ARTICLE IN PRESS

Adherence to Voice Therapy Recommendations Is

Associated With Preserved Employment Fitness Among
Teachers With Work-Related Dysphonia
*,†,‡Lilah Rinsky-Halivni, *Miriam Klebanov, ‡Yehuda Lerman, and †Ora Paltiel, *†Jerusalem and ‡Tel Aviv, Israel

Summary: Objectives. Referral to voice therapy and recommendations for voice rest and microphone use are common
interventions in occupational medicine aimed at preserving the working capability of teachers with occupation-related
voice problems. Research on the impact of such interventions in terms of employment is lacking. This study exam-
ined changes in fitness (ie, ability) to work of dysphonic teachers referred to an occupational clinic and evaluated employment
outcomes following voice therapy, voice rest, and microphone use.
Study design. A historical prospective study was carried out.
Methods. Of 365 classroom teachers who were first referred to a regional occupational medicine clinic due to dys-
phonia between January 2007 and December 2012, 156 were sampled and 153 were followed-up for an average of 5
years (range 2–8). Data were collected from medical records and from interviews conducted in 2014 aimed at assess-
ing employment status. Logistic regression models were used to assess associations between interventions and employment
outcomes. Survival analyses were performed to evaluate the association between participating in voice therapy and length
of retained employment fitness.
Results. Thirty-four (22.2%) teachers suffered declines in working capabilities due to dysphonia. Voice therapy was
demonstrated as being a protective factor against such declines (odds ratio = 0.05 [0.01–0.27]). Adherence to recom-
mendation of voice therapy was <50%. Most of the decline in working fitness among nonadherent teachers occurred
within 20 months after referral. Unlike voice therapy, voice rest and microphone use were not associated with reten-
tion of working capabilities.
Conclusions. Voice therapy, especially when instituted early, is a strong predictor for retaining fitness for employ-
ment among dysphonic teachers.
Key Words: Voice therapy–Voice disorders–Fitness to work–Teachers–Occupational dysphonia.

INTRODUCTION The most common clinical findings of professional voice users

Vocal problems among classroom teachers are considered a pro-
fessional hazard, leading to reductions in physical, social, and
emotional quality of life and negatively affecting their profes-
sional performance.1–3 Occupational dysphonia can lead to
absenteeism, decline in fitness to work and early retirement, as
well as to a subsequent decrease in the trained workforce.4,5 In
Israel, laryngeal disorders are recognized as an occupational
disease subject to compensation, and voice disorders represent
9.8% of all occupational diseases reported to the Israeli Regis-
try of Occupational Diseases in 2013.6,7 The point prevalence
of voice disorders among teachers was reported to range from
9% to 37%, and the 12-month prevalence to range from 15%
to 80%.8,9 In the USA, the cost of absenteeism and treatment
related to voice problems in teachers, who comprise 4% of the
workforce, has been estimated to be $2.5 billion annually.10,11
Accepted for publication September 8, 2016.
Presented at the 52nd Annual Conference of the Israeli Speech Hearing and Language
Association, Jerusalem, Israel, February 16, 2016.
Presented in part in the Master’s thesis of the first author as partial fulfillment for the
degree of M.Occ.H in School of Public Health in Tel Aviv University.
From the *Department of Occupational Medicine, Jerusalem District, Clalit Health Ser-
vices, Jerusalem, Israel; †Braun School of Public Health and Community Medicine, Hadassah-
Hebrew University Medical Center, Jerusalem, Israel; and the ‡School of Public Health,
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Address correspondence and reprint requests to Lilah Rinsky-Halivni, Department of
Occupational Medicine, Jerusalem District, Clalit Health Services, 1 Louis Lipski St,
Jerusalem, Israel. E-mail: lilah.rinsky@mail.huji.ac.il
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.09.011
with dysphonia are benign lesions, laryngitis or edema, and func-
tional dysphonia.12 Functional voice disorders, which account
for 41% of all voice problems among professional voice users,
are characterized by the absence of structural organic lesions.12
Clinical trials have demonstrated significant efficacy of voice
therapy for both structural and functional dysphonia, measured
mainly by improvement in voice quality parameters or, more
rarely, evaluated by vocal fold morphology (ie, a reduction in
the size of vocal fold nodules) and improved self-evaluation in
quality of life questionnaires.13–16 The impact of voice therapy
on employment status, however, has not been evaluated to date.
