Laryngeal Relaxation: Stretches and Massages

          I’ve had a request to include more description of the massages we used in my therapy sessions, and which I now use with all of my voice students as well.  I will give the descriptions here along with some visual aids, but I really do strongly suggest that if any of you are experiencing excess laryngeal tension that neither you nor your voice teacher can fully address to please go see your local ENT and/or voice-specializing SLP.  Excess tension can be a sign of many, many things…and it can also be the sign of nothing more than the not-so-solid technique we all sing on at some point in our lives…so it’s good to get it checked out just to know what’s officially going on.  Now, on to my personal set of laryngeal stretches, massages, and relaxation techniques*:

            

          First, start off with some neck stretches.  I usually start out with the standard:  tilt your head so that your ear gets close to your shoulder.  Now put your hand (same side as shoulder you’re tilting toward) on your head and let the weight of the hand gently (no pushing!) stretch your neck while you breathe deeply.  Or, what we did in therapy, was to gently push the head against the hand for one count, then release for one count, and do that three times.  Then, you take the hand away from the head while leaving it in its tilted position while you nod gently back and forth.  Repeat on the other side.  You can also do any amount of rolling the head to the side, forward, and other side—not going to the back (cause that doesn’t stretch anything)—if that feels good to you.  I believe this stretch mainly targets the scalene muscles of the neck, but I suspect it also loosens some of the infrahyoids (or strap muscles) as well.  (Scalene shown first followed by infrahyoids:)

           

          Next, I move on to some massages.  The first one involves tilting your head to one side yet again to shorten the sternocleitomastoid muscle.

This is a huge and powerful muscle of your neck.  (While it is not an extrinsic muscle of the larynx (meaning it does not originate nor insert into the thyroid cartilage, cricoid cartilage, nor hyoid bone), it flexes and rotates your head, so it can get pretty tight.  It also has some action in inhalation if you’re doing the “high,” clavicular breathing ...that we singers strive never to do.)  On the same side as where your ear is closest to your shoulder, try grabbing at the large strap of muscle on your neck with your thumb and middle finger.  Then, you’ll want to gently (it shouldn’t hurt) act like your turning a key in a lock with this muscle.  You can follow this muscle all the way down to the clavicle and all the way back up to near your jaw line doing this motion. Do the other side…remembering to tilt the head first to shorten the muscle!

 

The next one is my favorite:  you take your pointer finger and middle finger together, place them right behind your ear (right on your mastoid process…that hard “bump” behind your ear), press in somewhat firmly and trace your jaw line with your fingers from behind the ear, under the jaw, and under the chin.  Repeat this three times on one side before doing three times on the other one.  This is a great one for those laryngeal elevators, and it feels really good!  

Next, go ahead and do some deep, big massage circles into your checks.  The idea here is to massage your masseter muscle, which is your most powerful chew muscle (as my Anatomy and Physiology of Speech teacher says, this muscle is the reason you don’t want to hold an alligator’s jaw open!)  It is often a big source of jaw tension.  (It's the big muscle in the middle of this guy's cheek to the right of the blob-looking thing which is your parotid gland:)

 

Go ahead and do some gentle massage circles into your temples.  Along with relieving stress and feeling good, a lot of your facial muscles connect up near there which are involved in jaw movement and facial movement, so it’s good to massage as well.

 

Next, run your fingers down alongside the larynx just for one last neck massage.  Do some tongue stretches:  just stick out your tongue as far as it will go for one count, and then relax it back in your mouth for one count.  Do it five to ten counts depending on how tense you might feel at the start.

Follow this all up with three belly breathes (just letting your stomach relax out like you’ve had a big meal and then gently pulling the stomach back in to let the air out…not a big “singer” breath, you should barely be aware of the air going in and out those.  Honestly, if you try to keep the belly breathes as inaudible as possible, you’ll probably feel that relaxation in your throat after the first breath or two.)

And that’s my little laryngeal relaxation routine that my SLP taught me in a nut-shell.  When it came time to get back into singing, this routine is one I would use before singing, in the middle if things started getting tight, and also at the end so I didn’t hold on to any tension I might have been unaware of.  I now use all of these exercises with my voice students…especially any of my high school or college students during exam or mid-term weeks.  (All of that hunching over to look at your test can really tighten up the neck!)

*As I said before, I am NOT a licensed SLP, so none of these descriptions are intended to diagnosis or treat any tension of anyone reading this right now.  If you are experiencing a lot of unmanageable laryngeal tension, please see a good SLP or ENT in your area for a voice screening, scope, and/or treatment options.  And, since I suspect someone out there will try to do these based on my descriptions, please STOP IMMEDIATELY if you experience any discomfort, pain, or feel a “choking” sensation.  These are all signs that you are doing it wrong, so please…please stop at the first sign of discomfort and/or pain.  Good deal, guys?  

Back to Singing: The Introduction to the Longest Part of the Journey

So I had just finished my therapy with my wonderful SLP (getting sick of me calling her wonderful yet?) whose measurements were proof to me that I was healed up.  This obviously meant that my voice was completely fixed and that my singing would instantly be that polished, professional quality I had long sought for, right?  …Of course not!  Didn’t you read my last post?!  We all know how hard muscle memory dies, but add compensation for a decade-long injury into that muscle memory mix, and you’re in for one long, frustrating haul.  Basically, you’re back at square one, just with what feels like a brand spanking new voice.

Speaking of new voices, have you ever wondered what it would be like to sing with a totally different voice for one day?  Ever heard that one singer who sings more powerfully/higher/lower/more “shimmery” or “metallic” than you and wondered what it would be like to “borrow” that person’s voice for one day?  I used to wonder that stuff all the time and now I know the answer to that:  It feels totally weird.  When I started singing again, about three months after my diagnosis, I had been given a whole new voice…and I had no idea what to do with it.  Now, before my treatment, my voice was always referred to as a nice “light” voice.  It was basically a nice, light soprano sound; not too small for the operatic stage, but very light and floaty.  After my treatment, my voice seemed completely different to me.  First off, it sounded really dark inside my head.  Second, the resonance sensations were completely different.  And third, it was larger than it had ever been, and I had no idea how to control it.  One of the main symptoms of recurrent nerve paresis, which is different from secondary nerve paresis, is a reduction of volume.  Now, my voice didn’t jump from being a light coloratura to being a wagnerian or anything like that, but it did gain enough in volume to completely throw me off when I started singing with it.  I was so excited to have this brand new voice!  (If I had known the constant pendulum swing I was in for, it might have quelled my excitement a little bit.)

