ISSN 2317-1782 (Online version)

Vocal fatigue in dysphonic teachers who

Original Article
Artigo Original seek treatment

Mirna Abou-Rafée1  Fadiga vocal em professores disfônicos que

Fabiana Zambon1,2 
Flávia Badaró1  procuram atendimento fonoaudiológico
Mara Behlau1 

Descriptors ABSTRACT
Voice Purpose: to verify the self-perception of vocal fatigue of dysphonic teachers in school year activity who
Fatigue sought speech-language pathology assistance. Methods: Sixty teachers with voice complaints participated in
the study, 30 of whom sought treatment in the Programa de Saúde Vocal do Sindicato dos Professores de São
Dysphonia Paulo (SinproSP), and 30 volunteers’ teachers who did not seek treatment (G2). All the participants answered
Teachers a personal identification protocol and work characterization, vocal self-assessment, vocal signs and symptoms
Questionnaires checklist, Vocal Fatigue Index protocol (VFI). In addition, a number counting from 1 to 10 and sustained
vowel “e” were registered for the definition of the mean vocal deviation using perceptual-auditory judgment.
Speech Therapy
Results: Teachers who sought treatment (G1) obtained worst scores in the VFI, more numbers of signs and
symptoms, and worst self-evaluation of the voice when compared with those who did not seek treatment (G2).
In addition, teachers in both groups had light to moderate vocal deviation. Conclusion: Dysphonic teachers
who sought vocal treatment presented greater sensation of vocal fatigue, especially in the factors of tiredness
of voice and voice avoidance and related to physical discomfort associated with voicing of the VFI. In addition,
they reported greater number of symptoms and worse vocal self-assessment in relation to those who did not
seek treatment, although both groups present deviated voices.

Descritores RESUMO
Voz Objetivo: Verificar a autopercepção de fadiga vocal de professores disfônicos em atividade letiva que procuram
Fadiga atendimento fonoaudiológico. Método: Participaram desta pesquisa 60 professores com queixa vocal, dentre
estes, 30 que buscaram tratamento no Programa de Saúde Vocal do Sindicato dos Professores de São Paulo –
Disfonia SinproSP (G1) e 30 professores que não buscaram atendimento (G2). Todos os participantes responderam a
Professores um questionário de identificação, a um de caracterização pessoal e do trabalho, a uma lista de sinais e sintomas
Questionários vocais e ao Índice de Fadiga Vocal - IFV. Além disso, foram registradas contagem de números de 1 a 10 e vogal
sustentada “é” para definição do grau de desvio vocal por meio da análise perceptivo-auditiva. Resultados: Os
Fonoaudiologia
professores que procuraram o atendimento (G1) apresentaram piores escores nos protocolos IFV, maior número
de sinais e sintomas, além de pior autoavaliação da voz quando comparados aos professores que não procuraram
tratamento (G2). Além disso, os docentes dos dois grupos estudados apresentaram desvios de voz de leve a
moderado. Conclusão: Professores disfônicos que procuram atendimento fonoaudiológico apresentam maior
sensação de fadiga vocal, principalmente em relação aos domínios restrição vocal e desconforto físico do IFV.
Além disso, apresentaram maior número de sintomas e pior autoavaliação vocal em relação àqueles que não
procuraram o atendimento, apesar de ambos os grupos apresentarem vozes desviadas.