The role of occupational physicians is to identify and prevent
work-related injuries, as well as to treat and rehabilitate the af-
fected individuals with the aim of enabling their re-entry into the
workforce.17 Secondary prevention aims to reduce the impact of
an injury that has already occurred to prevent repercussions on
quality of life and working capability over time.18 The latter is as-
sessed by the evaluation of fitness to work, defined by the ability
of a worker to effectively continue to fulfill the job requirements.19
Full retirement or change of employment due to a disability can
result from a total lack of fitness for a duty, whereas medical rec-
ommendation for diminished working hours or prolonged sick leave
can be given when fitness to work is less compromised.20 There
are sparse data on the impact of profession-associated voice dis-
orders on the affected individual’s level of fitness to work. Reports
of effects of dysphonia on employment are limited mainly to self-
reported sick leaves due to the condition.4,5,21,22
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2016
Referral to voice therapy by occupational physicians is common
for teachers already exhibiting some degree of impairment (ie,
at the secondary prevention stage). Additional interventions which
are widely accepted in occupational medicine (despite a paucity
of data on their efficacy) include prescribing a period of reduced
phonation or voice rest, either alone or combined with voice
therapy, and guiding the teacher on ergonomic measures, such
as microphone use.23–25
The aims of this study were, first, to evaluate the impact of
occupational medicine interventions, namely, voice rest, micro-
phone use, and especially voice therapy, on the preservation of
fitness to work among dysphonic teachers referred to an occu-
pational health clinic and, second, to estimate the rate of decline
in fitness to work in this population.
METHODS
Study population
This study was conducted among patients of Clalit Occupation-
al Medicine Clinic, the largest health maintenance organization
(HMO) in the Jerusalem district, which provided occupational
services to 80% of the district population during the study follow-
up period. We included kindergarten and primary, secondary, and
high school teachers between 20 years of age and the age of re-
tirement (62 years for women and 67 for men) who were first
referred to the clinic for voice problems between January 2007
and December 2012. They all had undergone evaluations by an
ear, nose, and throat (ENT) specialist. Forty-five teachers who
had already experienced a decline in fitness to work upon first
referral to the occupational medicine clinic or did so within the
first 3 months from initial referral (ie, not in the secondary pre-
vention stage) were excluded. The historical cohort study was
carried out on 153 dysphonic teachers who agreed to partici-
pate in the study out of 156 who were randomly sampled from
a total of 365 suitable candidates.
Decline in fitness for work, as opposed to preservation of full
fitness for work, was defined as one of the following condi-
tions, each of them due to dysphonia: (1) permanent retirement
from teaching; (2) permanent part-time employment, meaning
a gap between the initial weekly working hours and those at the
time of interview; (3) prolonged (more than 3 months) inabil-
ity to work in the classroom; (4) prolonged duration of part-
time employment. A 3-month cutoff is frequently used in the
long-term disability insurance world,26 and we adopted it for de-
termining a decline in fitness to fulfill the requirements of a
classroom teacher.