The first thing I needed to do when I got back to lessons was I had to relearn the amount of air needed to sing.  Since I had only been speaking and doing speaking-like exercises, my body had forgotten the kind of support it needed to get up to my higher range.  Luckily, a few good breathing exercises al la Richard Miller would help get that support strength back up pretty quickly.  Unfortunately, finding the right air-flow balance during singing would take a lot longer.

I also needed to learn what pharyngeal space actually felt like.  This concept would take a long time for me to figure out, mainly because my tongue base still had this lovely way of wanting it’s hand in the process; kinda like that pesky neighbor on Bewitched.

Physically sensing pharyngeal space is a strange thing.  It’s especially strange to someone coming off an eight-year injury like me.  I think the main problem was that I had been trying to physically pry open my throat with every muscle I had, because nothing actually ever opened.  If I could have used the jaws-of-life to reach in my throat and open everything up, I would have!  But without proper laryngeal functionality, healthy phonation is simply not possible.  And without healthy phonation, a relaxed laryngeal position enabling pharyngeal space for resonance is also not possible.  That equals a big lose-lose for someone with an injury.  So when it came for me to try to find all that space international singers use to resonate with, I was kinda screwed.  The truth is, for someone coming off an injury, obtaining that “space” doesn’t feel like they’re doing anything at all.  It doesn’t feel special.  But I would wager money that what happens when you first ask someone coming right out of therapy to create “space” is they jam their larynx down, retract that tongue base so everything sounds “dark” in their head, or maybe they jack their soft palate up through their nasal passages (which isn’t really raising the soft palate at all if things are getting nasal.)  Either way, the result isn’t pretty.  My teacher would sometimes have me think of darkening the sound to find the space, but that mainly got the tongue too involved, so then we went back to just phonating comfortably.  I swung on the dark-light-dark pendulum so many times I got pretty dizzy and confused.  While I’m sure regular lessons with my fabulous teacher would have solved some of these issues more quickly, my finances and work schedule simply did not allow for it.  So I decided, since I was the one who would really have to solve the puzzle that was my voice, I would start to work from the beginning again.  Only, I had been singing on an injury for so long that I had absolutely no idea where “beginning” was.  (Dang...  New I should have gone to med school instead.)

And all the while, I had to continue to deal with all the emotional repercussions.  Was it mainly a confidence thing?  Of course!  My voice had been like that one incredibly unreliable friend that always cancels on you at the last minute and is never around when you really need them to be.  It’s very hard to trust something like that.  Now that it was healed, I had to learn how to trust it when it came time to perform.  That required a whole new bag of tricks than just technique…

It’s all in the details

I have had a request to go more into detail with the therapy exercises, and I will honor that request right now.  (Disclaimer:  I am not, as of right now, a licensed SLP, so any conjectures I make about the reasons behind therapeutic exercises are purely my educated guesses.  I cannot recommend these exercises as a way to treat any vocal difficulties for anyone.  If you have difficulties, please seek out a good ENT and SLP in your area.)

As I described the therapy exercises here, they really started out as simple, really-hard-to-mess-them-up exercises.  (Pretty sure that’s what makes them so darn effective.)  On the first week, my therapy practice CD comprised mostly of onset exercises.  Just a simple pulse (staccato-like) on one note on the three vowels: /a/, /i/, /u/ that all of my exercises were on.  So this would look like pulsing ah-ah-ah-ah-ah, then moving up in half-steps and back down to the starting pitch again.  Then the cycle would repeat on the /i/, and so on.  This might look very similar to many singing exercises, especially those mentioned by Richard Miller in his Solutions for Singers book, but the main differences were that the therapeutic exercises were done in the “speaking” mode not singing mode, they were done in a speaking range (not going higher than, say, A about middle C for me), and they were done following the stretches, massages, and belly breaths I mentioned in the above post.  I think the key there was that all those relaxation techniques set up a nice laryngeal posture before starting the onset exercises.  (I have no idea if they are referred to as onset exercises in the SLP literature, but speaking as a singer, that’s what you would call them.) 

On my second visit, my practice CD was about 30 minutes long, and included more of those onset exercises, slides (or glides) on thirds from the lower note to the higher note and back down again (1-3-1 pattern) going up by half steps, and the pattern would be reversed when descending by half steps (3-1-3 pattern).  Once again, these exercises would stay in a range of about A3 to A4.  (Remember, these exercises were purposefully pitched around there for my high-coloratura voice by my SLP.)  There was also an exercise of octave slides, just on /a/, from about middle C to the Eb above.  Other exercises involved going from the unvoiced /s/ to /z/ on the same pitch and breath and unvoiced /ʃ/ to voiced /ʒ/ on the same pitch and breath, usually around middle C.  Also, sustaining phonation for as long as possible on /a/, /i/, and /u/ became an exercise for me to do every day.  (By the end of therapy, the previous exercise had developed in to a sort of “spoken” messa di voce with a crescendo and decrescendo on each vowel and pitch, which also ascended by half steps and back down again on each vowel.)

This comprised the bulk of my therapeutic exercises.  The second therapy session was the only one with a 30 minute CD.  Most of the others were around 15 minutes in length, which made them very easy to do throughout the day, or once every hour after work in the evening if my voice wasn’t too tired.  I would actually make a point of doing the exercises at least once when I got home if I felt any focal fatigue, since I always felt a lot better after doing the exercises.  I think the whole key to that was the release of any excess tension being held in the laryngeal area.  Remember, throughout every practice CD, every exercise was sandwiched between either belly breaths, massages, or both.  Constant, regular relaxation seemed to be the biggest key to my recovery.  (My conjecture about this is that reducing the ineffective muscular compensation will either require the body to repair the injured nerve (the ideal situation), or it will allow for more effective compensatory actions to make up for the injury without causing vocal fatigue and strain.  I hope to read up some more about this, but unfortunately this semester is turning out to be a busy one!)

