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Dr. Turck:
COVID-19 has led to the development of several unexpected symptoms, but some patients are experiencing problems with their voice, including hoarseness and even vocal fatigue. What do we need to know about these related symptoms? And what kind of impact could they have on a patient's life?

Coming to you from the ReachMD studios, this is COVID-19: On The Frontlines. I'm Dr. Charles Turck. And joining me today to share their clinical experience in caring for patients experiencing vocal fatigue and dysphonia are Drs. Amy McGorry and Catherine Crowley. Dr. Amy McGorry is a Doctor of Physical Therapy and the Director of Clinical Education at Long Island University in New York.

Dr. McGorry, thanks for being here today.

Dr. McGorry:
Oh, it's great to be here. Thank you so much.

Dr. Turck:
Dr. Catherine Crowley is a speech pathologist and Assistant Professor and the Chair of the Communication Sciences and Disorders School of Health Professions in Nursing at Long Island University Post in Brookville, New York.

Dr. Crowley, welcome to the program.

Dr. Crowley:
Thank you for having me.

Dr. Turck:
So let's dive right in. Dr. Crowley, from your vantage point as a speech pathologist, would you break down how COVID-19 can lead to vocal fatigue and any other challenges in patients using their voices?

Dr. Crowley:
Absolutely. So let's first talk about, vocal fatigue as being both a short-term and a long-term effect of COVID. And so let's define vocal fatigue. And what we know as far as vocal fatigue is that it's a functional voice disorder, meaning that if I were to look at the vocal cords, they would look intact. They would look relatively fine, an absence of lesions, polyps, nodules. But the problem is more so in the speech mechanics. How is the voice being used? And what we know as far as complaints when we talk about vocal fatigue is that the patient will report, "It takes too much effort. It takes more effort than usual to produce my voice."

And so, what happens is, very often with voice problems in general is that they're cyclical, meaning that initially the problem might have been breath support where the patient had really reduced breath support because of COVID itself, and then what happens is the patient might start compensating. And so, in doing so, they might tighten up their vocal quality or might tighten up the muscles and might work a little bit harder, thereby producing voice but still not as strong and effective as it should be, and so, as a form of cycle is that they then now tighten up their voice a little bit more, strain a little bit more, and then they find themselves in this cycle where they try to compensate but really not getting much out of that, and so that's causing a little bit more of that fatigue.

Dr. Turck:
I imagine vocal fatigue has to put a strain on people who have to work every day. What kind of impact has this symptom had on patient quality of life?

Dr. Crowley:
Certainly, we can't forget about quality of life. And simply, for example, me, I was a professor. If I can't use my voice effectively, then simply, I can't perform my job; I can't perform my duties required of me so I can make a living. But beyond that, when we talk about quality of life, what about social interaction? So, when I'm straining and it's so much work for me to use my voice, then what will happen is I tend to not use my voice. I tend to become a little bit more introverted, use the telephone a little bit less, socialize a little bit less, thereby affecting overall quality of life. So certainly vocal fatigue can be an issue with quality of life.

Dr. Turck:
Turning to you now, Dr. McGorry, how has vocal fatigue impacted your practice as a physical therapist.

Dr. McGorry:
You know, it's interesting because I just actually had stumbled upon what vocal fatigue was for a patient. I was treating some of these, you know, frontliners in the beginning of COVID. A lot of my own doctors, had it, and a few of them are very world-renowned. They do these lectures throughout the globe. And, and I would be doing these PT sessions, working around their ribcages, doing these stretches, just overall development, trying to get their strength back, and a few of them I would try to hear what they're saying through the, you know, through the Zoom or Facetime, and they just would start to kind of fade off like this, and I thought, "Gosh, I can't hear you." And one or two of them had said, you know, "I just feel like I just don't have that strength in my voice." And let's face it. When you're a physician and you're trying to do a lecture and kind of project that voice and you've been very well-known in the industry, and you look weak, it kind of gets in your head, right? So the public speaking started to get affected.

So then I stopped for a moment and I was like—do you know what?—let me start incorporating the diaphragm and the diaphragm it deals with a lot of the breathing, a lot of the projection. So I started teaching some of my patients then how to self-release. It's a muscle. It can get stuck. And so a lot of my treatment then shifted from just overall getting these ribs moving, getting these muscles around the chest wall moving and the neck to relax a bit to focusing on self-manual releasing of the diaphragm muscle and working on projection, and I started hearing the voices getting stronger.