Voice therapy
Voice therapy was conducted by licensed speech therapists with
either a bachelor’s or master’s degree level. In most cases, in-
dividual sessions were conducted for 45 minutes on a weekly
basis. Therapy sessions combined elements from both direct and
indirect therapeutic approaches aimed at recovering vocal func-
tion, reducing vocal abuse, and improving voice quality.27,28 Direct
techniques focused on the components of voice production, such
as such as breathing, laryngeal re-posturing, and others.14 Indi-
rect approaches were based on the patient’s knowledge of
identifying factors that perpetuate the voice disorder (eg, gained
from vocal hygiene programs) and his or her ability to elimi-
nate them.23,29 Adherence to voice therapy recommendations, as
collected from medical records, was defined by attendance at a
minimum of five sessions (which included a first diagnostic
session) before any decline in fitness for work. This cutoff was
demonstrated in the literature as a predictor for course comple-
tion and for the successful treatment of presbyphonia.30–32 Teachers
who attended a minimum of five sessions comprised the “Ad-
herent Voice Therapy” (AVT) group, whereas the rest comprised
the “Non-Adherent Voice Therapy” (NAVT) group.
Data collection
The data were collected from comprehensive electronic medical
records of the HMO, which included the entire medical history
of each patient, such as encounters, prescriptions, billing, etc.
The following data were collected from those electronic records:
demographics (age, gender, ethnicity or religion), smoking status,
occupational variables (seniority, government or private em-
ployer, school level, main teaching subject, changes in weekly
teaching hours before first referral and during the occupational
clinic follow-up and their cause), variables describing the vocal
problem (symptom duration until first clinic visit and until ini-
tiation of voice therapy, aphonia, vocal fold pathology, history
of vocal fold surgery, reflux, number of sick days taken due to
dysphonia before first clinic visit, number of ENT visits), vari-
ables of adherence to occupational recommendations (number
and dates of voice therapy sessions or completion, use of mi-
crophone, and voice rest period [1–3 months of sick leave
following medical recommendation]) before any decline in fitness
to work. A structured telephone interview was conducted at the
end of 2014 to determine the current occupational status and actual
changes in employment attributed to voice problems implying
decline in fitness to work. The interview included questions about
history of changes in weekly teaching hours and their cause. In
addition, it included questions about occupational variables (se-
niority, government or private employer, school level, main
teaching subject) and adherence to medical recommendations
(number and timing of voice therapy sessions, microphone use,
number of sick days used due to dysphonia before and after first
occupational medicine referral) to fill in missing data in the
medical records. We used data in the medical records in cases
of discrepancy with the data obtained from the interview.
Statistical analysis
We performed descriptive statistics on characteristics of the par-
ticipants and an estimation of the rate of reduced fitness to work
among the dysphonic teachers attending the occupational clinic.
Univariate analyses of associations between the characteristics
of participants and attendance in voice therapy programs were
evaluated using a chi-square test for comparison of categorical
variables, the Student t test, or the nonparametric Mann-
Whitney U test for continuous variables. Two-sided tests of
significance were used, and statistical significance was set at
P < 0.05. The association between fitness to work and interven-
tions (primarily voice therapy) was estimated by odds ratios (ORs)
with 95% confidence intervals (CIs) using univariate analyses
 ARTICLE IN PRESS
Lilah Rinsky-Halivni et al Voice Therapy for Teachers With Work-Related Dysphonia
and multivariate regression models adjusted for various covariates,
such as demographics and occupational covariates. Variables were
chosen where they significantly contributed to the multivariate
models. To obtain a parsimonious model, covariates were removed
if the level of significance was greater than 0.05 in a likelihood
ratio test. Smoking status was not included because of the small
number of smokers (eight teachers). Seniority was not in-
cluded because of collinearity with the age variable. The survival
time at full fitness to work of the teachers who attended voice
therapy sessions and the teachers who did not attend voice therapy
sessions from the time of first referral to the occupation clinic
was assessed using the Kaplan-Meier method. Log-rank tests were
conducted to compare the survival times of teachers from the
AVT group and those from the NAVT group. Multivariate anal-
ysis was performed with a Cox proportional hazards regression
model to evaluate the impact of voice therapy on survival time
at a level of full fitness to work. Data were analyzed with SPSS
version 21 (IBM Corp., Armonk, NY).
Ethics
This study was approved by the ethics committee of Clalit Health
Services. The participants provided verbal informed consent at
study entrance.
