Folia Phoniatr Logop 2004;56:220–253
DOI: 10.1159/000078344
Occupational Safety and Health
Aspects of Voice and Speech
Professions
Erkki Vilkman
Phoniatric Department, University of Oulu, Oulu, and Helsinki University Hospital,
Helsinki, Finland
Key Words
Vocal loading W Occupational safety and
health W Ergonomics W Speech perception
Abstract
A well-functioning voice is an essential tool
for one third of the labour force. Vocal de-
mands vary to a great extent between the dif-
ferent voice and speech professions. In pro-
fessions with heavy vocal loading (e.g.
school and kindergarten teachers), occupa-
tional voice disorders threatening working
ability are common. Vocal loading is a com-
bination of prolonged voice use and addi-
tional loading factors (e.g. background noise,
acoustics, air quality) affecting the funda-
mental frequency, type and loudness of pho-
nation or the vibratory characteristics of the
vocal folds as well as the external frame of
the larynx. The prevention and treatment of
occupational voice disorders calls for im-
proved occupational safety and health (OSH)
© 2004 S. Karger AG, Basel
ABC 1021–7762/04/0564–0220$21.00/0
Fax + 41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/fpl
arrangements for voice and speech profes-
sionals. On the basis of epidemiological and
acoustic-physiological research, the pres-
ence of risk to vocal health can be substan-
tiated. From the point of view of the physical
load on the vocal apparatus, loading-related
physiological changes (adaptation) may play
a role in the occupational risk. Environmental
factors affect vocal loading changes. In
teaching professions, the working environ-
ment is shared with children, who benefit
from amendments of OSH legislation con-
cerning their teachers.
Copyright © 2004 S. Karger AG, Basel
Introduction
Recognition of the potential health risks at
work has a long tradition dating back at least
to Hippocrates (about 460–370 BC) [1]. It has
been reported that, during the past decades, a
considerable change has taken place in the
Prof. Erkki Vilkman
Department of Phoniatrics, Eye-Ear Infirmary
POB 220
FI–00029 Helsinki (Finland)
E-Mail erkki.vilkman@finnet.fi
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occupational safety and health (OSH) priori-
ties and strategies in the traditional sectors of
the labour market in the member states of the
European Union. At the same time, there are
many trends implying a need to extend the
OSH thinking to new domains [2].
The European Union has issued directives
on occupational health and safety require-
ments, the most important being the ‘frame-
work directive’ covering the general princi-
ples of the introduction of measures to en-
courage improvements in the safety and
health of workers at work. The basic OSH
principles state, for instance, that ‘The em-
ployer shall have a duty to ensure the safety
and health of workers in every aspect related
to work’, and that ‘... the employer shall take
the measures necessary for the safety and
health protection ..., prevention of occupa-
tional risks ..., provision of information and
training ..., provision of the necessary organi-
sation and means.’ Table 1 shows the princi-
ples defined in the same directive concerning
the prevention of occupational ill health [3].
According to current OSH legislation, the
starting point for understanding problems ar-
ising at work should be an analysis of the
interaction between the individual, the work
task and the environment. The task should be
adjusted to suit the individual and not vice
versa. All workers have a legal right to OSH
services.
Ergonomics (ergo- = work; -nomics = ar-
rangement) is closely linked with OSH think-
ing, as it has been defined as a ‘... way of look-
ing at the world, of thinking about people at
work (any type of work) and how they cope
with it ...’ [4]. In this paper, the term ‘vocoer-
gonomics’ (voco- = voice) is used to empha-
size the ‘voice as a tool’ aspect.
The purpose of the present review is to out-
line some current aspects of occupational
voice problems as an OSH issue. In a review
published by Vilkman [5] in 1996, it was
Occupational Safety and Health
Table 1. Principles of OSH (Directive 89/391/EEC) ...
‘the employer shall implement measures ... on the basis
of general principles of prevention
E avoiding risks
E evaluating risks
E combating risks at source
E adapting the work to the individual, ... design of
work places, ... equipment
E adapting to technical progress
E measures related to safety, hygiene and health ...
may in no circumstances involve the workers in fi-
nancial cost
E health surveillance appropriate to the health and
safety risks at work’
stated that this approach is poorly developed,
and that one of the main reasons for this ‘is
apparently that there is not enough knowledge
concerning the environmental and ergonomic
aspects of voice disorders as an occupational
health problem’. It seemed worth revisiting
the subject, as research in this field has been
very active during the past few years.
Ontological Decision
Voice production can be studied within
different frameworks. Prof. Aatto Sonninen
[6] suggested the use of an approach known in
the philosophical literature as the ontological
decision to depict the background of studies
of voice production. The basic principle is
that the human being is able to understand
the world at corporeal (physical, measurable),
conscious (subjective, perceptual, descriptive)
and situational levels (actual terms used to
describe perceptual observations) (fig. 1).
Terms and concepts defined at the con-
scious and situational levels are the corner-
stones of the prevailing voice care and cure
tradition. This is apparently related to the fact
that the roots of clinical vocology are deep in
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Ontological understanding of voice production
Consciousness
Situational
Corporeal
Fig. 1. Framework of sources of information on voice
production [6].
the traditions of training artistic use of the
speaking and singing voice. This basis may be
problematic, as the use of subjective terms
often leads to problems in communication
with other clinicians or voice coaches. One
example of this are the perceptual voice analy-
ses in which a few listeners are trained to use
similar rating scales. The results produced by
other groups might be different, and only a
few variables can be used in this way due to
the low inter-listener correlation. Neverthe-
less, this approach is practical in many ways,
not least because it gives useful information
for clinical purposes in a very (cost-)effective
way. From the viewpoint of OSH, ergonomics
and occupational health, however, objective
information obtained at the corporeal level is
also necessary.
Conceptual Framework of Vocal
Loading
In figure 2, the different stages of vocal
loading effects at the individual level are
shown as a continuous process model. The
physical concept of loading here refers to the
demands posed by voice use needs on the
222 Folia Phoniatr Logop 2004;56:220–253
vocal organ. The term ‘load’ illustrates the
physical, corporeal nature of voice production
and links occupational vocal loading to the
existing occupational safety and health frame-
work. Usually, at early stages of loading, there
is a phase generally known as vocal warm-up.
It can be defined as a positive subjective expe-
rience of voice production becoming easier.
This term is generally used in the context of
specific voice exercises, but warm-up is also
known to take place after reading aloud for
some time [7]. Sooner or later, however, vocal
loading leads to vocal fatigue.
‘Vocal fatigue’ is a subjective term, which
refers to negative sensations related to voic-
ing. Vintturi [8] presented a comprehensive
definition of vocal fatigue: ‘Vocal fatigue
is a vocal loading-borne change manifested
as physiological, perceptual, or subjective
changes; the perceptual (communicative) and
subjective (mental and emotional changes;
different symptoms) short-term effects of vo-
cal fatigue are usually considered negative.
Some of the fatiguing changes are necessary to
avoid physiological overstraining.’ A fatigued
voice may sound hoarse in the ears of the lis-
tener or the speaker, voice production is felt
to be more laborious, and this may eventually
lead to an inability to produce voiced sound at
all: there may be a need to clear the throat, a
feeling of mucus or a lump in the throat, etc.
[e.g. ref. 9]. In other words, the symptoms of
vocal fatigue may affect all parts of the physi-
ologic larynx (see below) and involve central
components as well.
In general, ‘fatigue’ has been considered a
problematic term in ergonomics literature, as
it has been used in so many different contexts
and its objective correlates are obscure. For
instance, a study of shoulder muscle fatigue
revealed that light and heavy loading both
caused subjectively perceived fatigue, but at
the physiological level, only heavy loading
resulted in electromyographically detectable
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 Fig. 2. Stages of vocal loading [modified from ref. 8]. The onset of vocal fatigue depends on
the weight of the load. In extreme cases (uncontrolled shouting), the warm-up stage can be
omitted. Inter-individual variation in vocal endurance, for instance, plays a major role in the
timing.
signs of loss of muscular power [10]. The dis-
covery of objective correlates for subjective
voice complaints and fatigue would be highly
desirable, as they could be used to substan-
tiate voice problems as a hitherto neglected
aspect of OSH.
It has been suggested that fatigue should be
divided into a central and a peripheral com-
ponent [11]. Central fatigue refers to a general
experience of tiredness without local symp-
toms. Vocal fatigue at the peripheral level is a
continuum where loading changes take place
in the external frame and the internal muscles
of the larynx and the vocal fold mucosa. An
example of thyroarytenoid muscle fatigue is
the finding of bowed vocal folds in a study
where extremely heavy vocal loading was
used [12]. Similar bowing of the vocal folds
can be seen when botulinum toxin injections
are used to treat spasmodic dysphonia, and
the patient’s voice gets hoarse as a side-effect
of the early stages of the treatment. Theoreti-
cally, this bowing could be compensated for
by cricothyroid muscle activity. In fact, as
Occupational Safety and Health
these muscles are anatomical antagonists, the
loss of contraction force in the thyroarytenoid
muscle should lead to lengthening of the vocal
folds in a mechanistic model [see ref. 13, for a
review]. A tentative explanation for why this
is not the case is apparently related to goal-
oriented motor control, which involves both
speech and general motor coordination [cf.
ref. 14] aiming to allow the individual to pro-
duce normal voice in terms of pitch, loudness
and timbre. Actually, in the tradition of voice
training, deliberate pitch raising has been sug-
gested by some authors as a manoeuvre of
choice to compensate for acute symptoms of
vocal fatigue.
Voice rest, in turn, is associated with a pos-
itive experience of recovery. The objective
correlates in terms of the acoustic-physiologic
parameters of vocal warm-up, vocal fatigue
and voice rest will be discussed later in this
paper.
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 Vocal Loading in a Laboratory

This chapter summarizes and discusses the

main results of a study on vocal loading car-
ried out in laboratory conditions at the Insti-
tute of Occupational Health, Helsinki, Fin-
land [15–22]. The project was funded by the
Finnish Work Environment Fund. This pro-
ject used the longest vocal loading test ever
performed in laboratory conditions and in-
volved the largest number of subjects, and it
was the first experiment to control environ-
mental factors in different combinations and
to control pre-test voice use, in addition to
which it used a larger battery of tested param-
eters than any earlier study. All the subjects
were totally naı̈ve to the experimental ar-
rangements and the hypotheses. The analyses
were carried out blindly, i.e. the persons in
charge of the analyses were not aware of the
exposure combination of the subject, with the
exception of the humidity conditions, which Fig. 3. Glottal flow waveform (top panel), its deriva-
were based on seasonal differences in cli- tive (middle panel) and a schematic triangular flow
waveform (O = open phase; Cl = closing phase; f = flow
mate.
amplitude; d = amplitude of the negative peak of the
differentiated flow; AQ = f/d). AQ equals Cl for the
triangular pulse.
Subjects and Methods