Although I was not really singing throughout my therapy course, I did use that concept of regular laryngeal relaxation to do some “silent” singing practice.  I would put on my favorite singers singing my favorite arias (that I know by memory), and I would lip-sing through the aria with the recording.  The whole time I would lip-sing, I would make sure to feel any sensation in my throat that felt the smallest amount like squeezing, and I would try to go back to releasing my throat and lip-singing with no constriction of the air flow whatsoever.  The belly breaths became my biggest asset when needing instant relaxation, as my body began to just equate those breaths with releasing the larynx by my third week of therapy.  In fact, I would sometimes just “think” through the belly breaths in between costumers at work to release any tension I was feeling.  I think this is what made me so highly tactile in terms of sensing what’s going on in my throat.  This process also made me realize just how much tension I had been feeling in my throat literally all the time!  No wonder I could never find “release” in my singing lessons!  It’s pretty much impossible to find a relaxed larynx if it’s something you haven’t experienced at any point, even in speaking, in about a decade.

But I must say the greatest thing I learned throughout therapy was how important it is to realize that vocal improvement is an ongoing process.  It’s not about just finding the right “space” or “placement” once and waiting for the light to go on.  It’s a constant pendulum swing from one place to another, but if you’re going in the right direction, the swings become less and less severe over time.  Maybe it was just my getting into yoga previous to the therapy or maybe it is just my getting older, but I have a new appreciation for accepting where I am at my point in the process and not expecting a magic spell or exercise to instantly fix my singing.  This rather Zen attitude of mine would not always hold throughout re-learning how to sing, (seriously, it was frustrating as all get-out,) but at least it would serve me well in the long run.

Up next:  Back to singing  

The End of Therapy

My last therapy session was about two and a half months after I started.  I had been coming every other week for the last three sessions, and I came back for the last session three weeks after my penultimate session.  My SLP took more measurements of my voice and the difference was a follows:

Vocal Range:  I had regained an extra third to the top of my voice (from high Eb at the start of therapy to the G above.)  I believe I had lost those notes due to excess tension from compensation rather than from the paresis (explanation here,) but it was nice to get those notes back nonetheless.  (I had been singing Queen of the Night on year prior to my diagnosis, so I was quite disturbed when my high F had progressively become very strained and hard to hit!) 

Vocal duration:  This is where she would have me take a big breath and phonate on /a/, /i/, and /u/ for as long as I could while she timed me.  At the start of therapy, this was my worst measurement at 15 seconds, due to incomplete fold closure. (Normal measurements for adult females are around 22 to 25 seconds (and that’s not professional voice users either, that’s just regular old folks…As you can imagine, it was pretty traumatic seeing my original measurement being about 10 seconds below normal.)  At the end of therapy, this measurement was around 30-35 seconds.  Awesome, huge improvement in my mind!  I was above normal, just where an opera singer would want to be!  Hurrah!

Habitual pitch:  Re-pitching worked, and I was regularly speaking around Bb to middle C…and my voice felt a whole lot better because of it.  (And I felt more resonant speaking in that range.)

Voice clarity and resonance:  As this is a perceptual measurement, it was much improved.  My voice was clear with no use of vocal fry when I read passages.

One interesting physical thing I had noticed was during the vocal massages we would always do in the session.  At the start of therapy, I noticed my right sternocleitomastoid (pictures and explanation here) was always very, very tight to the point of the massage hurting on that side.  Also, I noticed an asymmetry in that little notch between my hyoid and thyroid cartilage where the thyrohyoid membrane is located.  (You can feel that place if you palpate the sides of your larynx and move upward were it feels like it “ends”…if you keep moving up from there you’ll feel your hyoid bone.)  When I felt that notch at the beginning of therapy, the space on my left side was noticeably larger than my right side.  In fact, I could hardly feel any space between the thyroid and hyoid on my right side.  Throughout therapy, I began to feel space on the right side.  It wasn’t completely balanced by my last therapy session, but about six or so months later, it was totally balanced on both sides and my sternocleitomastoid on my right side felt the same as my left when I massaged.  Now, since this is just my personal observation, I’m not 100% sure why there was such a dramatic asymmetry there.  I can only assume it was related to long-term compensation for this long-standing injury.  Whatever the reason, it was additional proof of my injury and recovery that I could literally feel with my hand!

By the time of my last therapy session, I had not been experiencing any fatigue at work, and I could speak at a loud restaurant without fatiguing or shouting and be heard.  Everything was just feeling so much better!  But, I missed singing terribly.

I had not been singing at all throughout the process.  After my diagnosis I decided to postpone any auditions I had lined up and not take on any performances anywhere.  I also took a hiatus from singing in my church choir as well.  I had decided to go “all in” on the vocal healing process without encouraging any old, bad habits of compensation by still singing throughout.  The therapeutic exercises did keep my voice in good shape and I did start to add in some easy singing vocalizations per my SLPs instruction during these two months, but I did not sing any arias, take any voice lessons, and certainly no coachings during this time.  This break and therapy was an investment in my singing future, and I was not going to take any chances of delaying healing by doing too much too soon or getting too far ahead of myself.  It was definitely an exercise in patience!...which was never really my strong-suit.

But giving up singing wasn't easy, especially not through feeling slightly hopeless about my situation in the month between my diagnosis and seeing my SLP.  I remember walking through my church one day and hearing a soloist rehearse with the organist in the chapel.  The soloist was someone I knew from graduate school, and she sounded great that day…but just the act of hearing one my peers singing brought a lump up in my throat.  I just wanted to cry.  I missed singing so very much.  I missed being able to just sing whenever I felt like it.  I missed my practice time.  I basically felt the way every singer feels when they have some laryngitis or something they have to rest through, but I felt like it might never end.  I was really, really glad to be wrong.

One of the things I appreciated the most from my SLP was that she did not consider me healed until she saw my vocal measurements go well above normal.  As a professional singer, that felt so very, very good for me to hear, and it really helped me to feel like I was in very good hands.  I progressed through therapy pretty fast thanks to diligence and her excellent guidance.  I will be eternally grateful for my experience with her.

Rediscovering What I Had Lost

The exercises my therapist gave me really seemed to work without me trying to do anything to get them to work.  After a couple of weeks of doing the belly breathing, my larynx was automatically releasing in my throat.  In fact, this technique became my primary way of releasing my voice if it felt tense or fatigued at work.  If fatigue got really bad before the end of my shift, say on a busy day, I would go to the bathroom and do some laryngeal massages along with the belly breath and some pulses on a hum to get my voice back on track.  I carried a pitch pipe with me to work so I could check and make sure I wasn’t going back to a low, strained pitch.  I am hoping to go more into exactly how these exercises were so effective, but I’m afraid I need a little more time to research that one.