RESULTS
Study population characteristics and voice therapy
attendance
Table 1 summarizes the demographic and clinical characteris-
tics of the study population and their distribution between one
group consisting of teachers who were adherent to the recom-
mendation of voice therapy (AVT, N = 75, 49%) and a second
group consisting of teachers who were not adherent (NAVT,
N = 78, 51%). All 153 teachers received a recommendation for
voice therapy. The teachers in the AVT group attended an average
of 10.7 voice sessions (median 12.5), whereas those compris-
ing the NAVT group attended an average of 0.6 sessions (median
0). The majority of the AVT group completed the voice therapy
course in less than 6 months from first referral to the occupa-
tional medicine clinic, with an average of 4.25 months. More
government-employed teachers were nonadherent to voice therapy
compared with teachers in the private sector (P = 0.01). Anal-
ysis of teachers from these two categories of employers reveals
that government-employed teachers also tended to exploit more
sick days (P = 0.02). The two groups (AVT and NAVT) did not
differ in the rest of the studied parameters.
Decline in fitness to work
The proportion of the participating 153 teachers who under-
went a decline in fitness to work after an average follow-up of
5 years (range 2–8) was 22.2% (CI 15%–28%), of which nearly
one-quarter (n = 9) lost the capability to teach due to dyspho-
nia, 56% were still teaching part-time at the time of the interview,
and only 18% had resumed their initial number of weekly teach-
ing hours. A significantly higher proportion of teachers in the
NAVT group underwent a decline in fitness to work compared
with the AVT group (85.3% vs 14.7%, P < 0.001).
3
Effect of voice therapy on preservation of fitness to
work
The multivariate analysis showed that voice therapy was a pro-
tective measure against decline in the fitness to work among
dysphonic teachers [OR = 0.05 (CI 0.01–0.27)], after control-
ling for age, ethnicity or religion, and government or private
employer. These results indicate that the AVT teachers were much
more likely to maintain work fitness compared with the NAVT
teachers. Other covariates associated with decline in fitness were
male gender, prolonged hoarseness, and more sick leave days
and ENT visits (Table 2). A Kaplan-Meier survival curve was
constructed to plot the time until loss of work fitness of dys-
phonic teachers in the AVT and NAVT groups (Figure 1). There
was a significantly higher retention rate of fitness for full-time
employment among AVT teachers, whereas most of the de-
clines in fitness among the NAVT teachers occurred within 20
months from the referral to an occupational clinic. Over one-
third (37%) of the NAVT group experienced a decline in fitness
to work, of which 21 (27%) were within 20 months and 14 (18%)
were within 12 months since referral. Cox regression analyses
were consistent with the previous logistic regression analysis and
demonstrated increased time of being fully fit for the AVT com-
pared with NAVT teachers (HR = 0.14, CI 0.05–0.4) after
adjusting for age, ethnicity or religion, and government or private
employer (Table 2).
Effect of voice rest and microphone use on fitness to
work
Measures other than voice therapy that are frequently recom-
mended by occupational physicians were evaluated (Table 2).
Prescribing the dysphonic teacher a period of voice rest for a
period of 1–3 months, alone or combined with voice therapy,
did not demonstrate any significant association with job fitness
in the univariate analyses and was excluded from the multivari-
ate model. Interestingly, the use of a microphone had a nearly
significant negative (nonprotective) effect on retaining fitness to
work in the univariate analysis, but it was excluded from the par-
simonious multivariate model.