Only a brief outline is given, and the reader is

instructed to refer to the original papers for further
details. Forty female and 40 male, randomly chosen,
young and healthy (average age 22 years, range 18–45)
university students volunteered to participate.
The subjects’ voices were loaded by orally reading a
novel of their own choice (loading). The total reading
time was 5 ! 45 min. Three environmental or ergo-
nomic factors were controlled: output level (either
! 65 dB at 2 m or 1 65 dB at 2 m); posture (either sitting
or standing) and ambient air humidity (either 25 B 5
or 65 B 5%). The combinations (cells) of these vari-
ables amounted to 8, and there were thus 5 female and
male subjects in each cell (2 ! 2 ! 2 factorial design).
Five voice samples were recorded: (1) the first rest-
ing sample (rest 1) before the loading; (2) the first load-
ing sample after 45 min of reading (loading 1); (3) the
second loading sample after 3 ! 45 min of reading
(loading 2); (4) the second resting sample after the
lunch break (rest 2); (5) the third loading sample after
altogether 5 ! 45 min of loading (loading 3).
The recorded voice samples consisted of repeated
/pa:p:a/ word strings produced at a normal and as soft
and as loud a level as possible (speaking voice profile,
SVP). The first syllables of three /pa:p:a/ words were
separately stored on a disc for further analyses. During
the task, the subjects kept a plastic tube between their
lips for intraoral pressure recording. In addition, the
dynamic extremes of the subjects’ voices were mea-
sured at different pitches (voice range profile phona-
tions, VRP) using g, a, c1, e1 and g1 as model pitches
(males’ productions one octave lower). The energy at
the 2- to 4-kHz (‘singer’s formant’) range of the loud
phonation of the VRP phonations was also recorded.
The long /a/ vowel of the stressed syllable of the test
word /pa:p:a/ was inverse-filtered to obtain the glottal

224 Folia Phoniatr Logop 2004;56:220–253 Vilkman

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Table 2. Statistically significant (p ! 0.05) vocal warm-up, loading (morning samples: 3 ! 45 min) and rest
changes in parameters derived from SVP (loud, normal, soft) and VRP (loud, soft; SF = singer’s formant energy; g,
a, c1, e1, g1: target pitches) phonations

Time Test Females Males

rise drop rise drop

Warm-up SVP, loud AQ F0, d, SPL, p OQ, AQ

SVP, normal SQ, p ClQ, AQ
SVP, soft f, d, SPL
VRP, soft c1, e1
VRP, SF g, a, c1, e1, g1 a
Loading SVP, normal SQ ClQ F0, SPL OQ, AQ
SVP, soft f, d, OQ
Rest SVP, loud p
SVP, normal F0, ClQ OQ, SQ F0, OQ, AQ, lgf SPL
SVP, soft OQ, f, d, p

F0 = Fundamental frequency; SPL = sound pressure level; p = subglottal (intraoral) pressure; OQ = open
quotient; ClQ = closing quotient; SQ = speed quotient; f = flow amplitude; d = amplitude of the negative peak of
the differentiated flow.

flow waveform [23, 24]. The peak AC flow (f) and the
negative peak amplitude of the differentiated flow (d)
values were automatically determined (fig. 3). Their
ratio was calculated (amplitude quotient, AQ) [25]. In
addition, time domain quantification was performed
using the following parameters: (1) the inverse of the
length of the fundamental period (F0); (2) the ratio
between the open phase of the glottal cycle and the
length of the cycle (OQ); (3) the ratio between the
opening phase and the closing phase (SQ); (4) the ratio
between the closing phase and the length of the cycle
(ClQ). The sound pressure level (SPL) of the first sylla-
ble (Intelligent Speech Analyser, ISA, developed by
Raimo Toivonen, MSc) was measured. Subglottal
pressure (p) was estimated from the peak following the
long /a/ vowel of the first syllable.
In addition to objective data, a questionnaire was
also used to map the subjects’ voices use-related symp-
toms after each of the five loading sessions. There were
altogether 17 questions, which were combined into
five factors: (1) central fatigue; (2) symptoms of the
neck, shoulders and back; (3) drying of the mouth or
throat; (4) symptoms of the throat; (5) symptoms of the
voice.
Summary of Results and Discussion
Vocal Loading
All the subjects were able to complete the
5 ! 45 min loading test.
Statistical analyses were run separately for
the morning (rest 1 as baseline) and the after-
noon (rest 2 as baseline) samples. In the SVP
test, the normal voice level was more sensitive
to loading changes than the dynamic ex-
tremes. As can be seen in table 2, in the morn-
ing samples all changes refer to an increase in
phonatory effort. In soft phonation the phon-
atory threshold rose, i.e. getting phonation
started called for more effort after than before
voice use.
In the afternoon normal level samples, the
SPL, p and SQ values rose and ClQ dropped.
This result can be interpreted in the same way
as in the morning samples, i.e. as implying
increased effort. Again, the soft phonation