I suspect it was this vocal strain that would occur when I spoke too low that made the SLP want to re-pitch my voice.  She really did this with her exercises for laryngeal relaxation and by keeping all my vocalizations centered around the target pitch—or area of target pitches.  There wasn’t any more to it.  I wasn’t instructed to “think higher” or anything during my day-to-day communication.  I was only instructed to relax my voice with the belly breathing and massages if I felt fatigued or strained.  I think the success of re-pitching while improving my voice was a result of not thinking about it at all while staying very diligent about the laryngeal relaxation.  The simple act of doing the exercises a few times every day did the work for me.  This is why I became such a tactile voice user, I was feeling differences in my speaking voice day in and day out without consciously trying to bring those changes about.

Through this process, I learned a great deal about what I was doing wrong when speaking and what effects it was having on my life.  I realized that I had been speaking with a lot of strain and over-pressurization, so it was no wonder my voice was getting so fatigued by the end of the day.  My therapist was pitching my voice around middle C instead of the F below middle C where I was speaking before therapy.  She was totally right about the F below being too low.  I couldn’t even sing that pitch without feeling strain, so why was I speaking down there all the time? 

I learned that all this time, I had been going about the “speaking higher” concept entirely wrong.  When other people had told me to speak higher, what I had actually been doing was one of two things:  I either raised my larynx, which caused a lot of strain, or I was actually not speaking any higher at all, but using my head voice to talk too low.   This sounded like I was speaking higher in my head, when in reality I was just adding more strain and stress to my already-struggling voice.  (I really would suggest that voice teachers should probably just recommend a short round of voice therapy for the students they think have bad speaking habits, since there is simply not enough time to adequately address speaking habits in a lesson, and you never know what that student is doing with your well-intentioned suggestions outside of the studio day in and day out.)

What shocked me the most, though, was how much denial I had been in for years about the shape of my voice.  All throughout grade school, I was that girl with a loud voice.  (Which was actually just a naturally resonant voice; it wasn’t loud from strain.)  I was always the first to be shushed by my teachers, probably because they heard me above everyone else.  I was also the girl in theater class who never had to be told to project because folks could usually hear me just fine out in the house.  I know it’s not unusual for singers to have loud speaking voices, and I’m sure many of you could share the same stories of grade-school woes about your voice and how it stuck out.  But for the last several years of my life, I had not been hearing anything about how loud my voice was.  I was rarely shushed, and if I went out with a group of singers, I usually couldn’t speak loud enough to be heard over them.  I couldn’t be heard in loud restaurants very easily, and there was absolutely no hope for me in a dance club.  I don’t tend to like going out to loud places anyway, but being heard in those loud places used to not be a problem for me.  I had somehow forgotten that fact. 

Throughout my master’s degree, I always thought it was the fragile nature of my light soprano voice that made it so sensitive to fatigue and strain in comparison to other singers’ voices.  This “sensitivity” was in part what I credited to my not developing any secondary injuries as can be common with paresis.  I just had to be very careful about how I used my voice and when.  I had to make sure I rested it when it got tired, and I had to not go out to loud places when I had to sing the next day.  (Which is good advice for any singer, but if I went out to loud places and strained over the din, I would automatically have induced laryngitis.)  My recovery time from fatigue was also a lot longer than it should have been.  Normal recovery time shouldn’t take more than a couple hours at most, yet for me it took nearly a whole day to recover.  I had seriously been in denial about all of these issues pretty much through the whole of my twenties. 

Through my therapy, my loud (i.e. resonant) speaking voice came back.  I began to be shushed by colleagues at the bank who thought I was too loud.  And instead of being embarrassed or hurt by these comments like I had been in high school, I was so happy to hear them.  Not only was it a great reminder to back off the volume, it was also a great sign of my healing!  My speaking voice was finally returning to the voice it used to be.

Next up:  The End of Therapy

My Typical Voice Therapy Session

I decided to digress a little from my next entry to go into more detail about what my therapy sessions were like per some questions I’ve been receiving.  (More on the re-pitching of my voice in the next post...)

The very first session was an intake session, where the therapist took some objective and subjective measures of my voice.  She would continue to do this throughout our sessions to track my progress, but at the first session, we spent a little more time and went into more detailed measurements so she could see where my main problems were. 

Objective measures are quantitative, i.e. all about the numbers and how they add up.  They offer evidence on the health of the voice (especially post-diagnosis) by taking measurements of habitual pitch, mean pitch (or the most common pitch where you speak when saying a phrase), jitter and shimmer levels (where jitter is the measure of fluctuation in frequency and shimmer is the fluctuation of amplitude which relate to asymmetrical vocal fold motion), vocal range, and sometimes loudness in terms of decibel level.  At school, we have been using the PRAAT software to take these measurements at our voice screenings.  At my therapist’s office, she used individual instrumentation that I’m not currently familiar with to take these measurements.  (Another SLP in the area I observed for school actually had a very cool, and very expensive, computer program that allowed her to not only take these measurements, but also to measure the amount of muscular effort being used during phonation, i.e. sustained voice, using some complex algorithms...thanks engineers!  She was able to have that software because she worked through a hospital that would pay for it.  I suspect the cost of that program makes it not as widely used for SLPs in private practice.)  The PRAAT software is free for anyone to download and use to your liking.

The purpose of taking these objective measurements is to compare a person’s voice to the normal levels found in healthy voices and to track their progress in comparison to those norms.  However, SLPs who work with professional voices understand that a professional voice user should probably have measurements that exceed the norm, since they need a voice in pristine condition to perform at the high levels they do.  My SLP understood that, so whatever measurements fell below norms for me, she assured me she would try to get those measurements well above the norm before ending my sessions.  And bless her for that!

Subjective measures are perceptual rankings an SLP makes on the quality of the voice:  perceived loudness (rather than actual dB level), hoarseness, breathiness, harshness, resonance, nasality, etc.  These measures are intended to help track progress through the use of the SLP’s ear rather than computer programs or equipment.  They take these measurements during normal conversation and during the reading of the rainbow passage, because many people converse using their voice a little differently than when they read.  (The rainbow passage is a passage of text that contains every sound in the English language, so you can assess their voice and speaking with every sound.)  This is also where a voice specialist is very useful, as their ears have more experience assessing voice and are sharper, and every singer knows you want some sharp ears doing the assessment here, just like with your voice teacher. 

