our own knowledge and work to fill them appropriately.
Long-COVID is a bit of a slippery slope for multiple reasons. First, it is new and the best practices for dealing with it are ever-changing as new research emerges. I have waded through a large amount of rehabilitation literature and it is surprising how much the recommendations have shifted in a short amount of time. For example, only a few months ago rehabilitation best practices involved exercise. This has been adjusted as we come to understand that exercise can make the symptoms worse because of changes in the autonomic nervous system. Furthermore, the range of experiences with long-COVID is wide. Some recover well and need breath pattern retraining while others need much more in-depth rehabilitative intervention.
I am concerned about singing teachers diving into this novel approach to lung disease without due diligence. I am myself proceeding with caution even though I have the appropriate medical professionals at my side and a decade of experience. There is a part of me that says singing may be too athletic for many of these people and my focus should be on simply coordinating breath and voice. My pedagogical goal will be to have a student speak a few sentences without coughing or gasping for air.
I believe singing teachers have many tools that will ultimately prove useful within the medical community. As I said, we are an underused resource. However, I caution anyone who wants to work in this area to research the subject, collaborate appropriately and respect our scope of practice. We singing teachers are not allied health professionals such as physiotherapists, respiratory therapists, psychologists and speech-language pathologists but we are allies to them. We can provide reinforcement of the skills and principles they lay out in their therapy sessions and keep a dialogue regarding how they are being applied in real life.
If you are interested in training and learning more, please be in touch. I firmly believe we function best as a profession when we work together.
Dr. Rachel Goldenberg, D.M.A.