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samples showed p, d and f to rise. In loud pho-
nation, there was a drop in OQ and ClQ, both
of them signs of the remaining adductory
power to produce extremely loud phonation.
This was not, however, reflected in a system-
atic way in the output level in terms of SPL.
There were some statistically significant
gender differences. The direction of change
was opposite in SQ (normal level, morning
and afternoon samples; a rise for females and
a drop for males), reflecting the increased
skewness of the glottal flow waveform in fe-
males. In addition, the f values changed in
opposite directions (normal level, afternoon
samples: a slight rise for females, a drop for
males).
A review of the changes in the variable val-
ues over the entire test day shows that only a
few variables changed logically due to the
loading and the rest during the lunch break.
For instance, the F0 value of both females and
males rose in the normal output morning sam-
ples, but the rise continued past the lunch
break, and the values recorded at the end of
the test were, again logically, the highest. The
p values rose markedly after the first loading
session, but the next two loading sessions did
not cause the rise to continue (females’ and
males’ normal and loud output levels). All in
all, there were very few variables showing a
linear relationship with loading. For instance,
SPL showed (normal level) a slight rise for
both genders due to loading, a drop due to the
midday rest and a further rise in the after-
noon. For females, the f and d values in nor-
mal phonation reflected the tendency towards
more effort in voice production (rise due to
loading, drop due to rest). The conclusion was
that other phenomena apart from the direct
effects of vocal loading are involved. These
were studied further as the vocal warm-up
effect and the effect of a short voice rest.
As to the changes in the symptoms experi-
enced by the subjects, all factors changed sta-
226 Folia Phoniatr Logop 2004;56:220–253
tistically significantly during the vocal load-
ing. However, the score for the factor concern-
ing the drying of the mouth and the throat was
highest during the morning period of loading.
Effects of Vocal Warm-Up
It has been reported that vocal warm-up
takes place after approximately 30 min of
voice use [7]. In this study, therefore, its
effects were estimated as the change between
the first resting sample and the first loading
sample (table 2).
At the SVP normal level for females the
changes reflect the change towards the hyper-
functional direction, i.e. more effort in terms
of laryngeal adduction. For males, the
changes were more closely related to the loud-
ness axis than the type of phonation axis.
In the soft phonation of females, the
changes might suggest impaired function after
vocal warm-up. However, increased flow is a
causative factor of SPL via d changes. The
increase in AC flow (f) may be due to the
improved mobility of the vocal folds.
In loud phonation, the only statistically sig-
nificant finding was the drop in AQ values for
females, which implies a change towards hy-
perfunction or a more pressed type of phona-
tion [26].
VRP soft phonation results implied an in-
crease in effort. In loud phonation the singer’s
formant range energy increased as well.
In general, vocal warm-up is thought to
result in easier phonation. However, all the
results seem to indicate an increase in the
effort connected with voice production. The
background of this finding remains open for
discussion. It is possible that the primary rea-
son for these findings could be the improved
closure of the vocal folds, which increases
glottal resistance. One might expect that, in
such a case, the speaker would benefit from
this improvement and use less effort for nor-
mal voice production, thus, the phonatory
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threshold would drop rather than rise. In
female singers, after a 10-min warm-up ses-
sion, the phonatory threshold for higher
pitches rose statistically significantly [27].
Effects of Short Voice Rest
During the lunch break, in the SVP normal
level phonation the F0 rise of the morning
loading period continued (table 2). On the
other hand, SPL tended to drop, but this
change was only significant among male sub-
jects. Males also showed changes similarly
reflecting less pressed or softer phonation. In
females there was a similar trend, but the OQ
drop reflects improved glottal closure due to
voice rest. In soft phonation, the findings for
female subjects can be interpreted as signs of
improved vocal function due to the voice rest.
In males, loud phonation was logically pro-
duced by higher p after the voice rest, i.e. they
were able to improve their performance.
Effects of Ergonomic and Environmental
Factors
Humidity. In the morning samples, humid-
ity level combined with vocal loading affected
the loud phonation p and f values in a gender-
specific way: in females, the p values rose in
dry and dropped in humid conditions, while
the opposite was true in males. In loud phona-
tion, too, the f values of females dropped in
dry conditions and rose in high humidity,
while an opposite trend was again seen in
male subjects. During warm-up, a similar
loud phonation f change as above was ob-
served in females, in addition to which AQ
values (loud phonation) dropped in dry condi-
tions (no change in humid conditions), and p
values rose in dry and dropped in humid con-
ditions. As there was no simultaneous rise in
SPL in dry conditions, these findings imply
merely an increase in phonatory effort (with-
out any improvement in the target perfor-
mance).
Occupational Safety and Health
In male subjects’ warm-up samples, the p
values of soft phonation rose in dry and
dropped in humid conditions, i.e. their per-
formance improved. In loud phonation of
males (warm-up), the OQ values dropped in
dry and rose in humid conditions; the drop
can be considered a change towards a pressed
type of phonation. The lowest pitch (G) in the
male soft VRP analyses showed a trend to-
wards impaired performance (higher sound
level) in dry conditions and improvement in
humid conditions.
There is some earlier evidence to suggest
that rather extreme manipulation of body hy-
dration and ambient humidity affects the
phonatory threshold pressure [28, 29]. The
findings of the present series of studies imply
that even realistic variations in the ambient
humidity conditions bring about measurable
effects on vocal performance.
Female subjects had higher symptom
scores for all factors in dry conditions, sup-
porting the interpretation that the changes in
parameter values are related to fatigue (more
effort needed) [10].
Output Level. In the morning soft phona-
tion samples, the p values rose in the high-out-
put group and dropped in the low-output
group. The warm-up effects on normal phona-
tion were different in terms of F0 changes
among males: F0 rose less in the low-output
group. Males’ soft phonation samples showed
an increase of ClQ values and a drop of SQ
values in the low-output group, while an op-
posite trend was observed in the high-output
group, i.e. the subjects in the low-output
group were able to use a more sinusoidal pulse
form than the high-output group (warm-up).
Males’ VRP soft production at pitch A im-
proved (was lowered) in the low-output group,
whereas high output impaired performance.
Further, during vocal warm-up, the VRP loud
phonation at G showed improved perfor-
mance (higher sound level) in the low-output
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group, while in the high-output group the val-
ues dropped on the average. The singer’s for-
mant for the last-mentioned pitch among
males also showed an effect: the level dropped
in the low-output group and rose in the high-
output group. This finding can be interpreted
as adaptation or hyperfunctional develop-
ment in the high-output group. Among fe-
males, too, the output level affected both the
sound level and the level of singer’s formant
at the pitch G, but both levels dropped for low
output and rose for high output.
The lunch break effect was seen in normal
phonation as an SPL drop in the high-output
group (no change in the low-output group),
implying the positive influence of even a short
rest. In the afternoon samples, the SPL of the
loud phonation of males in the high-output
group dropped, whereas in the other groups
(females with low and high, males with low
output) performance improved. This is one of
the few results suggesting that a high output
level during loading started to cause vocal
fatigue.
Symptom scores showed no clear effects on
the different output levels.
Posture. Posture affected the three lowest
pitches (G, A, c) of male soft VRP phonations
in a systematic way due to vocal warm-up: the
level rose in sitting and dropped in standing
subjects. The background of this finding is
unknown. One possibility could be that the
psychophysiological state connected with
standing favours the delicate co-ordination
required by the softest possible phonation.
The loud extreme of VRP at the highest pitch
g showed a rise of sound level for the male
subjects who had been sitting.
The lunch break affected the loud phona-
tion SQ values of males: the values increased
in the sitting group and dropped in the stand-
ing group. The AQ for the normal level of
standing subjects rose more than that for the
sitting group. In VRP loud phonations of
228 Folia Phoniatr Logop 2004;56:220–253
males, the singer’s formant range energy
dropped in the sitting group and rose in the
standing group at the pitches e and g. These
findings imply less pressed phonation for the
subjects who had been sitting during loading.
This may, again, be understood as differences
in the psychophysiological activation levels.
For females, there was only one statistically
significant effect: in soft phonation the sound
level rose in the sitting group and dropped in
the standing group at c1.
The ‘symptoms of the neck, shoulders and
back’ factor showed higher scores for the sub-
jects who were standing during the loading.
Complex Interactions
There were many interactions between
gender, loading and two or three ergonomic
factors. Their interpretation is difficult and
calls for caution, because the number of sub-
jects in the subgroups is small. For instance,
the interaction between gender, loading and
two environmental factors leaves only 10 sub-
jects in each group. The conclusion that there
are complex interactions is clearly warranted.
I refer here to the original articles for more
detail.
OSH Conclusion
If we believe, as is generally believed, that a
low phonatory threshold or a large dynamic
range in low-chest phonation is advantageous
for a voice user, there is no doubt that low out-
put and high humidity are a good choice from
the point of view of the voice user’s health.
Our understanding of occupational voice
problems is based mainly on an analysis of the
problem in a cross-sectional situation in
which the voice disorder, similar to hyper-
function, is regarded as the cause of the prob-
lem rather than as a normal adaptation or an
attempt to compensate for the subtle organic
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changes caused by the heavy vocal load or, in
a more general sense, to cope with the de-
mands set by the working conditions.
Vocal Loading in the Field Conditions
of Teachers
In another series of studies, teachers’ voice
use and the changes occurring during the
working day and the week were studied [30–
35]. This study was the first to use speech
recordings made in field conditions, which
were later analysed in the laboratory. This set-
up provided an opportunity to use a wide
range of acoustic parameters. Results on F0,
SPL, jitter/shimmer and durational and spec-
tral characteristics are presented. Also, the
relationship between the subjective voice
complaints and the objective parameters were
studied.
Subjects and Methods
A brief outline will be given here; see the original
papers for further details. There were 10–12 female
primary and secondary schoolteachers in the studies
by Rantala et al. [32, 33] and Rantala and Vilkman
[34] and 33 female teachers in Rantala et al. [35]. The
teachers participated voluntarily. At the time of the
recordings they were capable of working, but most of
them experienced or had experienced various voice
complaints at work.
The recordings were made using a portable DAT
recorder and a microphone. Two separate sets of
recordings were made: a standard recording containing
maximally sustained phonation was made during the
breaks and a teaching speech recording was made dur-
ing the first and last lessons of an ordinary working
day. A questionnaire was used to collect information of
the subjects’ voice complaints in a cross-sectional situ-
ation only. A sum variable was formed of the results.
The recordings were analysed in a laboratory. The
following parameters were studied: (1) Running
speech: F0, SPL, phonation (F0) time using the analysis
environment described by Rantala et al. [31]. The F0
and phonation time results were used to formulate a
Occupational Safety and Health
simple index of vocal loading (index = F0 ! phonation
time), which gives the number of vocal fold vibrations
during the 4-min analysis period. Spectral parameters
were analysed using the Intelligent Speech Analyser
developed by R. Toivonen, MSc (Eng.), Tampere, Fin-
land. The spectral characteristics were determined
from stressed /a/ vowels in teaching speech [32]. (2)
Maximally sustained /a/ vowel phonation: F0, its stan-
dard deviation, jitter and shimmer using the Intelli-
gent Speech Analyser developed by R. Toivonen [33].
Summary of Results and Discussion
Teaching Speech and Its Changes during
the Working Day
The analysis of the recordings made during
lessons consisted of three 4-min samples of
the first and the last lessons. The samples
represented interactive teaching speech at the
beginning, halfway through and at the end of
the lesson. In terms of phonation time, i.e. the
time for which F0 was measurable, the values
were rather high: 30–40% of the total sample.
The order of magnitude was similar in mea-
surements made in Iceland [36] and also in
the work on customer service advisors [37]
(see above). The values obtained with other
methods, including sound level voice accu-
mulators, are generally higher [38]. The expla-
nation is that accumulators collect data dur-
ing breaks as well as during non-speech seg-
ments of teaching. On the other hand, it is
obvious that different speaking situations will
affect the percentage [33]. The values ob-
tained in the present series of studies reflect
the teaching style of the subjects in an interac-
tive situation. During teaching, F0 and SPL
are higher than in conversation [see also ref.
39–41]. It can be estimated from the index
values that the vocal folds vibrate – and col-
lide –1 million times during the daily working
hours of a female elementary schoolteacher.
In general, a static muscular load is consid-
ered to be more fatiguing than dynamic [11].
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As far as speaking voice is concerned, reading
aloud is apparently the most static kind of
voice use. The vocal folds vibrate for more
than 50% of the time [39]. In clinical practice,
reading aloud for children is often experi-
enced to cause vocal fatigue, which has also
been observed in questionnaire studies [42].
The use of automatic dictation machines also
involves a static load imposed on the voice.
There are already reports of occupational
voice problems related to the use of such
equipment [43].
During the day, F0 rose statistically signifi-
cantly from the first to the last lesson. The
order of magnitude of the F0 rise was 5% (n =
33). During the day, SPL values rose by
roughly 0.5 dB, but the rise was statistically
non-significant, as was the slight drop in pho-
nation time. The spectral characteristics
showed a levelling out of the spectral slope,
i.e. there was a relative increase in the energy
of the higher components. Two spectral pa-
rameters (the difference between the 2- to
5-kHz and the first formant regions, and the
ratio between the energies above and below
1 kHz) reflected this change statistically sig-
nificantly. The F0 rise in terms of the number
of vocal fold vibrations is a clear indication of
an increase in the workload. Spectral changes
refer to the increased adductory force of the
vocal folds, i.e. there is a shift towards hyper-
function along the hypo-hyperfunction axis.
Voice Complaints and Objective
Measurements
Teaching Speech. F0 (r = 0.28) and SPL (r =
0.27, n = 33) showed a statistically significant,
though low, correlation with the sum variable
of voice complaints when all the results were
pooled together. In addition, the index, i.e.
the number of vocal fold vibrations, showed a
significant correlation (r = 0.20).
When the samples and the single com-
plaint items were analysed separately, it
230 Folia Phoniatr Logop 2004;56:220–253
turned out that the second sample (recorded