A typical therapy session for me, after the initial assessment, went something like this:  I would be seated near my therapist while she would begin recording the session.  (She kept me in a seated position so I wouldn’t go into “singer mode” while doing the therapy exercises.)  We would then go through a series of massages for the extrinsic neck musculature, the jaw, the larynx itself, tongue root, etc., ending with some tongue stretches.  Then, we would do some belly breathing where I would just let my belly relax out, allow the air to go in without thinking about it or forcing it to do so, and then blow out.  We’d do three to five regular belly breaths, and then do the same thing while exhaling on ‘s’ and ‘sh.’  Then, using those belly breaths, we would do some vocal exercises that stayed mostly in my speaking voice range on /a/, /i/, and /u/.  These would include onset exercises (much like staccati on one note), glides of a third to a fifth to an octave, and some sustaining exercises going from soft to loud on one note as I progressed further.  Each session had a new set of exercises for me to take home and do for the week.  Throughout the exercise portion, we would frequently pause to do more massages and belly breaths with the ‘s’ and ‘sh’ exhales before moving on to other exercises.  The exercises started out very simple at first and increased with range and difficulty as the sessions progressed. 

The therapy session would end with the objective measurements, and I would be sent home with a CD of us doing the exercises to practice with and a copy of my measurements for that week along with notes of what to practice and for how long and how often.  (I have not observed many SLPs as of yet who do all of this in their practice. I really aspire to follow her model of being so organized and “with it” when I get to be a practicing SLP.)

One thing my therapist did not do was any fry register work.  I did ask her about that and she said that she had not done any training on how to use that technique effectively, so she didn’t use it.  She got great results with what she did do, so she did not feel it would add anything to her practice right now, and, as she said, “You get what you practice."  So basically, her stance is:  Since you don’t want an abundance of vocal fry during daily voice use, why practice it?  I have read some intriguing articles regarding the use of fry register in therapy, so I think it is a viable technique when used in the right situation, but I really respect my therapist for not using a technique she was not well trained for nor comfortable with.  That is a mark of a good SLP:  someone who doesn’t use techniques if they don’t know exactly how to use them and/or if they at all question the validity of those techniques.  That goes along with something called evidence-based practice in the field, and it's what separates the true clinicians from the rest.

Thanks for taking this little detour with me.  Now on to:  Rediscovering What I Had Lost!

Heading Out to Voice Therapy

It took me about a month to find my therapist. I did attempt to get in with one very well known SLP in the Denver area who specializes with voice disorders, but my work schedule just wouldn’t work out with her availability. Now, I’m a “get it done” sort of person, so having to wait and feeling helpless about my situation really wasn’t doing anything for my mental state about my injury. I was beginning to think I would have to quit my job to fix my voice, but that job was providing the health insurance that paid for most of these scans and therapy sessions, so quitting was not really an option. I decided I would just have to find another SLP in the Denver area with better availability. I contacted my voice teacher to see if she knew of any other therapists I could go to, and she was very quick to find me a list of three other names. I contacted the first one on my list, and she got back to me that same day with available times, so I went with her. I have now learned that this SLP I went to is very highly respected in the Denver area by other SLPs here, so I really was in better hands than I had originally thought! In either case, just the simple act of scheduling a therapy session and going to it eased my mind and relieved some of the stress and hopelessness I was feeling about my voice.

Now, I would suspect many university-educated singers would think something similar to what I thought about going to therapy:  “I probably know almost as much as a therapist about the voice, so this should be a piece of cake for me.”  Especially if you took all the graduate-level courses in pedagogy at your university, like I had.  I mean, I taught voice lessons, which couldn’t be all that different, right?  Boy, oh boy, was I wrong.

I had already been exposed to some medical jargon about the voice that I didn’t understand at the doctor’s office, and I had a sneaking suspicion the voice therapist would have actually understood all that stuff if she had been there, but when it came to the basic function of the voice, I figured I was pretty much on par with one of them.  Well…no.  Therapists come from a whole different field than singers…a much more scientific field.  Yes, we do learn about the voice, and yes, we do know a lot more than the average person if we’ve studied our pedagogy books well.  We singers and teachers of singing can teach you how to use your voice with ease, but therapists (the good ones anyway) can actually take a broken voice and rehabilitate it to the point of complete ease in most cases of injury.  I guess what I’m trying to say is that we all have our roles to fill, and they are all important and deserve to be respected.  So, I had decided that while I thought I wouldn’t really learn anything new at therapy, I would follow her instruction without question and see where it got me.  That was the best decision I’ve ever made.

On my first visit, she did an assessment of my voice.  She measured the pitch where I spoke, the intensity, clarity, resonance, and duration of my speaking voice.  She determined I spoke too low…which I had been told before by proponents of the “sopranos should sound like sopranos when they talk” school of thought.  She also discovered my duration (the length of time I can sustain a single pitch in my speaking range) was several seconds below the average (15 seconds for me instead of the average 25 seconds)…which is a bit disheartening for a singer to hear.  She also said my measurements lined up with my diagnosis, but that I had “a lot of voice to work with” so her prognosis for recovery was very good.  Then she gave me some exercises that she recorded and put on a CD for me to take home and practice a few times every day.  The exercises were more like “speaking” exercises.  As she said, she didn’t want me to go into my “singer mode.”  The exercises were nothing fancy.  In fact, my singer brain kinda laughed at them a little bit because they were so easy and simplistic.  But, as I was determined to get better, I followed her instructions and did my exercises every day about four to five times a day.  And, much to the surprise of my mocking singer-brain, they worked!  I went back the next week, and my measurements were already a lot better.  I got another CD, practiced it three to four times a day (it was longer than the first one) and got better some more.  My voice was getting less fatigued at work, and I was straining a little less than usual to talk.  I wasn’t singing at all during this time, as I thought it would be better to re-learn how to walk before I re-learn how to run.  I was limiting my talking in general to cut down on the fatigue, but I was noticing some good improvements already.  A month went by, and I was even better, another month went by, and my voice was feeling almost normal…which was something I hadn’t felt for years. 

Up next:  Rediscovering What I Had Lost

Voice Science Talk: Paresis

           

So, some of you may be asking:  What the heck is paresis anyway?  Here’s the definition straight from my text book, Anatomy and Physiology for Speech, Language, and Hearing by Seikel, King, and Drumright:  “Paralysis refers to loss of voluntary muscle motor function, whereas paresis refers to weakness.”  In other words, paralysis is the complete loss of motor function and paresis is a partial loss of motor function, or partial disruption in the nerve signal.  So, why would loss of nerve function be a big deal in vocal function?  To begin answering that question, let’s review some basic anatomy and physiology.

