Setting and Delivering Standards in Vocal Health

This article has been edited to include the updated BAPAM Vocal Rehabilitation Coach Competencies. We are currently piloting the provision of VRCs in NHS Voice Clinics and will publish the results when complete. 

A Vocal Rehabilitation Coach is a highly specialist singing coach who works with patients as part of a clinical team within a Voice Clinic, and/or has a significant relationship with a Voice Clinic and receives referrals from a clinician. VRCs have clinical supervision from a voice specialist laryngologist and speech therapist, as well as, ideally, a psychosocial professional.

This is a developing area of work and we welcome constructive feedback at info@bapam.org.uk.

The singing industry is completely unregulated, meaning anyone can call themselves a singing teacher, vocal coach or even vocal rehabilitation coach regardless of training, experience or lack of clinical supervision. At BAPAM, we have many calls from actors and singers with voice problems and we have been aware of an inconsistent approach to care.

Working with a group of vocal health specialists established by our Medical Committee, comprising Ear Nose and Throat specialist doctors, speech and language therapists, physiotherapists and vocal rehabilitation coaches from across the country, we have set standards for our vocal health advice, and competencies for Vocal Rehabilitation Coaches. We are also funding sessions for specialist clinics to have a Vocal Rehabilitation Coach for a pilot period so we can evaluate the impact.

We hope this will be a major step forward improving the quality of care for vocalists who present with problems in healthcare. It will enable them to get a rapid assessment by the right professionals to accelerate the right treatment. It will also provide a set of standards for singing practitioners in the UK who wish to work with a Voice Clinic and provides an improved level of protection and quality assurance for organisations supporting arts professionals accessing specialist health care.

The literature on dysphonia demonstrates that singers presenting with voice disorders are most likely to have Muscle Tension Imbalance (MTI). General ENT Surgeons tend to look for organic pathology or structural abnormality and do not always diagnose MTI.  Diagnosis of MTI in speech is usually made by a Speech and Language Therapist with experience and training in assessing the muscular function of the whole larynx and vocal tract via nasendoscopy.  MTI in singing is being assessed in a few leading clinics by a Vocal Rehabilitation Coach with experience and training in the assessment of the larynx and vocal tract in a wide range of singing styles, also diagnosed via nasendoscopy.  Only specialist Voice Clinics have access to equipment and personnel qualified to deal with this type of problem in professional singers.  Treatment of MTI in singers is carried out by Speech and Language Therapists and Vocal Rehabilitation Coaches, jointly or in succession.

The BAPAM Vocal Health Working Group recommends multidisciplinary clinics with a surgeon and specialist speech therapist using high definition cameras with stroboscopic or high speed videos to analyse the vocal folds as standard of care. BAPAM has adopted this standard for the advice we give to patients.

BAPAM’s advice for GPs is to refer to a specialist Voice Clinic when patients with the following characteristics present with a voice problem:

Patient population

  1. Elite Performers (professional singers, actors, broadcasters, etc)
  2. Studying Performers (FE, Undergraduate and Postgraduate singers and actors)
  3. Quality of Life Performers (singers whose singing is their primary means of socialising like older local choir members)

Presenting Voice Problems

  1. Loss of range, power, flexibility
  2. Pain, fatigue, hoarseness
  3. Gaps in range, delayed onset of phonation
  4. Increased recovery or warm-up time
  5. Chronic throat-clearing, sensation of lump in throat (globus)

Referrals

A referral to a specialist Voice Clinics should be made for:

  1. Any vocal symptom lasting more than 2-3 weeks
  2. Any vocal symptom lasting more than 2 weeks following resolution of a bacterial/viral infection

Advantages of a Specialist Voice Clinic

  1. Stroboscopy to view vocal fold vibration is only available in these clinics
  2. EGG and other specialist equipment for accurate measurements
  3. Expertise in muscular function and dysfunction of the vocal tract
  4. More accurate diagnosis, improving management and decreasing patient recovery time (P.S. Phillips 2005)

The large clinic team enables a multidisciplinary assessment because performance voice problems are likely to be multifactorial and more likely to be muscular with musculoskeletal and/or psychogenic causes. Staffing includes:

  1. Voice Specialist Laryngologist*
  2. Voice Specialist Speech and Language Therapist
  3. Vocal Rehabilitation Coach (Singing Voice Specialist)
  4. Performance Specialist Osteopath/Physiotherapist (in some clinics)

*Some Specialist Clinics are SLT-led with Laryngologist review

Accurate diagnosis and specialist treatments speed up recovery times and save money in the long run.

(see British Voice Association leaflet on Multidisciplinary Voice Clinics)

Patient Outcomes

  1. If organic lesions are present they may be listed for surgery immediately or referred for Speech Therapy then reviewed
  2. Functional disorders will be referred for Speech and Language Therapy and/or Vocal Rehabilitation
  3. Musculoskeletal disorder will be referred for Osteopathy/Physiotherapy
  4. Psychogenic disorders will be referred to Speech and Language Therapy and onwards to access Psychology/Talking therapies as appropriate (for Psychotherapy and/or Speech Therapy)
  5. Most patients will be referred to more than one of the above

The Vocal Rehabilitation Coach

In late 2017, BAPAM’s Vocal Health Working Group approved competencies for Vocal Rehabilitation Coaches to set a standard of practice in this important area. Vocal Rehabilitation Coaches on the BAPAM Directory of Practitioners must meet the competency criteria published here: BAPAM Vocal Rehabilitation Coach Competencies.

Applicants will be included on the directory for a term of three years before needing to revalidate their application.

Information about applying to join the Directory can be found here.

We look forward to reviewing and reporting on our pilot project to support specialist Voice Clinics by funding a Vocal Rehabilitation Coach.

Vocal rehabilitation is a truly multidisciplinary endeavour, with crucial contributions from laryngologists and speech therapists.  A central member of this team is the Vocal Rehabilitation Coach who is uniquely placed between the medical clinicians and the performers to carry the scientific aspects of vocal treatment into the performance practice.  It is critical that these coaches are well schooled in vocal anatomy, physiology, pathology and rehabilitation; this schooling should be assessed with a series of measurable competencies to ensure that they are providing the best possible care. Mr. Declan Costello – Consultant Laryngologist

Following treatment for any vocal problem, like any injury one might sustain during physical exercise, a patient must rehabilitate appropriately with the aim of getting back to their pre-morbid state; to allow them to sing and speak again. In the same way you must learn to walk before you can run, one must set up the larynx correctly before trying to push its limits. Speech therapy achieves this but translating this laryngeal work into the singing voice requires a vocal rehabilitation expert. The expert vocal rehabilitation practitioner will help the performer take their correct setup into their performing voice before returning to their genre specific vocal coach. It can be seen that this is an essential part of the recovery process and having trained, competent and expert help is a comfort to patients.To this end, having the appropriate knowledge and having been assessed as reaching a standard level of expertise means that you know your patient will be in good hands.  Mr Nicholas Gibbins – Consultant Laryngologist

BAPAM Vocal Health Working Group

Mr. Nicholas Gibbins ENT

Mr. Declan Costello ENT

Ms. Tori Burnay SLT

Dr. Ron Morris SLT

Ms. Linda Hutchison VRC

Mr. Dane Chalfin VRC

Mr. Ed Blake Phys.

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