And then, luckily, the dean here at LIU, Denise Walsh, had said to me, "Hey, have you ever connected with Dr. Crowley?" and I said, "You know, gosh, this is great." We always talk about relationship-centered care with patients where we all collaborate together, and this has been fantastic, because when I started picking her brain about, "Hey, are you seeing this?" More and more patients started talking about it, and that's when I said, "Gosh, it is a real thing," and Ii just kind of opened my eyes that we really all do have to work together as a team. COVID is definitely a multidisciplinary teamwork approach.

Dr. Turck:
For those just tuning in, you're listening to COVID-19: On The Frontlines on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Drs. Catherine Crowley and Amy McGorry about vocal cord fatigue as a result of COVID-19.

Staying with you, Dr. McGorry, you mentioned some about how you had connected with Dr. Crowley, but how do you approach treating vocal fatigue collaboratively with members of other healthcare disciplines?

Dr. McGorry:
So what I do first is from the physical therapy point of view. I'll take a look at that patient. I'll take a look at their ribcages. Are the lower ribs moving or not? and then after addressing that, I'll take a look and say, "What other muscles? What's not working? Are their muscles in their neck tight?" Then I would approach Dr. Crowley and say, "Okay, from a physical therapy standpoint, I'm trying to get the lower ribs to move so they can actually get that air in and get that diaphragm released." You know, "What do you see?" And then she will work with me and say, "Hey, this is what I need in order for them to project." So, if there are certain voice techniques that I can incorporate with my exercises, like maybe have them count out loud while they are doing their exercises. Instead of just moving their arms up and down 10 times, have them "1, 2." So it's a fun way to kind of get them to do their homework for their speech therapy at the same time.

Dr. Turck:
Dr. Crowley, how has vocal fatigue associated with COVID-19 impacted your practice?

Dr. Crowley:
So, two ways. One, as professor, what I find myself doing more and more is incorporating COVID-19 as a topic for my lectures. I certainly look to incorporate and talk about COVID-19 being a risk factor and teaching the students that this is something that they must now incorporate as part of their case history as a question is, Did the patient have COVID-19? Is this a risk factor? Is this something that the patient has experienced? As a practitioner, as a clinician, again, we need to look at this and consider that this might be a question or a case history, that we might have to question the patients as a possible risk factor for voice disorders.

Dr. Turck:
Now, before we close, I'd like to give each of you a chance to share any final thoughts for our audience. Dr. Crowley, do you have any takeaways you'd like to share?

Dr. Crowley:
My big takeaway, as Dr. McGorry was mentioning, is the importance of interprofessional treatment and the importance of incorporating the whole patient and the whole body and how it certainly would behoove and we would see some success or more success if we look at this as a team approach, as not just a problem of voice—although we say it's vocal fatigue—but as a generalized fatigue problem. And so the big takeaway is this interprofessional relationship that should be fostered in our treatment plans.

Dr. Turck:
And same question to you, Dr. McGorry. Any final thoughts for our audience?

Dr. McGorry:
I would say, just from a physical therapy point of view, when a patient comes in with vocal fatigue, they have to understand that when people are not breathing efficiently, they are not moving that lower ribcage, they're not moving that diaphragm, so their neck muscles, that upper ribcage gets so tight, so that's going to feed into this whole vocal dysfunction that we're seeing; so it is so important that we all work collaboratively, that physicians talk to these patients, let them be aware of it. I had talked to a support group, and one woman said, "Gosh, this is so nice because nobody has talked to me about this. I wasn't aware. I thought it was just me." And when she would speak to her husband, who's constantly saying, "What? What?" and that was leading to some, you know, some fights and they're getting annoyed at one another, so then she's like, "Okay, I'm not crazy. This is actually happening because of the COVID, and it's something that can be addressed."

So I think we can really help out a lot of people, and because of that, Dr. Crowley and I have decided we're doing a collaborative study. And we're looking for participants in the New York State region to do this virtual type of exercise program just for a few weeks, and we're going to see if we can really make an impact of the speech therapy with physical therapy addressing vocal fatigue. So we're obviously going to give you that information, to your website.

Dr. Turck:
Well, this has been such an interesting topic to hear about today, and I'd like to thank my guests, Dr. Amy McGorry and Catherine Crowley, for sharing their insights on vocal challenges in patients with COVID-19. It was great speaking with you both today.

Dr. Crowley:
Thank you for having us.

Dr. McGorry:
Thank you so much for your time. Thank you.

Dr. Turck:
For ReachMD, I'm Dr. Charles Turck. To access this and other episodes in our series, visit ReachMD.com/COVID-19, where you can Be Part of the Knowledge. Thanks for listening.