The voice functions through the combined effort of laryngeal muscles and aerodynamics, which is called the myoelasticaerodynamic theory of vocal fold vibration.  In this theory, the intrinstic musculature of the larynx helps to close, or adduct, the vocal folds, through the adductor muscles at the onset, or beginning, of vocal sound, aerodynamic properties of subglottic air pressure and the Bernoulli effect (http://en.wikipedia.org/wiki/Bernoulli_effect if you want to get your physics on), keep the vocal folds in motion during voice use, and the muscular action takes place again at the end of voicing to separate the vocal folds past their usual resting position so that the air stream for inhale is more open (especially important for a singer).  (I’m not going to go too far into the aerodynamic principles here, but I might in future posts, so keep checking back in for that info.)  I will focus on the musculature since this is where the effects of paresis take place.  

The main adductors of the voice are the lateral cricoarytenoid and the transverse and oblique interaryntenoids.  The thyroarytenoid has two parts:  the internal, or vocalise portion, which is the “vocalise muscle” located under the lamina propria, and the external portion, or muscularis.  This muscle does assist with adduction, but it is primarily used to regulate vocal fold tension.  (Note to add here:  The vocalise muscle is covered in four layers of tissue:  the first is the epithelial tissue which is extremely thin and is the outer most layer, and the next three layers make up the lamina propria, which is loose connective tissue.  The complex movement of the lamina propria during vibration is what makes up much of the complex sound wave produced at the vocal fold level during vibration.  I'll be getting into this more in future posts, but wanted to introduce it here.)   The main abductor, or opener, of the voice is the posterior cricoarytenoid.  This is the muscle that keeps your vocal folds out of the air way if you’re breathing very heavy (so after a good workout, thank your cricoarytenoid for opening up the passage way for those large breaths you were taking).  The other main muscle involved in vocalizing is the cricothyroid.  This is the muscle responsible for elongating the vocal folds, which results in changing the pitch of the voice.  (*For an excellent example of this muscle in action, as well as the adductors and abductors, see this video:  http://www.youtube.com/watch?v=ajbcJiYhFKY)

Here are some visuals of these muscles to help you out:

The biggest thing to know about the voice is this:  It is a system which works on symmetry.  If the symmetry of the voice is off, due to any reason, it results in vocal dysfunction, muscular compensation, and possible damage to the vocal fold itself.  It simply is not an effective system if both sides of the voice are not working correctly.

Why is this important to understand?  Well, the larynx is innervated by two branches of the vagus nerve:  http://en.wikipedia.org/wiki/Vagus (if you're curious about it.)  One branch, the superior laryngeal branch, innervates the cricothyroid muscle and the recurrent nerve branch innervates all the other intrinsic musculature:  the adductors, abductor, and thyroarytenoid muscle itself.  Due to this, paralysis or paresis of either of these nerve sets can have different symptoms.  

If paresis is affecting the superior nerve branch, it will mainly affect the range of the voice.  Singers who experience this might experience unexpected voice breaks and/or a shortened vocal range from what is normal.  There can also be breathiness present in the voice as well due to asymmetrical vocal fold motion.  If paresis is in the recurrent nerve branch, the symptoms can vary depending on which muscle is affected, but some symptoms can include:  breathy voice quality, horse voice quality (which is breathiness + harshness), vocal fatigue and reduced volume, (or loss of vocal power).  Paresis in the recurrent nerve does not usually affect vocal range.  Although singers who recover can gain a few notes on their range, the difference is not as dramatic as with recovery from superior nerve paresis.  The symptoms that brought me in were tongue tension, breathiness, and vocal fatigue.  My asymmetry was bad enough for the left side of my tongue root to be pulled downward as the left fold went over towards the right.  If you look at the picture above that shows the root of the tongue directly anterior and superior (in front of and above) the epiglottis, you can begin to see just how much the paresis impacted my laryngeal function after nine or ten years of muscular compensation.  

Here's what to take away from this:  Nerves are the communicators that transmit the impulse from the brain down to the muscles (as well as carries signals from muscles to the brain...to let it know how everything's doing, basically.)  If that communication system is damaged, it results in a loss of muscular function, mainly causing muscle atrophy if it goes untreated for a while.  (This is why my right vocal fold was notably thinner and smaller than my left vocal fold when I saw it on the video, which also strengthens the case for my injury being rather long-standing prior to diagnosis.)  What can cause this?  Well, these nerves can be affected by a virus from a respiratory infection, which is most likely my cause, although the superior nerve branch is more commonly affected by viruses.  (That was why it was unusual for the ENT to see paresis in the recurrent nerve in voice performers like me.)  Basically, in this scenario, the virus gets down to the nerve in the tissue and irritates or obstructs part of the nerve, and the nerve then remains that way after the virus has been killed off by the immune system.  Other more serious causes can be tumor of the thyroid or neck, blunt trauma to the neck area or thyroid, intubation during surgery or emergencies, and aortic aneurysms, which could affect the left recurrent branch.  Full paralysis of these nerves is an issue if you are having thyroid or heart surgery if the nerves get severed during surgery.

My ENT sent me for a CAT scan of my neck and upper chest cavity to rule out any of these more serious reasons for recurrent nerve paresis.  He also did some basic facial muscle tests to rule out Bells’ Palsy and other neurodegenerative conditions.  (Quite frankly, given all the possible issues that could have been wrong with me, I am rather grateful it was only a simple virus that had long passed out my system that caused the trouble.  Facing voice therapy is much, much simpler than facing chemo, surgery, or an untreatable, neurodegenerative condition.)

I hope this was not too much information packed into a small entry.  If you have any questions, please post below and I’ll be happy to answer them if I know the answer.  If I don’t know the answer, I’d be happy to search and find the correct one for you as well! 

Up next:  Heading Out to Voice Therapy

(All images are public domain and can be found on wikipedia if you wish for a larger view.)