DISCUSSION
To date, there have been no reports on the effect of voice therapy
on the status of employment among classroom teachers, whose
fitness to work requires the use of their voice. Previous works
had focused mainly on voice quality assessments and on self-
evaluated quality-of-life questionnaires but not on employment
outcomes.15,33 Some quality-of-life questionnaires include a few
items on occupation, such as self-perceived job activity distur-
bance or future career decisions.34 Positive correlations were
demonstrated between self-perceived quality-of-life and fitness
to work in employees suffering low back pain.35,36 However,
acoustic and perceptual analyses, the commonly used speech pa-
thologists’ measures of degree of voice-quality impairment,
showed little correlation with the patient’s self-perceived voice
problem,37 and therefore is probably not very likely to reflect
fitness for employment as a classroom teacher. Additionally, many
studies on voice therapy outcomes with regard to voice quality
failed to prove a long-term benefit.15 The results of the current
 ARTICLE IN PRESS
4 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 1.
Distribution of Baseline Characteristics and Adherence to Voice Therapy
Nonadherent Adherent Total
Variable N = 78 N = 75 N = 153 P Value
Sociodemographic factors
Mean age (years) 39.4 ± 10.8 36.9 ± 10.9 38.2 ± 10.9 0.14
Age (years) 0.39
<32 24 (30.8) 31 (41.3) 55 (36)
32–44 27 (34.6) 22 (29.3) 49 (32)
>44 27 (34.6) 22 (29.3) 49 (32)
Gender
Female 60 (80) 63 (80.8) 123 (80.4) 0.9
Male 15 (20) 15 (19.2) 30 (19.6)
Ethnicity or religion 0.24
Jewish nonorthodox 55 (70.5) 49 (65.3) 104 (68)
Jewish orthodox 10 (12.8) 17 (22.7) 27 (17.6)
Arab 13 (16.7) 9 (12) 22 (14.4)
Smoking 5 (6.4) 3 (4.1) 8 (5.2) 0.72
Occupational factors
Mean seniority (years) 15.3 ± 9.8 14 ± 10.2 13.1 ± 9.4 0.31
Seniority (years) 0.24
<10 31 (39.7) 40 (53.3) 71 (46.4)
10–20 23 (29.5) 17 (22.7) 40 (26.1)
>20 24 (30.8) 18 (24) 42 (27.5)
Employer
Government 58 (74.4) 41 (54.7) 99 (64.7) <0.001
Private 20 (25.6) 34 (45.3) 54 (35.3)
School level of students 0.32
Kindergarten 25 (32.1) 16 (21.3) 41 (26.8)
Elementary school 31 (39.7) 34 (45.3) 65 (42.5)
High school 22 (28.2) 25 (33.3) 47 (30.7)
Teaching profile
General studies 51 (67.1) 42 (56) 93 (60.8) 0.16
Specific subjects 25 (32.9) 33 (44) 58 (37.9)
Clinical factors
Mean symptoms duration (years) 1.6 ± 2.4 1.5 ± 2.2 1.6 ± 2.3 0.7
Symptoms duration (years) 0.99
<1 47 (60.3) 46 (61.3) 93 (60.8)
≥1 to <3 15 (19.2) 14 (18.7) 29 (19)
≥3 16 (20.5) 15 (20) 31 (20.3)
Pathology
Functional 33 (44.6) 27 (37.5) 60 (41.1) 0.38
Mass lesion 41 (55.4) 45 (62.5) 86 (58.9)
Voice loss (aphonia) 51 (68) 40 (56.3) 91 (62.8) 0.14
Vocal cord surgery 9 (11.5) 6 (8) 15 (9.8) 0.46
Reflux 32 (41) 28 (37.3) 60 (39.2) 0.64
Mean sick leave before inclusion* (days) 0.28 ± 0.5 0.14 ± 0.2 0.2 ± 0.4 0.27
Sick leave before inclusion* 0.59
Minimal sick leave (0–3 days) 43 (55.1) 46 (61.3) 89(58.2)
Up to 2 weeks 21 (26.9) 15 (20) 36 (23.5)
More than 2 weeks 14 (17.9) 14 (18.7) 28 (18.3)
No. of ENT visits 3.2 ± 2.7 3.6 ± 3.2 3.4 ± 2.9 0.61
Treatment
Voice rest 13 (16.7) 13 (17.3) 26 (17) 0.91
Microphone use 13 (16.7) 18 (24.7) 31 (20.5) 0.22
Notes: Categorical variables are displayed as N (%); continuous values are displayed as Mean + SD. P value was obtained by chi-square test for comparison
of categorical variables or by Student t test or the nonparametric Mann-Whitney U test for continuous variables.
