When I listened to Christine Estes (SLP at the Sean Parker Institute for the Voice at Weill Cornell) present about vocal injury in fitness instructors at Fall Voice Conference in October 2017, my mind raced. What she was talking about was applicable to so many people I know! We are no longer the Richard Simmons and Jazzercise consuming athletes, but morphing into a more "community-experience" idea of getting our workout on. This includes Orange Theory Fitness, Crossfit, Pilates/Barre method classes and Camp Gladiator to name a few. Instructors have a hard job because they must keep their clients engaged. They can do this through social media, but many are self employed, owning "boxes" or overseeing "camps" that depend on them being present, mentally, physically and vocally, many times per day, as early as 4:30 in the morning.
Let's Talk Numbers
Most of these fitness instructors enjoy working out! Shocking... So they feel they must push themselves to be examples for their clients. If they are sick, this results in a huge loss in income because most don't have replacements which can lead to a decrease in quality of life. Many times, what Estes refers to as a "Heavy Vocal Load" paired with "Forceful Glottic Closure" results in Phonotraumatic Injury. What this means is that talking a lot, and doing so while squeezing your vocal cords to get volume, can lead to voice issues.
What is Heavy Vocal Load?
You get what you pay for with these classes. Your instructor is constantly cheering you on, encouraging you to be your best, and correcting your form. But it doesn't end with your class. That instructor likely has taught 2 classes before yours, teaches more after you and then goes home to talk and decompress, likely on the phone or in person. This would be considered a heavy vocal load. Doing this 6-7 days per week, sets a person up for possible injury.
What is Forceful Glottic Closure?
Instructors' most popular classes are the ones that get you motivated. This can involve the instructor working out, and trying to project over music, equipment noises and the chatter of other attendees. According to Beach & Nie 2014, the average volume level in a high intensity workout class is 93.1 dB. Pair that with the Lombard Effect, which is our own intuitive occurrence of trying to speak louder as it gets harder to hear the sound of our own voices. Most instructors model what to do, so this can significantly increase phonation threshold pressure, and laryngeal effort and closure. Think: SQUEEZE the THROAT!
So What's The Big Deal?
The amount of fitness instructors who experience voice issues that continue to recur is 44-70%, according to Rumbach 2013. 78% report feeling a change in their voices after teaching just one class. And the very sad thing is that 80% of these folks regularly use microphones, but they constantly malfunction or the instructor has no idea how to use them efficiently.
Can We Do Better?
As clinicians, we listen to these patients. "I can't afford to skip any classes," and "Jenni hasn't had voice problems, and she teaches the same amount of classes, so my boss just says I don't know how to use my voice correctly," is what we hear. Estes and colleagues suggest these measures to help this client population which continues to grow.
1) Complete direct voice training inside these companies
2) Provide adequate training for use of amplification devices/ microphones
3) Give these trainers a visual for how loud they actually are with a Sound Level Meter
4) Create a schedule that allows for the trainers to rest their voices, or better yet, create electronic noises that signal when to change a movement, or use pre-recorded instructions
We need to get larger sample sizes for these studies, says Estes, and look at objective measures especially in amplitude/loudness, subglottal pressure (pressure beneath the vocal cords) and airflow in speech. We need comparative studies that look at the roles of vocal hygiene, voice therapy and voice training in the gym/studio.
Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.
-Presentation from Fall Voice 2017 Weill Cornell Medicine Sean Parker Institute for the Voice at New York Presbyterian: Christine Estes, Babak Sadoughi, Rachel Coleman and Lucian Sulica.
-Beach, EF, Nie V. Noise Levels in fitness classes are still too high: Evidence from 1997-1998 and 2009-2011. Arch Environ Occup Health 2014; 69 (4): 223-30
-Fontan L, Fraval M, Michon A, Dejean S, Welby-Gieusse M. Vocal problems in sports and fitness instructors: A study of prevalence, risk factors and need for prevention in France. Voice 2017; 31 (2): e33-261.
-Rumbach A. Vocal problems of group fitness instructors: Prevalence of self-reported sensory and auditory-perceptual voice symptoms and the need for preventative education and training. Voice 2013; 27(4) 524.e11.
-Rumbach A. Voice problems of group fitness instructors: Diagnosis, treatment, perceived and experienced attitudes and expectations of the industry. Voice 2013; 27(6): 786.e1-786.e9.
-Sandage M, Connor N, Pascoe D. Voice function differences following resting breathing vs sub maximal exercise. Voice 2013; 25(5): 572-578