halfway through the first lesson) showed the
highest correlations. For instance, ‘fatigue af-
ter loading’ (r = 0.53), ‘lack of vocal pene-
trance in noise’ (r = 0.55) as well as the sum
variable of voice complaints (r = 0.54, n = 33)
correlated moderately with the index. This
implies that there is a connection between the
amount of work done and the voice problems
experienced.
The results of spectral analyses (n = 10)
revealed another interesting connection with
the voice complaints: the general trend of rela-
tive increase in the energy of the higher spec-
tral components could not be maintained by
the subjects reporting more vocal complaints,
and the difference was most marked halfway
through the last lesson. The correlation be-
tween L1-L5 and the sum variable of vocal
complaints was also highest (r = 0.70) at that
time point. These results support the conclu-
sion that the levelling out of the spectral tilt
during vocal loading is an inherent character-
istic of a normally functioning voice during
tolerable vocal loading.
Sustained Phonation. The sustained pho-
nation samples were recorded during breaks
on three weekdays (Monday, Wednesday, Fri-
day) before the lessons, after the first lesson,
after the lunch break and after the last lesson.
A pairwise comparison of the samples for the
whole group showed, for instance, a decrease
of jitter between the sample recorded after the
first lesson on Monday and after the last les-
son on Friday. The lowest shimmer values
were also measured after the last lesson on
Friday. This value differed statistically signif-
icantly from many samples recorded on other
days.
Pooled over the entire material, the only
statistically significant difference between the
groups with few and many complaints, re-
spectively, was the higher standard deviation
of F0 in the group with many complaints. This
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finding might indicate that changes in the
vocal fold mucosa are causing some instabili-
ty, but this was not reflected in the jitter val-
ues, however. There was a trend towards high-
er F0 before and after the first lesson in the
group with many complaints on the 2nd day
(Wednesday) samples, which might be inter-
preted as a compensation for the changes in
organic loading. Shimmer values also differ-
entiated between the groups: on the 3rd re-
cording day (Friday), after the last lesson, the
values were lower for the group with many
complaints. This finding suggests that more
strained voice production stabilizes the sus-
tained phonation, which is, again, most likely
due to the subjective voice symptoms.
OSH Conclusion
Analyses of tape-recorded field material
proved to be highly informative. The results
confirm the assumption based on the labora-
tory study that the F0 rise and the levelling out
of the voice spectrum should be considered
physiological changes of normally functioning
voices. Also, the teachers’ sustained phona-
tion samples recorded during breaks reflected
similar trends as far as the decrease in shim-
mer values is concerned. The analysis of both
teaching speech and sustained phonation
samples revealed features that distinguish be-
tween the teacher groups experiencing many
and few voice complaints.
General Discussion and Conclusions
on Laboratory and Field Studies
From the point of view of OSH develop-
ment, attempts to define the state of vocal
health (see below) solely on the basis of the
speaker’s subjective evaluation would be
problematic. In this sense, it is very important
Occupational Safety and Health
that significant, though low, correlations be-
tween the scores of subjective complaints
(symptoms) and objective measures were
found, i.e. field examinations can be expected
to provide objective evidence of occupational
voice disorders diagnosed in a clinical setting.
Naturally, a clinical examination of voice and
larynx may reveal objective correlates of a
work-related voice disorder as well.
The F0 rise can be considered an inherent
feature of vocal loading. The loading-related
rise is, however, not linear, as was noticed in
the laboratory study: there was an initial rise
due to loading, and vocal rest (lunch break)
caused the F0 values to rise further, the differ-
ence between the morning and afternoon
samples among both females and males being
of the order of 5%. The teaching speech sam-
ples also showed a similar increase in F0 val-
ues in the last lesson compared to the first. An
alternative explanation for the loading change
would be that the rise was based on diurnal
F0 variation. However, in a well-controlled
study, in which 60 normal male subjects un-
derwent an experiment that did not involve
the use of voice, the F0 changes during the day
were dependent on the subjects’ psychophy-
siological state, i.e. no time effect was ob-
served [44]. In a recent study of females and
males during a day when normal social con-
versational vocal loading was permitted, no
statistically significant F0 changes implying a
circadian rhythm were observed [45].
Another normal feature of vocal loading,
also observed in both laboratory and field
studies of teachers, is the shift in the type of
phonation towards the hyperfunctional direc-
tion along the hypo-hyperfunctional axis, i.e.
there was an increase in effort. The laboratory
studies showed that there are parameters,
such as the negative amplitude of the first
derivative of the glottal flow waveform, whose
changes reflect vocal loading, i.e. there is a
consequent rise due to vocal warm-up and
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Table 3. Ad hoc characteristics of the dynamics of
vocal loading (see text for details)
Early stages or warm-up and tolerable vocal loading
Subjectively positive sensations (warm-up) or increase
in symptoms of fatigue (loading)
Rise in F0
Rise in SPL
Phonatory threshold pressure rise
Change towards hyperfunction
Short vocal rest
Subjectively positive sensations
Rise in F0
Recovery of some loading changes
Vocal overload
Increase in symptoms of fatigue
No F0 change
No SPL change or loss of output power
No change or change towards hypofunction in type of
phonation
loading and a drop due to voice rest during a
lunch break. It is noteworthy that the primary
source of acoustic power, the subglottal pres-
sure, also shows the highest values in the after-
noon, but the changes during the day reflect
the major effects of especially vocal warm-up.
The field studies also showed that vocal load-
ing results in a tendency towards an increase
in the energy levels of the higher spectral com-
ponents. An ad hoc list of objective correlates
of different stages of vocal loading is present-
ed in table 3.
Telemarketers have been reported to expe-
rience twice as many voice symptoms than
the control group of subjects with a low level
of vocal loading [46]. In a field study, vocal
loading and its effects on the voice of custom-
er service advisors (CSAs), who mainly use
the telephone during their working hours,
were investigated [37] (see below). The pro-
ject was sponsored by the largest Finnish tele-
communications operator Sonera (currently
Telia-Sonera). Four recordings of 27 female
232 Folia Phoniatr Logop 2004;56:220–253
CSAs were made using a microphone and a
DAT recorder at the workplace. The record-
ings were 20 min long and took place at the
beginning of the working day (sample 1), be-
fore the meal break (sample 2), after the meal
break (sample 3) and at the end of the working
day (sample 4). A 5-min excerpt of each sam-
ple was analysed using a computer-based
analysis program [47]. The program classifies
the excerpt into segments of voiced speech
and unvoiced speech in a semiautomatic fash-
ion. The following parameters were studied:
fundamental frequency (F0), SPL and the ra-
tio between the spectral energies below and
above 1,000 Hz (alpha ratio) and speech seg-
ment information, such as the speech-to-
silence ratio. The proportion of voiced seg-
ments (time of vocal fold vibration) remained
stable throughout the day. It accounted for
35–37% of the total length of each excerpt, i.e.
it was very similar to that of teaching speech.
The F0 of CSAs also rose during the day (F01:
185.2 B 6.6 Hz vs. F04: 189.4 B 7.5 Hz). SPL
remained stable (approximately 88 dB at
6 cm). The F0 and SPL levels of the CSAs
were much lower than those of teachers [35].
The reason for this is obvious: the background
noise level (45 dBA) [48, 49] was low despite
the fact that the working space was an open-
plan office. The SPL level of speech corre-
sponds approximately to 55 dB at 1 m, i.e. to
normal or even soft speaking voice (relaxed
level according to ISO9921-1) [50]. From the
vocoergonomic point of view, this is naturally
a very positive finding.
Alpha ratio changed towards the hyper-
functional direction during the meal break,
i.e. there was a levelling out of the spectral tilt.
A short vocal rest during loading has been
observed to cause significant changes in var-
ious vocal parameters (see above) [20]. The
change towards the hyperfunctional direction
in this case can hardly be considered poten-
tially harmful. The change together with the
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simultaneous slight rise in SPL might imply a
recovery of the vocal organ or perhaps of the
psychophysiological state.
It was estimated by the employer that the
net time spent on the phone was approximate-
ly 5 h for CSAs, and by combining this infor-
mation with the relative vibration time and
the F0 results, it was calculated that the num-
ber of vocal fold vibrations is of the order of
300,000 per working day. Compared to teach-
ing, this figure for CSAs (vs. 1,000,000 in
teachers) [30] is considerably smaller. Despite
the lighter vocal workload, the changes in
acoustic parameters and the changes in voice
symptoms during the working day were well
in line with the laboratory study and the field
study of teachers. The process of setting
norms for vocal loading also seems compli-
cated in the light of the reported Polish expe-
riences: the maximum number of weekly
working hours of teachers is 18 [51], but occu-
pational voice disorders continue to be com-
mon [52] (see below).
The background of the F0 rise and the
increase in effort may be linked with the gen-
eral principles of physiological activity. From
the point of view of vocal ergonomics, how-
ever, these changes obviously increase the
speaker’s workload. Whether or not this as-
pect should be addressed as part of vocoer-
gonomic measures remains open for discus-
sion and further research. As the increase of
effort is an essential part of vocal loading, it is
natural that when a speaker or singer runs into
trouble during performance, the solution of
choice is to increase effort, which often leads
to further impairment of vocal function. This
may give rise to a vicious circle.
The manipulation of ergonomic factors in
the laboratory studies affected mainly the re-
sults of the extremes of performance tests, not
normal phonation. Both single and combined
effects were observed. Apparently, the manip-
ulation of the conditions can be compensat-
Occupational Safety and Health
ed for in normal phonation, but comes into
light when extreme vocal performance is de-
manded. The results of the effects of humidity
in the light of common clinical and normal
life experience permit the interpretation that
high humidity levels are recommendable. As
to the relative humidity levels, there are no
recommendations. In practice, values around
65% could be a reasonable target. The output
level used during vocal loading was also re-
flected in voice production, naturally showing
an increased level of effort. Here, too, no safe-
ty limits are known as to how high an output
level can be considered safe in speaking situa-
tions. The CSAs reported an increase in voice
fatigue during the day despite their low speech
output level. The most obscure of the three
factors studied was posture while speaking. It
affected the loading results, but apparently no
recommendations can be given so far. Still,
the result warrants trials in practical situa-
tions. Indeed, for all these factors, there was a
great deal of individual variation. This im-
plies that, when improvements of working
conditions are planned, the solutions should
be largely individual.
As to the links between voice complaints
and objective parameters, in the field studies
the number of glottal vibrations (index) corre-
lated positively with the scores of voice com-
plaints, especially in the middle part of the
first lesson. This finding raises the crucial
question of a causal relationship between the
two variables. The index showed higher corre-
lations than its components F0 and phonation
time. Because there were findings showing
that the groups with many and few complaints
already differed in some respects in the morn-
ing before the lessons, the behaviour of the
index values should be understood as a com-
pensation for minor changes at the vocal fold
level. An F0 rise can be used unconsciously to
stabilize phonation. In the laboratory study,
female subjects reported an increase in the
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roughness of voice during loading. On the oth-
er hand, phonation time can be considered to
reflect the teaching style, but it is also possible
that, as the differences were rather small, the
intonation patterns differ parallel to the sub-
jective voice complaints: those with many
complaints are not able to produce soft vocal
attacks or ends of phrases due to organic
changes, leaving more vocal cycles to be mea-
sured. All in all, the higher index values of the
subjects with many voice complaints repre-
sent a risk of further impairment of the voice
in a physical sense. No doubt, this is a clear
target and challenge for vocoergonomic mea-
sures at work. As the change towards hyper-
function during continuous speaking can be
considered a normal phenomenon, it is inter-
esting to note that the subjects who experi-
enced more problems could not follow this
trend. In other words, the physiological back-
ground of the personal feelings of vocal health
and well-being are of dynamic character.
Based on the reviewed studies, it can be
concluded that vocal loading per se changes
phonation in such ways that the question can
be raised as to whether these changes repre-
sent a risk for vocal health. The combination
of elevated phonation threshold, heightened
F0 and increased effort might be an ‘unhappy
triad’ calling for attention when improving
the vocoergonomics of professional speakers.
It apparently reflects adequate adaptation to
the working task, which can be misinterpreted
in voice clinics as the cause (voice abuse) of
the voice problem.
Voice Demands at Work and Voice
Disorders
It has been estimated in Finland that ap-
proximately one fourth of the total Finnish
labour force are working in professions that
require the use of voice [53], and similar sta-
234 Folia Phoniatr Logop 2004;56:220–253
tistics have been presented for the USA [54].
The biggest groups of voice users consist of
persons working in business and in teaching
professions. Other large groups consist of tele-
phone operators, military personnel and cler-
gy. Smaller groups important from the point
of view of voice use are radio and TV staff as
well as singers and actors [53]. In addition,
there are industrial workers whose tasks in-
clude voice use at high levels of background
noise when giving instructions, for instance,
which may place their vocal health at risk [5].
As to the subjective voice complaints of
teachers, the results of relevant studies can be
summarized as follows: a majority of teachers
have experienced vocal problems, about one
tenth can be considered to have severe prob-
lems, and 5% have experienced so severe,
numerous and frequent voice problems that
there working ability is questionable [55–60].
Kindergarten teachers also experience voice
problems [38, 61]: in one study, all subjects
reported experiencing or having experienced
voice problems [61]. A recent study showed
teachers to be at a considerable risk for
chronic voice problems [62], and a follow-up
study of students revealed a similar tendency
[63].
How should a voice disorder be defined?
As far as working ability is concerned, it is
obvious that if an individual’s voice does not
meet the occupational criteria and demands
(table 4), we should talk about a voice disor-
der from the occupational point of view. In a
vast majority of cases, voice endurance is the
essential part of vocal health. However, when
we consider the tradition of our logopedic-
phoniatric discipline, it is apparent that very
much effort has been invested in describing
aspects of vocal quality by using objective and
subjective methods in cross-sectional and
therapeutic setups, whereas there are very few
studies on vocal behaviour in working condi-
tions [31, 64–66]. Voice quality has been con-
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Table 4. Classification of voice and speech professions according to the demands on voice quality and vocal
loading from the point of view of working ability