* Inclusion in the study.
 ARTICLE IN PRESS
Lilah Rinsky-Halivni et al Voice Therapy for Teachers With Work-Related Dysphonia 5

TABLE 2.
Association Between Treatment Variables and Declines in Fitness to Work
Reduced Fitness to Work?
Yes (n = 34) No (n = 119)
Variable n (%) n (%) OR (95% CI) P Value
Univariate
Voice therapy 5 (14.7) 70 (58.8) 0.12 (0.04–0.33) <0.001
Voice rest period 9 (26.5) 17 (14.3) 2.16 (0.86–5.41) 0.09
Voice therapy* Voice rest period 1 (2.9) 12 (10.1) 0.27 (0.03–2.15) 0.29
Microphone use 11 (32.4) 20 (17.1) 2.32 (0.97–5.5) 0.05
Symptoms duration (years) 1.17 (1.01–1.36) 0.14
Symptoms duration until voice therapy (years)
<1 6 (17.6) 43 (36.1) 0.37 (0.13–1.02) 0.05
≥1 10 (29.4) 28 (23.5) 0.95 (0.38–2.34) 0.91
No voice therapy 18 (52.9) 48 (40.3) 1
Logistic regression—adjusted model†,‡
Voice therapy 5 (14.7) 70 (58.8) 0.05 (0.01–0.27) <0.001
Symptoms duration (years) 1.27 (1.0–1.6) 0.04
Cox proportional hazard regression adjusted model†
Voice therapy 5 (14.7) 70 (58.8) 0.14§ (0.05–0.4) <0.001
Symptoms duration (years) 1.29§ (1.1–1.52) 0.001
* Interaction variable.
†
Logistic regression model and Cox proportional hazard regression model adjusted for age, gender, ethnicity or religion, government or private employer,
pathology, number of sick days taken for dysphonia before first visit and number of ENT visits.
‡
Nagelkerke R2 = 0.52.
§
Hazard ratio.

study demonstrated, for what we believe to be the first time, that

voice therapy has a strong protective effect for retaining full fitness
for employment among classroom teachers diagnosed as having
profession-based dysphonia in the secondary preventive stage.
This employment outcome was evaluated from 2 to 8 years from
the time of referral to an occupational clinic, with an average
of 5 years of follow-up. Our findings thereby add to the evi-
dence of benefit for voice therapy for dysphonia associated with
job profile.

Effect of early implementation of voice therapy

FIGURE 1. Kaplan-Meier survival analysis displaying preservation
of full working capability (in months) of teachers with dysphonia who
adhere (blue) or did not adhere (red) to the recommendation for voice
therapy (log-rank P value < 0.001). (For interpretation of the refer-
ences to color in this figure legend, the reader is referred to the Web
version of this article.)
The findings of the current study also demonstrated that voice
therapy was associated with a longer duration of retained fitness
to work compared with no voice therapy. The results derived from
the chart review (Figure 1) emphasize the importance of begin-
ning voice therapy soon after the initial referral, because almost
one-fifth (18%) of the group that did not comply with voice
therapy recommendations experienced a decline in fitness to work
within the first year after referral, and 27% of them experi-
enced a decline within around 2 years. It stands to reason that
voice therapy within these time limits might prevent a possible
decline in the capability of teaching in front of a classroom.
