Hearing Protection for All Musicians - Music and Medicine on MondayClick Here

Teaching Vocal Health as a Music Educator -- Music and Medicine on Monday

Music and Medicine on Monday at the University of Iowa - Schedule of Events

protocol page initiated Feb 2024  Piper Wenzel BS, Henry Hoffman MD

see also: A Singers First Look at Her Vocal Cords - Transoral Videostroboscopy - How to Look at the Larynx

Teaching Vocal Health as a Music Educator (full length: 32:40)

Singing at the U of Iowa (60 seconds)

Singing with Stroboscopy (60 seconds)

The Lombard Effect (60 seconds)

The Science of Straw Phonation to Help the Voice (60 seconds)


Warming up:  "a part of stretching and preparation for physical exertion or a performance by exercising or practicing gently beforehand, usually undertaken before a performance or practice. Athletes, singers, actors and others warm up before stressing their muscles" (Wikipedia 2024)

Lip Trills: vibration of the lips including interactions with the vocal tract with air exhaled from the lungs

Bilabial Fricative: produced by both lips - by consticting air flow through a normal channel cuasing turbulence - symbolized as β (Wikipedia 2024)

Semioccluded vocal tract exercises: "distinct set of vocal warm-up maneuvers that enhance both the vocal source and vocal tract filter function" (Duke 2015)

  • Narrowing of the vocal tract - 'semiccluded' increases back pressures to the glottis keeping the folds separated - with 'impedance that allows for greater ease of p honation"
  • Lip trills, tongue trills, and production of bilabial fricatives as well as humming as into tubes or straws well as  are considered 'semiocclusives'
  • Used to train singers and also manage dysphonia in speech clinics (Nam 2019) 
  • "Straw phonation has the potential to adjust aerodynamics within the vocal tact leading to improved vocal efficiency, optimized vibration mode and attenuated vocal fatigue" (Kang 2020)

Lombard effect: speakers amplify their voice in response to an increase in background noise in an involuntary or unconcious manner (Schiller 2017, Zollinger and Brumm 2011 citing Lombard 1911) 

Lombard effect in choral singing -the "masking of an individual voice by the sound of surrounding voices" resulting in diminished auditory feedback often resulting in 'tendency for singers to push or force thier foces to enhance feedback" (Tonkinson 1994)


Reckers et al (2020) identified that singers studying to perform and teach classical voice usually begin with a four-year Bachelor of Music (BM) followed by Masters of Music (MM) which may be followed by a Doctorate of Musical Arts (DMA) and/or Artist's Diploma (AD). Their study of 286 vocal performance majors in these three categories was accomplished through questinonnaires administered as part of a vocal health screening offered at the start of their vocal performance program taking place the week before the beginning of the semester or orientation week. They identified the following:

University of Cincinnati College Conservatory of Music



N= 79

Graduate Master's

N= 171

Graduate Doctoral

N= 36

Currently affected (among 8 problems including fatigue/hoarseness/prolonged warmup/loss of range)




Previously Received Voice Therapy 




Proportions reported: regularly warming-up / cooling down before and after singing

96.2% / 17.7%

97.1% / 24.6%

100% / 27.8%

Average # hours singing per day

~ 2.25 hours

~ 2.75 hours

~ 2.6 hours

Warming up exercies for singers

"vocal effort increases in relation to the Lombard effect" (Whitling 2023). 

Management (Education about Vocal Health)

Vocal Overuse

   see: Voice Rest - Vocal Conservation as a Management Strategy (Non-operative and Post-op)

   see: Handout: Voice Conservation


    see: Singers Packet (Voice Clinic Handouts)


    see: The Voice Clinic

    see: Common Voice Disorders Take Home Points

    see: Data Base Recording and Report Generation Voice Clinic


Additional Resources (Links to external sites):

American Laryngologic Association (ALA) Patient Education: https://alahns.org/research-education/voice-problems/

Voice science works  https://www.voicescienceworks.org/sovt-exercises.html 

Vocapedia from NATS  https://vocapedia.info/wiki/Main_Page

Voice foundation giving an overview of voice disorders  https://voicefoundation.org/health-science/voice-disorders/voice-disorders/

The pink trombone is an adjustable vocal tract that you use to create vowel sounds by changing the shape of the oral cavity and the position of the tongue  https://dood.al/pinktrombone/

Semi-occluded vocal tract ("Straw Phonation") science and exercises by Dr. Ingo Titze:

      Primary video: https://youtu.be/0xYDvwvmBIM?si=BmPQ-nQFDMCZROJk

      Sequence of 3 videos: 

               (1) https://www.youtube.com/watch?v=cb9jouDHWeM

               (2) https://www.youtube.com/watch?v=PQrcDUUDYps

               (3) https://www.youtube.com/watch?v=9oKNRgcpLFM



Kaneko M, Sugiyama Y, Mukudai S, Hirano S. Effect of Voice Therapy Using Semioccluded Vocal Tract Exercises in Singers and Nonsingers With Dysphonia. J Voice. 2020 Nov;34(6):963.e1-963.e9. doi: 10.1016/j.jvoice.2019.06.014. Epub 2019 Jul 22. PMID: 31345679.

Duke E, Plexico LW, Sandage MJ, Hoch M. The Effect of Traditional Singing Warm-Up Versus Semioccluded Vocal Tract Exercises on the Acoustic Parameters of Singing Voice. J Voice. 2015 Nov;29(6):727-32. doi: 10.1016/j.jvoice.2014.12.009. Epub 2015 Mar 12. PMID: 25770376.