Quality Loading Profession

+++ ++ Actors, singers (0.3%)

+++ ++ Radio and TV journalists (0.2%)
+ +++ School teachers and kindergarten teachers (16%), telephone operators (0.9%),
telemarketers, military (1.4%), clergy (0.3%), cantors
++ ++ Bank, business and insurance personnel (50%), physicians (0.2%), lawyers (0.1%),
nurses (0.5%)
+ ++++ Foremen, welders, platers

The proportion out of the total number of voice professionals in parentheses. Proportions partly from [1995].
+++ = High significance; ++ = moderate significance; + = low significance.

sidered the primary outcome measure in
voice therapy efficiency studies. Both percep-
tual and objective measures have been used,
and the results show that voice quality
changes take place in the way researchers
expected [see ref. 67, for a review]. This con-
clusion could be considered obvious, as voice
training has been successful, throughout cen-
turies and in obviously all human cultures, in
mediating the various vocal traditions of each
particular culture.
From the point of view of working ability,
however, occupations calling for voice use dif-
fer notably as to the demands they make on
voice quality (table 4). To clarify this view-
point, it can be stated that, in most clinical
situations, the way a voice sounds is not cru-
cial, and the core of the problem lies in the
way it serves as the carrier wave in the speech
communication situations the subject is faced
with. An example of the odd consequences of
choosing voice quality parameters as primary
outcome measures, we could mention a recent
study where jitter and shimmer measure-
ments were used to detect the effects of in-
haled corticosteroid treatment for asthma
[68]. The authors concluded that the patients’
voices improved because it was found that
shimmer values dropped at the 5% level of
significance due to the treatment without any
attempt to relate the finding to the patients’
coping or even a perceptual evaluation. This
finding, or actually its interpretation, is con-
tradictory to earlier studies and clinical expe-
rience.
The coping with the vocal (work) load set
by the tasks should be considered the primary
outcome measure in studies on voice treat-
ment outcomes. This view is emphasized by
studies comparing voice quality and coping,
in which no significant correlation was found
in a cross-sectional test (Voice Activity and
Participation Profile) [69], or in a therapy out-
come study (Quality of Life Index) [70]. There
is no doubt, however, that in some cases there
is a relationship between these aspects. In gen-
eral, it is necessary to establish objective phys-
iological and acoustical change patterns that
correlate with subjective data in the long run.
This line of thinking is related to the World
Health Organization’s International Classifi-
cation of Impairments, Disabilities and Han-
dicaps [71] (fig. 4). According to this frame-
work, an impairment, e.g. hoarseness, is a ‘de-

Occupational Safety and Health Folia Phoniatr Logop 2004;56:220–253 235

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 Health condition (ICD 10)

Body functions
Activity Participation
and structures

Environmental Personal
factors factors

Fig. 4. The WHO (2001) framework of health condition (ICD 10 = International Classifica-
tion of Diseases, WHO, 1990) related activity and participation restrictions. Limitations on
activity can be solved by modifying environmental and individual factors.

viation from certain generally accepted popu-
lation standards in the biomedical status of
the body ... definition undertaken ... by ...
those qualified ... ’, and ‘Impairments ... do
not ... indicate that a disease is present or that
the individual should be regarded as sick.’
Based on statistical probability, if we as-
sume that voice quality is normally distribut-
ed in a population, we should find about 16%
of people having slightly impaired (–1 stan-
dard deviation) voice qualities and 2.5% hav-
ing markedly deviating (–2 standard devia-
tion) voice qualities. In the WHO structure,
the need for rehabilitation is determined by
whether or not there are limitations on activi-
ty and participation.
Against this background, it goes without
saying that the frequently used normative
concept of ‘pathological voice’ based on per-
ceptual or instrumental analyses should be
avoided in any clinical context. However, de-
viant voice quality and voice function impair-
ment may be extremely important signs of
underlying pathology. The cause of hoarse-
ness that has lasted for more than 2 or 3 weeks
should always be examined lege artis.
Vocal Loading and OSH
The current status of voice care and cure
and the voice disorders of European voice and
speech professionals as an OSH issue were
studied a few years ago [51]. A comprehensive
enquiry was sent to all European countries
(basically one questionnaire to each), and
completed questionnaires were received from
altogether 15 countries. Professional voice us-
ers were divided into four groups: high voice
quality demands (e.g. singers, actors), high
(e.g. teachers, child minders) and low (e.g.
doctors, secretaries) vocal loading and others
(e.g. foremen, platers, welders). The following
aspects derived from the European OSH legis-
lation [3] were investigated: prevention and
surveillance, training, working environment,
protective equipment, diagnostics and treat-
ment, and social and economic aspects. The
inevitable conclusion of the survey was that
the OSH situation of voice and speech profes-
sionals is poor in Europe. Besides, textbooks
of occupational medicine, OSH and ergonom-
ics do not even mention professional voice
problems.

236 Folia Phoniatr Logop 2004;56:220–253 Vilkman

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 There is no doubt that application of the
principles and legislation of OSH to the care
and cure of occupational voice disorders
would be fair and right from the point of view
of occupational voice and speech users. It
would improve the possibilities of voice clini-
cians to arrange training and surveillance and
to develop services, disseminate information,
participate in developing working environ-
ments and carry out risk analyses (table 1).
Is it possible, then, to prove that occupa-
tional voice problems are caused by risk fac-
tors present at the workplace and should,
thus, be considered as an OSH issue? As the
OSH thinking originally developed in the tra-
ditional ‘blue collar’ professions, it seems
plausible to look at the analogies between the
physical workload in ‘blue collar’ and voice
and speech professions. Firstly, the vocal or-
gan should be defined as one of the locomotor
systems of the body. Secondly, to understand
the wide variety of symptoms reported by
patients [72] and occupational voice users
with voice disorders [e.g. 34, 35, 38, 42], it is
also important to make a distinction between
the anatomical and the physiological larynx,
as suggested by Kenyon [73] as early as in the
1920s: ‘Particularly, the larynx, hyoid and
base of the tongue cannot but be considered as
a physiologic entity. The larynx is suspended
from the hyoid bone, the hyoid from the base
of the tongue, the tongue from the lower jaw
and the skull. All three are intimately in-
volved in a complicated musculature whose
action alters their relationship to each other
and to the fixed bony structure of sternum,
spinal column and skull. They constitute defi-
nite factors in vocal cord physiology and all
must be considered as belonging to the physi-
ologic larynx.’ This means that the voice and
speech production put a load not only on the
vibrating structures of the larynx but also on
the so-called external frame of the larynx
[13].
Occupational Safety and Health
Questionnaire studies of subjective voice
problems comparing teachers with other pro-
fessional groups have shown that teachers ex-
perience more voice problems [38, 55–57]. In
clinical series, too, patients with vocally de-
manding jobs are overrepresented [54, 74,
75]. Studies of this kind, however, do not
alone prove that teachers’ voices are at risk at
work, as it can be claimed that voice profes-
sionals consider their voice more important
and are more aware of their vocal symptoms
and also more easily referred to voice clinics
than other people. More evidence of occupa-
tional risks will be presented below.
Occupational Hazards
The total load consists of the single and
combined effects of various loading factors,
shown in figure 5, which may also appear as
occupational health hazards and risks. The
term ‘hazard’ is defined as a source or situa-
tion potentially harmful in terms of injury or
ill health. Risk, in turn, is a combination of
the likelihood of occurrence of a specified
hazardous event and the severity of injury or
damage to health caused by this event [76,
77].
In figure 6, the linkage between loading
factors and voice production is shown. As
gender and psychosocial and personality fac-
tors will influence voice production at all lev-
els, they were excluded from the figure. How-
ever, there is much evidence that female gen-
der is a risk factor not only for voice disorders
[57, 60, 75, 78] but also for other work-related
problems of the musculoskeletal system [79].
It has been suspected that the statistical fe-
male predominance in musculoskeletal disor-
ders would disappear if the physical load were
matched to the gender differences in body
proportions and muscular strength [79]. In a
similar way, it would be important to study
the effects of compensating for the gender dif-
ference in the number of vocal fold vibrations
Folia Phoniatr Logop 2004;56:220–253 237
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Loading factors
Fig. 5. Vocal loading factors and
individual co-factors influencing
the coping with the vocal work-
load.
(see below). The hypothesis would be that the
vocal symptoms of females and males would
be equal if the working hours of females in
vocally demanding professions would be half
(F0 difference) of that of males. In addition,
the gender difference in voice problem statis-
tics may be affected by the fact that women
more often care for children at home, which
may involve a considerable additional vocal
load.
The psychosocial aspects of work have
been grouped into stressors arising from work
organization, job and task design, technology
and working environment [80, 81]. Stress
brings about voice changes that are based on
the general physiological consequences of psy-
chophysiological arousal. Stress has been
found to be connected with a rise in F0, sound
level and spectral characteristics (vibratory
features) of voice [44]. It is also a common
problem in stressful situations that vocal fold
vibrations are hampered by mucosal dryness.
The increased muscular tone doubtless also
affects the external frame of the larynx. Fe-
238 Folia Phoniatr Logop 2004;56:220–253
Coping with loading
Contributing individual
factors
duration of voice use gender
background noise endurance
room acoustics health condition
quality of air life habits
other ergonomics vocal skill, experience
psychosocial psychosocial/personality
male teachers have been found to have ‘higher
depression levels’ in a study comparing occu-
pational differences in anxiety and depres-
sion. Depression has been found to show con-
siderable similarities with burnout symptom-
atology [82, 83].
Individual factors that affect the coping
with vocal loads include such aspects as con-
stitutional vocal endurance, which is likely to
be based on genetic variations in the biome-
chanical properties of the vocal folds [84].
Individual skill may affect the effectiveness of
voice production at the level of glottal func-
tion [85, 86] or the person’s ability to main-
tain a relaxed level of muscular activity with-
in the physiological larynx [87].
As to the individual’s health condition in
clinical practice, the most important contrib-
uting factor to the development of an over-
load situation is infection of the vocal folds,
which temporarily reduces the endurance of
the mucosa. Asthma and its medication are
also common problems suspected to reduce
the loading endurance of the voice [88].
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 Below, loading factors (fig. 5), which can
also be called vocoergonomic factors, will be
characterized as hazards and risks for vocal

other ergonomics
health. The number of vibrations, or phona-
tion time (also: F0 time) [30], is not only

vocal skill
dependent on the voice production at work
and leisure time (life habits: e.g. parental du-

external frame
ties, hobbies) use, but also closely linked with
the output level of speech in normal subjects.
This can be easily understood when the basic
task of the voice is kept in mind. It can be
defined as the carrier wave of the speech.