Another aspect is the importance of initiation of voice therapy
early in the course of symptom appearance, supported by the
finding that a longer period of vocal symptoms to voice therapy
performance for the adherent teachers was an independent risk
factor for a future decline in fitness. Adoption and persistence
of bad habits of voice production and poor vocal hygiene that
perpetuate repetitive mechanical trauma to the vocal folds may
be a possible reason for the poor outcomes of delayed
 ARTICLE IN PRESS
6 Journal of Voice, Vol. ■■, No. ■■, 2016
treatment.38,39 Our findings are corroborated by a study in which
a shorter duration between voice therapy referral and the first
therapy session strongly predicted the adherence to complete the
course,31 a factor which we demonstrated has a protective effect
on the preservation of fitness to work. We therefore recom-
mend that a proactive approach, such as screening, should be
considered to implement voice therapy as soon as possible among
teachers with voice problems.
Adherence to voice therapy
In spite of its efficacy, the compliance rate with a voice therapy
course (at least 5 sessions) that was recommended to our study
participants was only about 49%, with an average of more than
10 sessions in the AVT group and 0.6 sessions in the NATV group.
This rate is higher than that reported in the USA, where 38%
of patients did not attend a voice evaluation after referral by an
otolaryngologist, and only 30% attended more than two ses-
sions of voice therapy.32 This may be due to differences in funding
for this therapy, which is partially covered by the HMOs in Israel.
Portone et al pointed out obstacles to voice therapy adherence
other than economic ones, such as geographical inaccessibility
and disbelief in the treatment’s effectiveness.32 Those authors
observed that every week of delay in instituting voice therapy
since its recommendation reduced the chance of completing the
course by 10%.31 It is clearly necessary to raise awareness of
the advantages of voice therapy for the individuals who need it
and to enhance the accessibility of the courses to improve ad-
herence. We demonstrated (Table 2) that government-employed
teachers were more likely to be nonadherent to voice therapy
compared with teachers in the private sector. Our finding that
the former took significantly more sick days than the latter may
imply that the difference in motivation lies in the difference
between the social benefits which are preferential to state and
municipal employees compared with private employees, such
as the rights to exploit sick leave, reduction in working hours,
retirement agreements, tenure, etc.40 The teacher may prefer to
use those benefits rather than a voice therapy course. Support
for this likelihood can be found in the US National Health Survey,
which reported that taking sick days among both women (88%
of employees) and men (88% and 90% of employees, respec-
tively) was most widespread in the public sector, far beyond the
national average of 60% of all workers.41
No association between voice rest or microphone
use and fitness to work preservation
As opposed to the conclusive evidence of the benefits of voice
therapy on employment outcomes, the other commonly recom-
mended interventions of occupational medicine did not show any
obvious protective effect for the retention of fitness to work among
the dysphonic teachers in our study. We are not aware of any
evidence to support a clear benefit of voice rest, despite its fre-
quent application, and the OR > 1 in the current study implies
that it might even serve as a risk factor for future negative em-
ployment outcomes (Table 2). The combined variable of voice
rest involving a period of sick leave and voice therapy, as as-
sessed in our current study, may not reflect the real picture,
because some teachers might have had voice therapy during the
summer vacation without using any sick leave whereupon their
data would not have been included in the analysis. A random-
ized controlled trial is needed to evaluate the effectiveness of
the combined intervention of voice therapy during voice rest or
reduction in vocalization. Several studies demonstrated benefit
from the use of amplification systems.23,42 However, we found
that microphone use had a nearly significant association with a
decline in fitness to work. In light of reports of the minimal use
of amplification systems in classrooms,43 we suspect that a pos-
sible explanation for the higher proportion of microphone use
among the teachers who experienced declines in fitness for work
compared with those who did not (34% vs 17%) might be that
they used a microphone as a last resort when they felt immi-
nent work incapacitation. Further research is needed to explore
the motivation for its use among this population.
