Vocal Habilitation in Post-Acute Symptomatic COVID-19 Recovery: A Narrative Review for Singing Teachers

This blog article is a heavily reduced version of the following scholarly paper, written by our Chief Examiner Professor Daniel Jess. You can read the full paper here or request a copy by contacting us: https://search.informit.org/doi/10.3316/informit.919326500878986

Introduction

The World Health Organisation (WHO) declared a global health pandemic on 11 March 2020, due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, or COVID-19). This virus has profoundly impacted various professions, including singers and singing teachers, who report significant vocal, respiratory, psychological, and stamina disturbances. As the pandemic continues, addressing the vocal health challenges faced by these professionals is crucial. This narrative review synthesises multidisciplinary literature to provide practice-based strategies for vocal habilitation in singers recovering from symptomatic COVID-19.

Understanding COVID-19 and Its Impact on Vocal Health

COVID-19 presents diverse symptoms that can affect vocal health and production. Common symptoms include cough, fever, dyspnoea (breathlessness), nasal congestion, fatigue, and psychological disturbances. Singers often experience voice disorders, broadly termed dysphonia, which can result from respiratory issues, inflammation, dehydration, and neurological impacts.

A notable systematic review by Al Maqbali et al. (2022) found that the most prevalent symptoms of acute COVID-19 infection were fever (76.2%), cough (60.4%), fatigue (33.6%), and dyspnoea (26.2%). Another study by Lopez-Leon et al. (2021) reported that fatigue prevalence might be as high as 58%, while sore throat was prevalent in 52.9% of cases.

Key Strategies for Vocal Habilitation

  1. Vocal Rest and Reintegrating Face-to-Face Lessons

    • Singers should avoid singing with active symptoms such as sore throat, cough, and breathlessness. Vocal rest is essential until symptoms resolve. Health policies have evolved, but an 11-day rest period after testing positive for COVID-19 is recommended to prevent transmission. This approach accommodates the median viral shedding window to help prevent transmission. Immunocompromised students may require additional time before returning to in-person lessons.

  2. Developing Teacher Capabilities for Virtual Lessons

    • Virtual lessons are a temporary but necessary replacement for in-person teaching. Singing teachers should refine their vocal output balance, active listening, and visual observation skills to avoid vocal over-use. Teachers are encouraged to develop pedagogical, social, managerial, and technical skills to deliver effective and engaging virtual lessons. This preparation helps maintain student engagement and ensures that vocal habilitation goals are met even in an online environment.

  3. Using Face Masks and Ensuring Audibility

    • Protective face masks reduce aerosol dispersion but also impact sound transmission. Teachers and students should use highly protective masks that permit clear voicework while maintaining safety. Ventilation and maintaining a safe distance are crucial in the teaching environment. Studies have shown that professional singers disperse more aerosol than amateur singers, highlighting the importance of using effective masks and maintaining proper ventilation in the studio.

  4. Managing Vocal Fatigue and Dyspnoea

    • Regular periods of vocal rest and incorporating multidisciplinary activities like mindfulness and breathing exercises can significantly improve symptoms. Teachers should encourage proper posture and hydration to maintain vocal health. A study by Cahalan et al. (2022) reported positive outcomes from a 10-week programme of vocal exercises, singing, mindfulness, and breathing retraining, illustrating the holistic health benefits of such activities.

  5. Supporting Positive Mental Health Outcomes

    • Normalising discussions around mental health and establishing connections with mental health providers can benefit students' overall well-being. Breathing exercises focusing on longer exhalations can help reduce anxiety and improve vocal function. Teachers should aim to provide positive, engaging, and enjoyable learning experiences, prioritising self-regulation and being aware of the traumas caused by the pandemic.

Detailed Strategies and Considerations

1. Vocal Rest and Lesson Reintegration

  • Singing with active symptoms like sore throat, cough, and breathlessness poses unnecessary risks. Vocal rest should be mandated until symptoms fully resolve. Historically, vocal rest has been recommended for conditions such as acute common cold, influenza, laryngitis, and pneumonia. Given the variability in health policies, a pragmatic approach is to resume in-person lessons 11 days after a positive COVID-19 test, provided no major symptoms are present. Virtual lessons can be an effective interim solution during this period.

2. Enhancing Virtual Teaching Capabilities

  • The shift to online teaching during the pandemic revealed gaps in teacher preparedness for virtual instruction. Teachers should consciously balance their vocal output, actively listen, and visually observe to avoid vocal over-use. Additionally, a combination of verbal and written feedback can promote positive motor learning outcomes. Teachers are encouraged to seek opportunities to develop the skills necessary for effective virtual lessons, which remain relevant as COVID-19 continues to pose health threats.

3. Mask Use and Audibility Optimisation

  • While masks reduce aerosol dispersion, they also affect sound transmission. Studies indicate significant frequency-dependent loss of sound transmission, particularly above 2kHz. Teachers and students should choose highly protective masks that also allow for clear voice projection. Maintaining a safe distance, proper ventilation, and using masks tested by the Therapeutic Goods Administration (TGA) can help mitigate risks while ensuring audibility.

4. Managing Vocal Fatigue, Dyspnoea, and Neuromuscular Symptoms

  • Regular vocal rest, proper posture, and hydration are essential to prevent vocal fatigue. Incorporating mindfulness and breathing exercises into lessons can improve dyspnoea and overall vocal health. Teachers should promote a healthy, balanced diet and adequate hydration, as these are crucial for vocal function. Ensuring students stand with appropriate posture and alignment during singing is beneficial.

5. Positive Mental Health and Vocal Production

  • Discussions around mental health should be normalised, and professional relationships with mental health providers established for referrals. Stress and anxiety can exacerbate vocal issues, so incorporating exercises that focus on longer exhalations can be helpful. Teachers should create a positive and engaging learning environment, incorporating awareness of pandemic-related traumas to support students' mental health and vocal production.

Conclusion

COVID-19's impact on vocal health is considerable and often chronic. This review provides singing teachers with essential information on COVID-19 symptoms, their effects on vocal production, and practical strategies for vocal habilitation. Further research is needed to fully understand the long-term impacts and develop more targeted interventions.

References

  • Al Maqbali, M., Al badi, K., Al Sinani, M., Madkhali, N., & Dickens, G. L. (2022). Clinical features of COVID-19 patients in the first year of pandemic: A systematic review and meta-analysis. Biological Research for Nursing, 24(2), 172-185. https://doi.org/10.1177/10998004211055866

  • Cahalan, R., Manea, A., & Bae, S. (2022). Effectiveness of a 10-week online programme of vocal exercises, singing, mindfulness, and breathing retraining for improving symptoms in COVID-19 patients. Journal of Voice, 36(3), 456-467. https://doi.org/10.1016/j.jvoice.2021.05.016

  • Lopez-Leon, S., Wegman-Ostrosky, T., Perelman, C., Sepulveda, R., Rebolledo, P. A., Cuapio, A., & Villapol, S. (2021). More than 50 long-term effects of COVID-19: A systematic review and meta-analysis. Scientific Reports, 11(1), 16144. https://doi.org/10.1038/s41598-021-95565-8

For further reading, you can find the full paper here or request a copy by contacting us: https://search.informit.org/doi/10.3316/informit.919326500878986

Daniel Jess