health condition
quality of air
Within this carrier wave, the main energy is
produced during the closing phase of the vocal

vibratory properties
fold vibration period, i.e. when the glottal
flow declination reaches a maximum detect-
able as the negative peak of the first derivative
of the glottal flow waveform, which, in turn,
determines the output level of speech (fig. 3).

background noise

other ergonomics
To raise the output level, shortening of the

room acoustics
glottal period, with the other relationships

vocal skill
vocal organ

kept constant within the glottal period, will

phonatory features

make the derivative deeper simply because

there is less time for the closure to take place
[89].
The primary loading factor in voice and
speech professions is naturally the need for
background noise

prolonged use of the voice, i.e. the repetitive

room acoustics

movements. Field examinations of teachers

have revealed that, during teaching, the vocal
folds vibrate for 15–40% of the teaching time
output level

[35, 38, 39] (see above). It has been reported

that the voiced ratio is lower in professions
where voice problems are less common, such
duration of voice use

as office work [41]. A simple calculation (e.g.

background noise

room acoustics

assuming that phonation time accounts for

30% of total teaching time) shows that, during
life habits
number of v.f. vibrations/
phonation time

Fig. 6. Effects of vocal loading factors and individual

co-factors on voice production. Gender, personality
and psychosocial factors have been omitted, as they
can be expected to affect all aspects of voice produc-
tion.