Heading Out to the Doctor

The week after the dreadful Met competition, I went to my scheduled voice lesson with my teacher.  We talked about what had happened at the competition, and I must have alluded to my conclusion that I just wasn’t as talented as everyone else.  Instead of agreeing with me, my teacher that day said something both great and wonderful that day, (although I didn’t think so at the time).  She said:  “I think it’s time we really get your voice looked at by a doctor specializing in professional voices.”  She went on to say that there is still so much tongue tension, breathiness, and “valve-ing” (which is her way of describing that “squeezing the tooth paste tube” feeling I was talking about earlier), when I sang.  She also said, and I will forever love her for saying this, “I don’t think it’s your fault that these problems are still there.  I think there’s something wrong at the laryngeal level.”  I nearly cried for joy at that.  I had had other teachers give me a similar talk, but it always went something more along the lines of, “Why are these problems (i.e. tongue tension and airiness) still there?  Are you just not practicing your technique?”  These talks always left me thinking to myself, “Why am I just not getting it?  Am I just too stupid or something?”  To have a teacher emphasize that it wasn’t my fault, that I was too intelligent and thoughtful about my singing to just not be “getting it,” was such a miracle!  It was probably the reason I wanted to get to that doctor right away.  This visit, this stroboscope could be the answer to all my problems.  It could be the absolution for my singing troubles!  (Although to be completely honest, I didn’t actually think they would find anything particularly wrong with my voice.  I was still holding on to my “ballet” theory of comparative singing talent.)

I made my appointment for the next week and walked in to the ENT’s office expecting for him to find something common and simple to treat, like acid reflux or something.  About mid-way through, the physician’s assistant, who was handling the camera, and the doctor, who was watching the video up on the big screen behind me, were talking about something in that shocked “is that really what we’re seeing” kind of voice doctors’ occasionally use that totally freaks their patients out.  (Seriously, aren’t they taught not to do that in med. school?)  So I was getting a little uncomfortable.  Nonetheless, they took the camera out of my throat and swung my chair around to tell me what they saw.  First, there were some red spots that were indicative of acid reflux.  (Ah!  I was right!  It’s probably nothing really all that wrong with me!  I’ll get a prescription, go home, and be better by my next audition.)  Well, no.  My vocal folds started out looking pretty good at the beginning of the scope.  They were that grayish-white color they’re supposed to be.  The surrounding tissue was a nice shade of pink.  There weren’t any signs of asymmetry on the folds themselves, no nodes, hemorrhages, or polyps.  They were open symmetrically during my breathing.  Then, the real problem showed up.  As I started to phonate, my vocal folds started actually going a bit diagonal.  My left fold was crossing the mid-line in order to meet up with my right fold…which seemed to be almost getting stuck at a certain point of closure.  It was almost as if someone had put a pin in the tissue to the side of my right fold that kept it from moving all the way in.  And, my right fold looked shorter and smaller than my left fold, which was pretty big in comparison to the other one.  I had had enough vocal pedagogy to know this was not what a 29 year old classical singer’s voice was supposed to look like.  I started to panic.  (Of course, at the same time the vocal science geek in me was excited to see this problem first hand…if I forced myself to forget temporarily it was my voice I was seeing.)

So basically, the diagnosis was: vocal fold paresis of the right recurrent nerve.  And this, apparently, was not what the doctor was used to seeing in singers.  He did ask if teachers have ever complained about tongue tension when I sing.  I said “yes, quite frequently.”  Then he said, “This is why,” and he pointed on the paused video to the left side of my tongue base that was just peaking into view of the camera during phonation.  It was being pulled down when the left folds had to pull so far over to the right.  He also pointed to how there was occasionally an opening near the arytenoids when the left fold didn’t get far enough over, which would explain any breathiness in my voice as well and the reason why that breathiness was not always there.  He asked how long had teachers been mentioning those issues, and it took me a while to think back that far.  I said the breathiness comment showed up about junior year of my undergraduate degree and that both of those problems were abundant during the entirety of my master’s program.  He said it was highly likely the paresis had happened during my undergraduate degree in that case, (which I graduated from in 2001…so yeah, it’d been around a long time).

The first thing I did after getting back to my car was cry for about ten minutes.  The second thing I did was to call my voice teacher.  I left her a voice mail with the diagnosis and drove home.  She called back later that day to give me words of reassurance that therapy will take care of it.  She said “now we know what’s wrong, and we’ll get it fixed.”  

Next up:  We'll take a little detour from my story and go more in depth about which nerves innervate the larynx as well as what paresis is and what the symptoms are.  So up next:  Voice Science Talk:  Paresis!

Realizing I have a problem...

In early January of 2009, I was competing in Denver, CO in the Metropolitan Opera Young Artist Competition preliminary competition.  I got there about an hour before my time (which is my normal thing) and settled in.  I tried to cover my nerves by talking too much chatted a little with people I knew from school who were there, looked over my music, sipped my water, etc.  I had just come off of my Christmas vacation where I had sung at my church to rave reviews (of course…those are easy to get at church), I had had coachings with a very good local coach, I had worked on all my arias for several months to a year with my new and brilliant voice teacher and my hair was doing everything right that day.  I was feeling pretty good.  Then I sang...

Let me make one thing very clear:  I sucked.  I totally, completely, embarrassingly sucked that day.  I was 29 years old with a master’s degree in voice performance, which should have made me a contender, but instead, I sucked so hard I really wanted to run away from the place and never come back.  For my first selection, I sang…or butchered, rather…Donizetti’s “Regnava nel Silencio” from Lucia di Lammermoor.  I ran out of breath on nearly every phrase…and I don’t mean I felt like I was running out, I literally ran out.  I struggled through every single note I had to sing, and I was sure everyone could hear it.  And to make matters worse, the judges asked me for a second selection.  (While that might seem like a compliment, I think they had just decided to let everyone sing two arias that day.)  I would’ve been quite content to walk off after my first aria and go start my crying in the bathroom, but I had to fumble my way through a second piece.  I was still feeling out of breath after every phrase.  And I was horrified.

I couldn’t understand how a 29 year old with a good voice teacher, a graduate degree, and a modest amount of performance experience could suck so badly in one day.  I mean, sure, I was working a day job at a bank where I used my voice all day, and sure, I wasn’t getting regular lessons with my teacher due to schedule and finances…but what singer out there wasn’t doing those same things?  Why was my voice such a problem for me?

And I noticed something else that day:  the good singers that day really just opened their mouths and a great sound came out.  Sure, for some of them their technique wasn’t completely even up and down the scale, but when it came time for them to sing, they just inhaled and sang.  Why couldn’t I do that?  For me, I would inhale, think about opening my voice, force my throat to open as much as I could, and sing through whatever semblance of “open” I could create.  I felt like I was squeezing tooth-paste through a tube.  I knew it wasn’t supposed to feel that way, but it took me so long to manage an “open throat” in my lessons.  And even then, I couldn’t sustain that position for more than 15 minutes at a time.  Just the simple act of beginning the sound was a huge ordeal for me.  And I was noticing more and more vocal fatigue as I got older…which is what had brought me to my new teacher in the first place.