Wikipedia contributors, "Warming up," Wikipedia, The Free Encyclopedia, https://en.wikipedia.org/w/index.php?title=Warming_up&oldid=1195833913 (accessed February 22, 2024).

Titze IR. Voice training and therapy with a semi-occluded vocal tract: rationale and scientific underpinnings. J Speech Lang Hear Res. 2006;49:448–459

Titze IR  Phonation Threshold Pressure Measurement With a Semi-Occluded Vocal Tract Journal of Speech, Language, and Hearing Research, 2009

Andrade PA, Wood G, Ratcliffe P, Epstein R, Pijper A, Svec JG. Electroglottographic study of seven semi-occluded vocal tract exercises: LaVox, straw, lip-trill, tongue-trill, humming, hand-over-mouth, and tongue-trill combined with hand-over-mouth [published online ahead of print Feb 19 2014]. J Voice. 2014; http://dx.doi.org/10.1016/j.jvoice.2013.11.004

Nam IC, Kim SY, Joo YH, Park YH, Shim MR, Hwang YS, Sun DI. Effects of Voice Therapy Using the Lip Trill Technique in Patients With Glottal Gap. J Voice. 2019 Nov;33(6):949.e11-949.e19. doi: 10.1016/j.jvoice.2018.07.013. Epub 2018 Aug 10. PMID: 30104127.

Schwarz K, Cielo CA. Vocal and laryngeal modifications produced by the sonorous tongue vibration technique. Pro Fono. 2009;21:161–166.

Laukkanen AM, Titze IR, Hoffman H, Finnegan E. Effects of a semioccluded vocal tract on laryngeal muscle activity and glottal adduction in a single female subject. Folia Phoniatr Logop. 2008;60(6):298-311. doi: 10.1159/000170080. Epub 2008 Nov 14. PMID: 19011306; PMCID: PMC4629998.

Wikipedia contributors, "Voiced bilabial fricative," Wikipedia, The Free Encyclopedia, https://en.wikipedia.org/w/index.php?title=Voiced_bilabial_fricative&old...(accessed February 22, 2024)

Kang J, Xue C, Lou Z, Scholp A, Zhang Y, Jiang JJ. The Therapeutic Effects of Straw Phonation on Vocal Fatigue. Laryngoscope. 2020 Nov;130(11):E674-E679. doi: 10.1002/lary.28498. Epub 2020 Jan 23. PMID: 31971264.

Whitling S, Wan Q, Berardi ML, Hunter EJ. Effects of warm-up exercises on self-assessed vocal effort. Logoped Phoniatr Vocol. 2023 Dec;48(4):172-179. doi: 10.1080/14015439.2022.2075459. Epub 2022 Jun 17. PMID: 35713650; PMCID: PMC10020864.

Reckers H, Donahue E, LeBorgne W. Comparison of Reported Vocal Habits of First-Year Undergraduate and Graduate Vocal Performance Majors. J Voice. 2021 Nov;35(6):852-858. doi: 10.1016/j.jvoice.2020.04.001. Epub 2020 May 21. PMID: 32446659.

Tonkinson S. The Lombard effect in choral singing. J Voice. 1994 Mar;8(1):24-9. doi: 10.1016/s0892-1997(05)80316-9. PMID: 8167784.

Sataloff RT. Ten good ways to abuse your voice. The NATS Journal 1985;42:23-5, 30. 

Schiller IS, Morsomme D, Remacle A. Voice Use Among Music Theory Teachers: A Voice Dosimetry and Self-Assessment Study. J Voice. 2018 Sep;32(5):578-584. doi: 10.1016/j.jvoice.2017.06.020. Epub 2017 Jul 25. PMID: 28754577.

Zollinger SA, Brumm H. The Lombard effect. Curr Biol. 2011 Aug 23;21(16):R614-5. doi: 10.1016/j.cub.2011.06.003. PMID: 21854996.

    [cites:  Lombard, E. (1911). Le signe de l’élévation de la voix. Annales des Maladies de L’Oreille et du Larynx 37, 101–119]. 

Lee, S. J., Dvorak, A., & Manternach, J. (in press, 2023). Therapeutic Singing and Semi-Occluded Vocal Tract Exercises for Individuals with Parkinson’s Disease: A Randomized Controlled Trial of a Single Session Intervention. Journal of Music Therapy. https://doi.org/10.1093/jmt/thae004

Manternach, J. N., Clark, C., & Sweet, B. (in press, 2023) Effects of a straw phonation on acoustic and self-reported measures of adolescent female singers: A pilot study. Voice and Speech Review. doi: 10.1080/23268263.2023.2269059

Manternach, J. N., Mann, L., & Kotsonis, A. (2022) Effects of straw phonation on choral acoustic and perceptual measures after an acclimation period. International Journal of Music Education, 40(2), 177-189. https://doi.org/10.1177/02557614211073145

Manternach, J. N., & Schloneger, M. (2021). Vocal dose of pre-service music therapists, pre-service teachers, and other undergraduate students. Journal of Voice, 35(2), 328.E1-328.E10. doi: https://doi.org/10.1016/j.jvoice.2019.09.008

Manternach, J. N., Schloneger, M., & Maxfield, L. (2019). Effects of straw phonation and neutral vowel protocols on the choral sound of two matched women’s choirs. Journal of Research in Music Education , 66, 465-480. doi: 10.1177/0022429418809976