Occupational Safety and Health Folia Phoniatr Logop 2004;56:220–253 239

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a five times 45-min working day, a female ele-
mentary schoolteacher uses about 1,000,000
vocal fold vibrations (fundamental frequency
250 Hz). The corresponding value for CSAs
was about 300,000, the main explanation be-
ing their lower F0 (see above). The total num-
ber and frequency of vibrations account for
the greatest number of repetitive movements
taking place in the human body. It is also
important to remember that, during each vi-
bration, the vocal fold mucosae collide. It
seems logical to assume that these collisions
may lead to repeated injuries, which are re-
paired by the body with connective tissue
thickening, occasionally resulting in nodules
[90]. In this sense, vocal fold vibrations are
the physical factor present at work presup-
posed by the occupational disease legislation
(see below). As the number of vibrations used
at work is closely related to F0, it is important
to bear in mind that many studies show that
F0 in teaching situations may be much higher
than the level comfortable for the subject [40,
91]. This is naturally related to the greater
voice output demands set by the working task
[41, 66, 92].
Based on the above calculations, it can be
estimated that identical phonation times
cause a 50% lower total number of vibrations
in a male than a female speaker. This is most
likely the main reason why female teachers
generally report significantly more often voice
problems [57, 60]. It is also tempting to as-
sume that these figures have something to do
with the fact that vocal nodules are almost
exclusively seen in females only and very sel-
dom in tenor singers. It has also been suggest-
ed that the gender differences in the histo-
chemical structure of the vocal fold mucosa
may play a role in this respect [93]. The latter
does not, however, explain why there is a
reversed gender difference in the prevalence
of vocal nodules in premutational voices
[94].
240 Folia Phoniatr Logop 2004;56:220–253
It is well known that a high output level of
phonation is fatiguing and leads to hoarse-
ness, loss of voice or discomfort even after a
short period of voice use. The effects of ex-
treme shouting on the vocal folds and voice
were studied by Lira et al. [12]. The results
showed reddening and swelling of the vocal
fold mucosa, but occasionally also bowing of
the folds, implying a loss of muscular force of
the thyroarytenoid muscle [12]. It has further
been observed that a higher output level
(!65 dBA vs. 165 dBA at 2 m) during pro-
longed loading is reflected in the voice perfor-
mance tests [17, 18] (see above).
Speakers and singers are often compelled
to use a high output level due to their working
conditions. Background noise makes the
voice user to automatically raise the loudness
of speech due to the Lombard effect. Accord-
ing to an ISO standard [50], the ratio of
speech output rise to increased background
noise level is +3–6 dB/+10 dB, starting from a
40 dB level of ambient noise (ISO). Back-
ground noise levels of 75–80 dBA have been
found to be relatively common in kindergar-
tens and schools [38, 39, 61, 95, 96]. The
background noise level is increased due to
reverberation in the space used [95–97]. On
the other hand, excessive damping when us-
ing voice outdoors, for example, is an extra
loading factor for voice production, as there is
no feedback in terms of acoustic reflections.
Further, as voice intensity drops by 6 dB per
doubled distance, an increase in the distance
between the speaker and the listener also rap-
idly leads to increased effort by the speaker.
The latter conditions are commonly experi-
enced by clergy and sports teachers [42, 97].
In a noisy environment or a large room,
projection of the voice is necessary for a per-
son to be heard. In terms of the type of phona-
tion [85] and the glottal waveform shape, this
calls for the production of a sharp enough neg-
ative peak amplitude of the first derivative.
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Consequently, on the hypo-hyperfunctional
or breathy-pressed dimension, a shift towards
the hyperfunctional or pressed direction
usually takes place following a rise in the
speech output level. The sharpness of the neg-
ative peak of the first derivative of the glottal
flow waveform correlates closely with the
(normalized) amplitude quotient [(N)AQ]
(fig. 3) [37, 98]. Other ergonomic factors, es-
pecially posture while working, may also be
reflected in the type of phonation and, even
more so, in the state of the external frame of
the larynx.
The F0 rise, the elevated phonatory thresh-
old, and the change of the phonatory features
in a hyperfunctional direction as a normal
physiological adaptation to the loading [17–
22, 30–35] (see above) obviously add to the
weight of the vocal load, but the practical sig-
nificance of this phenomenon, potentially an
‘unhappy triad’, is not known.
Air quality factors, especially humidity
and dusts, moulds (‘sick building syndrome’),
fumes and mists, may affect directly the vi-
bratory properties of the vocal folds. As
stated above, high humidity of ambient air
has been found to be beneficial for vocal fold
vibrations [8, 17, 18, 28, 99] (see above).
Also, such humidity-related aspects as the
state of the vocal folds [100–102] and overall
body hydration [29] have been found to play
a significant role in this respect. There is also
interaction between air humidity and dusts,
as dry air increases the amount of air-borne
dust, which may also dry the vocal fold mu-
cosa [103]. As to fumes in indoors air, the
glues, paints, etc. used in modern construc-
tion and furniture may affect the mucosa of
the upper respiratory tract [104] and thus
alter the vibratory properties of the vocal
folds.
The final objection to voice problems at
work being an OSH issue that can be present-
ed is that ‘if there are risks at work, why do not
Occupational Safety and Health
all teachers develop occupational voice prob-
lems?’ According to questionnaire surveys, a
majority of teachers do experience voice
problems at some stage of their career [55, 61,
92]. Those who do not can be considered to
have an exceptionally endurable vocal appa-
ratus, or they have taken individual initia-
tives to improve the occupational safety and
health arrangements. In addition, it is known
from clinical experience that occasional fac-
tors, especially respiratory infections, play a
major role in the evolution of a long-term
voice problem at the individual level.
It can be concluded that there is a causal
relationship between the total physical work-
load on the vocal apparatus and the voice
complaints experienced by voice users, and
that working conditions involving a need for a
high speech output level and prolonged voice
use have a negative interactive effect on vocal
health. No doubt, there is a physical/physio-
logical basis for interpreting occupational
voice disorders as an OSH issue.
Measuring Loading
Figure 7 shows the parameters used in
studies on vocal loading. As to the different
ways of collecting data of long-term voice use
in field conditions, the methods can basically
be divided into two groups: (1) audio-record-
ings made in the field and analysed with lab-
oratory computers [30–36, 105, 106], and
(2) portable microprocessors with analysis
programs storing the results of the analyses,
called dosimeters or voice accumulators
(time, F0 [64, 107]; time, SL [41, 65, 66, 108];
time, F0, SL [109–111]). The major advantage
of the aforementioned approach is that the
laboratory analyses are not limited in any
way, whereas the major drawback is that the
analysis process can be very laborious and
time-consuming. The opposite holds true for
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number of v.f. vibrations/
output level
phonation time
fundamental frequency
vibrating time
Fig. 7. Parameters used in vocal loading studies.
the portable, microprocessor-based methods
[107]. Specifically in detecting voice changes
taking place during a working day, it seems
that the only way to do this is to rely on
audio-recordings to ensure that the samples
chosen for comparisons represent comparable
speech situations. It goes without saying that,
from the point of view of OSH problematics,
work-related voice changes are of paramount
importance.
The voice analysis results of loading exam-
inations in the field can be further elaborated.
One possibility is to combine the phonation
time and F0 data, which gives the number of
vocal fold vibrations. This has been called the
vocal loading index [30]. Svec et al. [109] have
postulated relevant vocal doses: the time
dose, the cycle dose and the distance dose.
The time dose is equal to phonation (F0) time
[30], and the cycle dose measures the total
number of cycles accomplished by the vocal
folds (vocal loading index) [30]. The distance
dose measures the total distance travelled by
the vocal folds on their mediolateral oscilla-
tions. The distance dose is sensitive to both
the frequency of oscillation of the vocal folds
and the vocal output because the estimated
amplitude of the vocal folds changes with the
242 Folia Phoniatr Logop 2004;56:220–253
vocal organ
vibratory characteristics,
external frame
phonatoryfeatures
sound (pressure) level source waveform electromyography
subglottal pressure spectrum
source waveform short term variation
vocal output. Svec et al. [109] have estimated
that the safety limits set for vibrating hand-
held tools (520 m accumulated distance per
working day) are exceeded in less than 1 h
while speaking at a comfortable level.
In laboratory loading tests, it is possible to
use, in addition to acoustic analyses, a wider
variety of physiological, e.g. electromyograph-
ic recordings [53, 88] or to measure aerody-
namic parameters, such as airflow [112] or
subglottal pressure [19].
Measurements of the loading factors set by
the working task and present in the working
environment are given in figure 8. The mea-
surement of phonation time was presented
above. The principles of background noise
measurements are well established [97],
whereas reverberation time and speech trans-
mission measurements are probably not so
often performed, but as they are important
from the point of view of both the speaker and
the listeners, their use should be a routine part
of any examination of the working conditions
of voice and speech professionals. Rasti mea-
surement is a subtype of the speech transmis-
sion index [92, 96]. It is a commercially avail-
able method measuring speech in two-third-
octave bands, centred at 500 Hz and 2 kHz,
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duration of voice use background noise
phonation time sound (pressure) level
Fig. 8. Assessment of loading factors.
respectively. It uses a speech-like excitation
signal and correlates modulation depth to loss
of intelligibility. The deterioration of intelligi-
bility is mainly a problem to the listener, but
in an interactive situation, it will lead to repe-
titions and probably to louder voice use by the
speaker to improve the penetration of the
message.
As to examining air quality, measurement
of humidity is a simple task, and a hygrometer
should be included in the standard equipment
in rooms predominantly used for speaking
and singing. Analyses of dusts, moulds, va-
pours, fumes, mists, etc. call for special meth-
ods [113] which, however, are usually avail-
able at OSH institutions.
The general principles of speech and sing-
ing training are the basis for observations con-
cerning other ergonomic aspects (e.g. posture)
of the working place of voice and speech pro-
fessionals. In addition, the use, quality and
condition of voice amplifiers, if any, should
be included in the observations. To the best of
my knowledge, there are no checklists that
could be used in on-site examinations of the
working conditions of voice and speech pro-
fessionals.
The principles for work-related psychoso-
cial stress analyses and prevention are well
developed within the OSH systems, and there
is a plethora of methods and approaches to
choose from [114].
Occupational Safety and Health
loading factors
room acoustics quality of air other ergonomics psychosocial
humidity observation
reverberation time
dusts, moulds observation questionnaire
speech transmission
vapours, gases, mists stress hormones
Work-Related Voice Problems as an
Occupational Disease
As to the socio-economic consequences of
occupational voice disorders, perhaps the
most important issue is their status as an
occupational disease. In some countries (En-
gland [115], Finland, Poland [52]), an occupa-
tional voice disorder may be recognized as an
industrial injury or an occupational disorder,
although this is far from the rule. Probably the
most comprehensive statistics of the inci-
dence of work-related voice disorders are
available from Poland. According to the sta-
tistics, voice disorders are the biggest group of
all announced cases of occupational diseases.
The proportions have varied between one
fourth and one third during the past 5 years.
In 2002, the number of reported new cases of
voice disorders was 1,225 [52].
When occupational voice disorders are un-
derstood as a consequence of repeated move-
ments (and collisions) of vocal folds, the anal-
ogy with repetition strain injuries, such as
‘tennis elbow’, is evident. According to text-
books of occupational medicine, repetition
strain injuries are caused by an overload of
repetitive movements and static and dynamic
muscle loading combined with biomechani-
cal, ergonomic and psychological factors as
well as poor treatment of early symptoms
[116]. In many countries, such repetition
strain injuries as occupational tennis elbow
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are recognized as occupational diseases,
whereas occupational vocal nodules, for in-
stance, are generally not accepted in this cate-
gory. As will be discussed below in more
detail, the definition of repetition strain inju-
ries is consistent with the current understand-
ing of the origins of occupational voice disor-
ders. It should be pointed out, however, that
in the OSH field, repetitive movements are no
longer considered to be of central importance
for the development of injuries such as epi-
condylitis in occupational settings. It seems
that forceful work is a more important factor
in this respect [117].
Direct proof of the increased risk of kin-
dergarten teachers to develop vocal nodules
was presented in a study conducted by Sala et
al. [92]. In a group of kindergarten teachers
(n = 262), the prevalence of vocal nodules was
6 times higher than that in nurses (n = 108).
This finding implies that the vocal load is
heavier among kindergarten teachers than
nurses.
The definitions of occupational diseases
may differ from country to country. The Fin-
nish legislation on occupational diseases
states that they are likely to be mainly caused
by physical, chemical, biological and psycho-
social factors present at work. Two levels of
evidence are requested to prove causality:
general level, which means that there must be
evidence that a certain exposure or loading
factor can lead to the state in question. In
addition, it must be shown at the individual
level that such factors are present at the work-
place of the person in question. As to the gen-
eral aspects and the methods that can be used
to demonstrate the presence of risk factors at
workplaces, I refer to the above discussion.
Below, a case of an occupational voice disor-
der will be presented (by courtesy of docent
Eeva Sala).
244 Folia Phoniatr Logop 2004;56:220–253
Case
The patient was a 39-year-old kindergarten teacher,
who had been in this profession for 18 years. At the
time of the examination, she was teaching a group of
23 five- to six-year-old children. She had suffered from
periodic hoarseness for many years (1–2 weeks per
year), but during the past 6 months, her hoarseness had
become continuous and she was unable to sing or read
for any longer period.
She had had no recurrent infections or allergic
symptoms, and she did not smoke. She had some
heartburn.
In the phoniatric examination, her voice was per-
ceptually very hoarse (grade = 3; rough = 2; breathy =
2; asthenic = 1; strained = 2). The vocal fold mucosae
were reddened and thickened, and at the border of the
anterior and middle thirds of the vocal folds there were
vocal nodules (left: small; right: medium-sized). In
addition, there was reddening and oedema in the pha-
ryngeal and hypopharyngeal mucosae.
It was judged by the examiner that the vocal fold
nodules were caused by the vocal workload. The red-
dening of the mucosae was most likely to have been
caused by gastro-oesophageal reflux, and the patient
was prescribed treatment for that.
The insurance company of the patient’s employer
rejected her claim for an occupational disease. The
patient appealed to the national work injury board.
The board stated that there is evidence that the risk of
kindergarten teachers to develop vocal nodules at work
is increased (from the general level). Further, in this
particular case (individual level), the board found that
it was likely that the vocal fold nodules had been main-
ly caused by the work-related mechanical strain of the
vocal folds, which is the kind of physical factor re-
ferred to in the law on occupational diseases. Thus, the
case should be considered as an occupational disease.
The fact that, in most countries, voice dis-
orders are not considered occupational dis-