Occupational effects of profession-related voice
disorders among classroom teachers
Studies on employment outcomes of professional dysphonia are
sparse. Roy et al found that voice disorders adversely impact-
ed job performance, with self-reporting of work limitation in 4.3%
of participants out of a sample of 1300 individuals from the
general population.21 Previous reports of occupational out-
comes of teachers with vocal problems included a few
questionnaire-based studies which focused mainly on the lengths
of self-reported sick leave taken for voice disturbances.4,5,21,22 Van
Houtte et al’s cross-sectional questionnaire-based study on almost
1000 teachers found 20.6% of absenteeism, with 2% of dys-
phonic teachers reporting having missed more than 2 weeks.5
It should be borne in mind, however, that not all dysphonic teach-
ers consult a doctor and therefore do not receive official
recommendations to take sick leave when medically indicated.
Indeed, the same study discovered that only the more severe half
of teachers with vocal complaints—those who reported on greater
severity of vocal complaints—sought medical help, which was
mostly limited to a general practitioner.5 Our findings that 100%
of the teachers in our study were referred to professional prac-
titioners and that 15% were absent due to dysphonia for more
than 2 weeks before inclusion may suggest that the partici-
pants in our cohort may also comprise the more severe cases
of dysphonic teachers, thus explaining, at least in part, the marked
reduction rate (22.2%) in fitness for work.
Drawbacks and strengths of the study
One drawback of our study is its relatively small number of par-
ticipants (153), which resulted in several parameters that could
not be adjusted for by the multivariate analyses and insuffi-
cient power to analyze some of our variables categorically. The
fact that we grouped a variety of sequelae of decreasing fitness
for work (eg, retirement, long periods of loss of fitness, and partial
decline in fitness) may have prevented a more detailed charac-
terization of each of outcome. Another weakness is the lack of
randomization of the allocation to the groups who did and did
not undergo voice therapy, but rather the choice of each par-
ticipating teacher. Teachers who self-select to adhere to voice
therapy recommendations may differ inherently from those who
do not, in their willingness to make an effort in treating their
 ARTICLE IN PRESS
Lilah Rinsky-Halivni et al Voice Therapy for Teachers With Work-Related Dysphonia
vocal problem, and in their motivation to continue working. None-
theless, the covariate distribution between the two groups was
balanced, except for the type of employer category (adjusted for
in the analyses). The strengths of this study include: a prospec-
tive design, a relatively long follow-up, and full access to medical
data that facilitated an objective assessment of clinical param-
eters and treatment participation and less likelihood of recall bias
from the use of historical parameters or self-reporting. The use
of parameters from electronic medical records can serve as a proxy
for validating the severity of the vocal problem, via variables
such as number of ENT visits, having an operation, period of
sick leave before inclusion, etc. In addition, adjustment for a de-
tailed set of covariates enabled us to mitigate confounding
variables and achieve an accurate risk estimate and higher good-
ness of fit. Finally, the large sample size of almost one-half of
the total population studied (153 teachers out of 365 eligible)
and random sampling techniques provide a reliable estimate of
the reduction in fitness to work within this population.
CONCLUSIONS
Classroom teachers with occupation-associated dysphonia undergo
significant decline in their ability to maintain sufficient fitness
to continue working in their profession. The current findings rep-
resent the first demonstration of the protective role of voice
therapy on long-term employment status by preserving fitness
to work full-time among teachers with dysphonia who were re-
ferred to an occupational medicine clinic. Major declines in work
capabilities occurred within the first year since referral and were
associated with a longer period of symptoms before referral to
an occupational clinic and voice therapy initiation. These find-
ings highlight the importance of early implementation of voice
therapy. They may also have implications for public health policy
by indicating that an efficient way for early detection of
profession-related voice problems is warranted to enable prompt
referral for voice therapy among affected teachers. Accessibil-
ity to treatment should be enhanced, and awareness of its benefits
should be heightened to improve the relatively poor adherence
to voice therapy. Finally, further research is required to confirm
our findings in a larger population of teachers.
Acknowledgments
Gratitude is expressed to the speech-language pathologists Ofer
Amir and Sari Lotem, and to Dr. Adi Primov-Faver who re-
viewed various drafts of this paper and assisted during the
development of this study.
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