So directly after the Metropolitan fiasco, I went and cried for a while.  Then, I had to go to work at my day-job.  As I sat at work, I pondered why it was that other singers there that day, whether their technique was good or not, had more ease of vocal production then I did.  Could it be something wrong with my voice?  Nah.  I had seen an ENT a year ago who said my voice was fine.  My folds looked healthy.  Was it my technique?  Well, yeah, it wasn’t totally solid yet.  I figured no one could suck as much as I did at my age and actually have good technique.  But why was it so bad?  Why did I feel like my voice and technique were never improving and even getting harder and harder to handle?  I thought your late twenties into your early thirties were supposed to be when your voice was at its best, but it felt like mine was circling the drain.

I also thought about how I used to dance ballet when I was younger.  (I know this is an abrupt transition, but just go with it.)   I danced at my local company as a student for eight years, but my bow-legs, hips, and chest (thanks, Puberty!) killed my dream of being a ballerina.  I had realized I wasn’t that talented at ballet a couple of years before I quit, but I kept doing it because I liked it so much.  This was my truly horrifying thought:  Was that what I had been doing with singing?  Was I actually a completely untalented hack who keeps going when she should stop?  Did that major university give me a master’s degree out of pity?  I must have just been fooling myself all these years about having talent of some kind.  How sad.  And how completely heart breaking.  I should probably just resign myself to being a church choir member (unpaid) and leave it at that.

This was my conclusion at the end of the day of the Met competition.  Luckily for me, it was not the end of my singing...the sad conclusion to all the time, effort, and money put into the craft for nearly fifteen years.  It was the beginning of a journey of a different type.  It was a journey that gave me a new direction and passion, in addition to saving my singing.

Up next:  Heading to the doctor.  

Vocal Injury and Recovery

In January of 2009, I was diagnosed with recurrent nerve paresis of the right vocal fold. I am an opera singer with a master’s degree in vocal performance from a major university. I am a lyric coloratura. This diagnosis was both cathartic and devastating. Cathartic because it explained so many of my vocal troubles which had plagued me for years, and devastating because, well, what exactly is an opera singer without a voice? My voice has healed completely and my singing still needs some work; but this process of recovery led me into a new passion. I am currently training to become a speech-language pathologist who specializes in voice disorders and injury. I am in my first year of college study towards this new goal, and I decided to write this blog to tell my story of recovery, to give hope to those who are dealing with vocal injury, and to educate those who work with professional voices…with some of the knowledge I am gaining right now.

The effects of vocal injuries are wide-reaching. Through my own experience, I have begun to understand just how wide-reaching they are. Vocal injuries carry with them a wide array of emotional upset for anyone experiencing difficulty with vocal function, but this is especially true for the professional voice user. There is not only the trauma of having a dysfunctional voice, but also the burden of dealing with assumptions made by others that the performer has done something to cause it. This can carry a great deal of guilt. If a performer takes their craft seriously, they either did not cause their injury, as in the case of a nerve disorder, or they simply lacked the education to know that their behaviors could damage their voice.

Even though I did not carry the guilt of harming my own voice, I still had far-reaching issues to deal with in this realm. I wasn’t sure my voice would ever just be “normal.” After therapy, I had to re-train my voice to sing from scratch. And although I made progress, I have made the most progress in recent months due to my recognition that I must start at the beginning to have my voice work properly. I must re-learn how to breathe with an open and relaxed throat, how to coordinate a clean on-set, and how to form my vowels without creating tension. Instead of being an advance singer who was just tweaking her technique here and there, I was really starting from the beginning.

Before I get into my story too deeply, I would like to go ahead and put in some pragmatic suggestions up front for those singers out there currently recovering and for their voice teachers (which will all be expanded upon as the blog goes on!):


For the injured singer: 

• If you suspect you have an injury, please see an otolaryngologist (ENT) in your area to get a stroboscope done of your voice. (It’s even better if they specialize in professional voices!) 
• If you have had a diagnosis of an injury already, find an SLP who specializes in voice. (The SLP field is a very wide one with many different specialties to go around, so this is particularly important.)
• Follow the SLPs instructions and do the necessary work, or practice, outside of therapy to yield the best results. (They are not magicians who can fix your voice with just one hour of work every week. You’ve got to put in your time outside as well…just as with voice lessons!)
• Do not be surprised if the SLPs measurements show a healed voice, but your singing is not automatically better. Muscle memory dies very, very hard.

For the voice teacher of an injured voice:

• Reserve extra patience for your student as they recover. As I said, old muscle memory dies hard, and singing on an injured voice inherently trains in more than the usual amount of “bad habits.” It will take some time to recover from that.
• If this student seems to “lack confidence,” please realize it is most likely not a confidence issue, it is a trust issue. Singing on an injured voice is like playing Russian-Roulette, you just never know when you’re going to sound great or awful. Whatever comes out that day seems to be out of your control, and no matter how much you focus on “technique” it just never gets better. Even after healing, this trust issue of the “unpredictable voice” will still linger. Instead of saying “work on your confidence,” say instead “you can trust your voice now, so let’s just sing.”
• We don’t “listen” to ourselves as much as we “feel” in our throats. The process of recovery made me highly tactile in terms of what healthy laryngeal sensations are vs. unhealthy ones. I really don’t mind not hearing myself, but, as a master-manipulator (see below), I sometimes don’t know what I’m really supposed to be feeling, since sensation is very deceiving for someone suffering this compensatory muscle action for an injury that is not even there anymore.
• You’ve probably got a master-manipulator on your hands. Those of us who sang on an injured voice for years prior to a diagnosis got very, very good at all sorts of laryngeal and pharyngeal manipulation to accomplish some sort of passable sound. We need the most help with finding where relaxed “neutral” actually is! Relaxed doesn’t feel like “space” to us, it feels like we’re not doing anything. And not doing anything will freak us out. All we’ve ever done is over-do just to sound decent. If your student seems to get frustrated or seems to get more manipulative as a lesson goes on, just remind them that they should be sensing a very miniscule amount of muscular effort rather than really “working at it.” 

As I begin my story of vocal injury, diagnosis, and recovery, I hope this information is helpful to those dealing with this in some way, through personal experience or teaching.  Thanks for reading so far, and I hope you come back again soon!