eases is unjust from the point of view of the
individual in question. In many countries,
this state of affairs leads to personal economic
losses in terms of the lower compensation
paid for sick leaves, the lower compensation
for treatment and rehabilitation as well as the
poorer opportunities for re-education and, fi-
nally, the lower disability pension [51]. It
should also be kept in mind that, psychologi-
cally and socially, the difference between the
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Highly
unlikely
Fig. 9. Risk assessment cross-tabu- Unlikely
lation. Risk is defined as a combi-
nation of the severity of conse- Likely
quences (columns) and the likeli-
hood of a hazardous event (rows)
(BS8800, 1996).
status of an occupational disease and a prob-
lem caused by ‘abusive behaviour’ (voice
abuse) is significant.
Risk Analyses
Risk analyses are an important part of the
OSH systems. The process has been defined
as follows: (1) classify work activities; (2)
identify hazards; (3) determine risk; (4) de-
cide if risk is tolerable; (5) prepare risk action
plan; (6) review adequacy of action plan [76,
77]. Figure 9 shows the different risk levels.
Trivial risk calls for no action, whereas a toler-
able risk level calls for monitoring and im-
provements, which should be cost-effective
but do not require controls. If a moderate risk
level is considered to be present, efforts
should be taken to reduce the risk, but the
costs of prevention should be limited. At an
observed substantial risk level, work should
not be started until the risk has been reduced,
and the situation calls for urgent action. In
this case, considerable resources may need to
be allocated. Finally, intolerable risk should
lead to a decision that the work should not be
started or continued.
Before attempting to apply these principles
to voice and speech professions, a reminder of
Occupational Safety and Health
Slightly Harmful Extremely
harmful harmful
Trivial risk Tolerable risk Moderate risk
Tolerable risk Moderate risk Substantial risk
Moderate risk Substantial risk Intolerable risk
the factors affecting the risk level analyses
seems necessary. It should be taken into ac-
count whether: the activity is voluntary or
involuntary, its effects are immediate or de-
layed, there are alternatives or not, the expo-
sure is inevitable or can be considered luxury,
the risk is present at work or not, the hazard is
common or especially frightening, the hazard
affects normal or only sensitive persons, and
finally, whether the consequences are revers-
ible or not. It is obviously common that peo-
ple have hobbies involving inherent risk levels
that would not be acceptable at work [76,
77].
The hazards that play a major role in
speech and voice professions are, briefly,
overload due to repetitive movements of the
vocal folds, need for high voice output levels
due to background noise, poor room acoustics
and long speaking distance, poor quality of
air, poor working posture, stress, non-existent
or poor-quality aids and inadequate treat-
ment of early symptoms, especially laryngeal
infections.
As to the severity of the consequences of
work-related exposure (vocal loading) (fig. 9),
a tentative classification shall be attempted. A
slightly harmful or harmful consequence (in-
jury or ill health) could be defined as hoarse-
ness after the working day or other voice use-
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related complaints, e.g. sore throat, lump in
the throat, which disappear completely before
the next working session starts. Harmful con-
sequences could consist of the aforemen-
tioned problems that only disappear after a
longer period of rest, e.g. weekend or holiday,
and, in addition, vocal nodules, polyps and
other loading-based vocal fold changes, and
permanent deterioration of voice endurance.
The severity of voice quality changes should,
however, be considered in relation to the
practical consequences at the level of activity
and participation limitations [71] (see above)
or working ability.
The information concerning the epidemi-
ology of voice disorders and the severity of
their consequences are combined within the
framework presented in figure 9, and this war-
rants the inevitable conclusion that moderate
to substantial risks are common in speech and
voice professions, meaning that efforts should
be made to reduce these risks. The fact that
not much effort is generally undertaken could
be taken to imply that there are only trivial or
tolerable risks present at work. One possible
reason for this is that the significance of func-
tional voice in voice and speech professions is
underestimated by laymen and even general
practitioners (‘It is only the voice’). On the
other hand, the interpretation of voice prob-
lems as a lack of vocal skill (‘voice abuse’) or
as a consequence of vocal personality factors
(‘talkative person’) or emotional problems by
voice clinicians and professional voice users
themselves has doubtless led to the low level
of understanding of the occupational risks to
vocal health, i.e. these problems have been
considered individual health problems rather
than occupational or work-related disorders.
Finally, based on questionnaire studies, voice
complaints are accepted by teachers as a part
of their job [57, 60]. The question can be
raised whether they should thus be accepted,
and what would be an acceptable level of com-
246 Folia Phoniatr Logop 2004;56:220–253
plaints. From the point of view of recovery
times, a tolerable risk level might be that the
complaints induced by a working day do not
hinder normal social conversation or, for in-
stance, reading aloud or singing to one’s chil-
dren at home. The fact that work-related
fatigue makes voice-intensive hobbies (e.g.
choir or solo singing) impossible, which is rel-
atively common in heavily loading voice pro-
fessions, might be interpreted as an unavoid-
able consequence of the vocal loading at
work.
Voice Therapy in the OSH Context
As was pointed out above, voice produc-
tion is basically physical, and the problems
associated with it bear many similarities to
the OSH problems in traditional ‘blue collar’
professions. One important analogy is that
with the basic principles of lifting loads (cf.
vocal load) at work, which are based on expe-
riences gathered within weight-lifting sports
(cf. vocal performance of trained singers and
actors). Much effort has been invested in
training people who need to lift loads at work
to adopt these principles (bend their knees,
maintain a straight back, not rotate their
body, etc.). It has now become obvious that
these principles are not observed in practice
[118]. There are many excuses: the correct
technique is felt to take more energy, more
time, to look strange, to be easily forgotten, to
make the knees hurt or get in the way during
the movement, etc. The final conclusion is
that ‘the back-saving lifting technique cannot
be applied and correctly followed through,
and critical situations for the spine then oc-
cur. Therefore most people are justified in
refusing to lift loads at workplaces in industry’
[119]. It can be suspected that voice (quality)
therapy for occupational voice disorders in
professions that do not demand high voice
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quality is faced with similar problems. The
prerequisites for both weight lifting and pro-
fessional singing are similar: the individual
must show proper material in terms of body
and mind proportions, properties and coordi-
nation, in addition to which motivation and
self-discipline are needed to attend training
containing endless repetitions and efforts to
optimize the performance. Thus, it can be
expected that the training of high-quality
principles often fails, and it is also well known
that occupational voice problems among
trained singers are common [120], i.e. train-
ing in, for instance, a physiologically econom-
ical shouting technique for teachers is a long
process and will probably not prevent occupa-
tional voice problems, one major reason being
that unexpected events frequently take place,
making controlled vocalization difficult if not
impossible.
The actual contents of voice therapy pro-
vided to patients with occupational disorders
vary a lot between voice clinics, but it is gener-
ally claimed to be holistic, i.e. including such
components as voice hygiene. For the devel-
opment of clinical practices and scientific re-
search in the field of occupational voice disor-
ders, it is very important that the knowledge
accumulated so far should be used and devel-
oped further within the OSH framework, and
that the OSH principles should be included in
the domain of voice therapy.
When the locomotor and musculoskeletal
aspects of voice production are kept in mind,
it is important in terms of individual skill and
experience that a voice and speech profession-
al recognizes the signs of vocal fatigue and is
able to distinguish between a tense and re-
laxed physiological larynx, for instance. Gen-
erally speaking, however, the most important
measures to be taken to maintain and restore
vocal health are related to the loading factors
per se (fig. 5). These may involve pedagogical
rethinking, e.g. taking advantage of pre-re-
Occupational Safety and Health
corded audiovisual material to reduce loading
time, reduction of background noise, improve-
ments in the acoustic conditions [120]. In
many cases, using a voice amplifier as one’s
personal protective equipment is the fastest
and most effective way to reduce vocal load.
The use of voice amplification has recently
been studied by Jonsdottir [106] [see also ref.
36, 105, 122]. One of the conclusions was:
‘Both teachers and pupils agreed that amplifi-
cation in classroom was beneficial, and the
results suggested that amplification in class
may be ergonomically desirable both for teach-
ers’ voices and for students’ listening effective-
ness’ [106]. Voice amplification was also
found to be effective in a clinical trial [123].
The general principles concerning the role
of training in the OSH context [124] may shed
light on the role of prevention and treatment
of occupational voice problems. The process
starts with an evaluation of the nature of the
problem. Instead of training, the problem can
sometimes be solved more effectively by ad-
ministrative (e.g. smaller teaching groups) or
technical (e.g. voice amplification) methods.
In the field of vocoergonomics, training of
individuals is important but not sufficient to
control the occupational health hazards with
an acceptable cost/effect ratio. Nevertheless,
if it is decided that the problem can be solved
by training, the next step is to assess the
client’s needs and learner characteristics and
to determine the goals and priorities. The
third step is to specify the instructional objec-
tives in terms of relevant learning domains
followed by planning and execution of train-
ing. The sixth step is to evaluate the results,
i.e. the questions to be answered: Were the
objectives set for training achieved, and if not,
was that due to the program? It is obvious that
totally different training decisions will be
made, depending on the goals set, i.e. whether
the voice quality is considered the problem or
the way of coping.
Folia Phoniatr Logop 2004;56:220–253 247
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 In connection with the study on CSAs, the
effects of a short vocal training course (2 days)
were studied. The employer’s underlying ob-
jective was to reduce the number of sick-leave
absences related to voice failures. The work-
ing environment, the subjective vocal load-
ing-related complaints [48, 49] and the vocal
load (see above) [37] at work were analysed.
Voice complaints before and after the course
as well as signs of vocal fatigue during the
working day were studied using question-
naires. On the average, the subjects reported
relatively low levels of voice complaints. Dur-
ing the working day, all the variables reflect-
ing vocal fatigue changed statistically signifi-
cantly. The short vocal training course re-
duced the average level of voice complaints
[48], and the level of voice fatigue during the
working day also dropped slightly but statisti-
cally significantly. The positive effects of the
course could still be detected 18 months later
in a follow-up study [49]. All in all, the work of
this group of CSAs can be considered to be
moderately loading vocally. Intuitively the
biggest occupational risk for the voices of
these persons is the rather common co-occur-
rence of acute laryngitis and the vocal de-
mands set by the working task. In such cases,
vocal rest is naturally obligatory. The em-
ployer has arranged an opportunity to choose
non-speech tasks (e-mail, text messages) when
the worker’s voice becomes tired or is tempo-
rarily not in a normal condition. This arrange-
ment might, to some extent, reduce the need
for sick leaves.
Listener’s Perspective
The working environment at school is
shared by the teachers and the pupils. There is
no legislation concerning children’s working
conditions. There are, however, some occupa-
tional recommendations concerning noise
248 Folia Phoniatr Logop 2004;56:220–253
levels, the signal-to-noise ratio, reverberation
time, etc. [50, 97], which may be applicable to
children as well. The rule of thumb is that, in
working situations where speech communica-
tion is important (as in control rooms), the
background noise level should not exceed
55 dBA, to ensure effective communication.
As was pointed out above, the average back-
ground noise levels in classrooms and kinder-
gartens are 55–75 dB [38, 39, 61, 96]. When
the recommendation concerning the signal-
to-noise ratio of +15–20 dB [50, 125] is kept
in mind, the demands set on the voice output
level are high. Besides, shouting voice reduces
speech discrimination to 70% for trained lis-
teners [97]. From the point of view of children
with developmental problems, especially lan-
guage impairment, the signal-to-noise ratio is
important, but it may be too robust a mea-
sure, as short noise periods naturally also dis-
tract and disturb concentration. This is ex-
tremely problematic, as kindergartens and
schools are often given rehabilitative tasks by
child language clinicians. If the child has not
adequate listening conditions, the therapeutic
goals cannot be achieved, and the attention
deficit may develop further, impairing the
working conditions of the child in question,
the other children and the teachers.
The vast majority of measures alleviating
the working conditions of teachers are posi-
tive from the point of view of children as well.
The most important measures aim to reduce
background noise. The only issue of contra-
dictory preferences apparently concerns the
reverberation properties of the room. A longer
reverberation time is favoured by the speaker
or singer, whereas the listener prefers direct
sound [126]. This means that excessive acous-
tic damping of reverberation may cause prob-
lems to the speaker if speech amplification is
not used.
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 Conclusion
It can be concluded that there is substantial
epidemiological and physiological evidence to
support the view that occupational voice dis-
orders are a large subcategory of occupational
safety and health problems. The problems are
not life-threatening [127], but they cause con-
siderable discomfort and psychosocial stress
to professional voice users.
Whenever the person is engaged in teach-
ing, the same environmental and ergonomic
factors that threaten the teacher’s vocal health
may have serious effects on the pupils’ cogni-
tive development and concentration.
As vocal normality is defined largely on the
basis of the person’s ability to cope with the
working tasks, reliable and valid tools for
reporting on voice complaints are extremely
important. Such standardized questionnaires
already exist (Voice Handicap Index [128],
Voice Activity and Participation Profile [69]).
However, further instruments suitable for es-
timating specifically voice-related working
ability are needed.
In the long run, as it can be expected that
the OSH arrangements and occupational dis-
ease status of persons working in voice and
speech professions will improve, finding ob-
jective correlates for voice complaints will be
of paramount importance to ensure legally cor-
rect and fair treatment of these cases. It is likely
that such correlates will be found in field exam-
inations of the voice in clinical materials.
A European standard defines the ergonomic
design principles as follows: ‘... the term “er-
gonomics” refers to a multidisciplinary field of
science and its application. In applying ergo-
nomics to the design of work systems, it is
important to take human capabilities, skills,
limitations and needs into account when ex-
ploring the interaction between people, tech-
nology and work environment’ [128]. This
might be a good platform for developing ‘vo-
coergonomics’ as well. Close co-operation with
the existing OSH organizations, teacher educa-
tion colleges and other educational institutions
will naturally be of crucial importance for suc-
cessful development.
Acknowledgement
The author wishes to thank all his co-workers, espe-
cially Professor Anne-Maria Laukkanen, Professor
Paavo Alku, docent Eeva Sala, docent Marketta Sihvo,
Ms Leena Rantala, PhD, Mr Juha Vintturi, MD, PhD,
Ms Valdı́s Jónsdottı́r, PhD and Ms Laura Lehto, MA
for cooperation. This work was supported by the Acad-
emy of Finland.

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