Correspondence address: Study conduct at Centro de Estudos da Voz – CEV - São Paulo (SP), Brasil, as a requirement for conclusion of
Mirna Abou-Rafée Curso de Especialização em Voz.
R. Machado Bittencourt, 361/1001, 1
Centro de Estudos da Voz – CEV - São Paulo (SP), Brasil.
Vila Mariana, São Paulo (SP), Brasil, 2
Sindicato dos Professores de São Paulo – SinproSP - São Paulo (SP), Brasil.
CEP: 04044-001.
Financial support: nothing to declare.
E-mail: [email protected]
Conflict of interests: nothing to declare.
Received: July 02, 2018

Accepted: October 23, 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abou-Rafée et al. CoDAS 2019;31(3):e20180120 DOI: 10.1590/2317-1782/20182018120 1/6

INTRODUCTION All the individuals agreed to participate and signed an informed
consent form, in accordance to the Brazilian resolution 466/12
The term vocal fatigue has been widely discussed in the (BRAZIL Resolution No. 466/12 of December 12th, 2012(12)).
literature as a current and relevant topic for researches working Sixty teachers with voice complaints, both male and female,
with the dysphonic and populations at risk to develop vocal participated in the study, they were divided in two groups:
disorder(1-3). G1 = 30 teachers who sought treatment in the Programa de Saúde
Vocal fatigue can be defined as a negative vocal adaptation, Vocal do Sindicato dos Professores de São Paulo (SinproSP),
self-reported by the individual due to prolonged vocal use(2,4). assessed by the researcher in the first day of voice assessment,
It can also be described as the effort felt by the individual and G2 = 30 volunteers’ teachers with vocal complaints and
due to vocal loading(1), which improves with adequate vocal that did not seek professional guidance, they were evaluated
rest(1,3,5). in their work place. The teachers who participated in this
The presence of vocal fatigue is often characterized as a
study taught in different private schools of São Paulo city, in
global syndrome identified by several symptoms, such as a
different levels of education (kindergarten, elementary and
sensation of increased effort, laryngeal discomfort, neck and
high school). The teachers were asked for the presence or not
shoulder tension, neck or throat pain, loss of flexibility and
of vocal complaint that was later confirmed by the signs and
vocal projection(1,3,5,6).
symptoms checklist. This data was used to define the inclusion
Vocal fatigue is very common in teachers(4), because these
professionals spend several hours of their day teaching(1) in criteria and to make sure that the complaint was related to
extremely noisy environments(7). The working environment voice use. Teachers who reported not to have vocal complaint
condition and the professional own performance are the two or who sought SinproSP only to improve communication were
main reasons that lead to vocal fatigue. In addition, to the long excluded from the analysis.
periods of work, which makes the vocal rest, necessary for an All participants were submitted to the following procedures:
adequate vocal recovery, not possible(8). personal identification protocol and work characterization,
However, the evaluation of vocal fatigue is still a challenge, vocal self-assessment, vocal signs and symptoms checklist,
due to its multi-causality(9) and the lack of specific instruments(7). Vocal Fatigue Index protocol (VFI) and voice recording for
Thus, finding an instrument that objectively measures this subsequent auditory-perceptual judgement.
aspect is important, once it might guarantee early diagnosis The personal identification protocol and work characterization
and standardize treatment for vocal changes(4). is composed of 11 questions that investigate data such as:
Recently, a self-assessment instrument, the Vocal Fatigue gender, age, level of education taught (Early childhood,
Index (VFI) was developed. This protocol presents 19 questions Primary education - elementary and middle school), years of
to investigate vocal fatigue in three factors: factor 1 related teaching experience, number of students per classroom, daily
to tiredness of voice and voice avoidance; factor 2, related hours lecture/work load, presence of noise in the classroom,
to physical discomfort associated with voicing; and factor 3, search for previous medical and/or speech-language pathologist
related to improvement of symptoms with rest(9). assessment due to voice problems, vocal use in activities not
It is known that teachers who do not seek treatment, even in related to their work(11).
the presence of vocal complaints, do not perceive variations in The group of dysphonic teachers who sought treatment
vocal fatigue during the school year and present lower scores was composed of 25 women (83.33%) and 5 men (16.67%).
in the factors of the VFI protocol when compared to dysphonic Teachers’ age was between 24 and 55 years old (median 37.5),
individuals(9,10). In addition, these professionals tend to seek years of teaching experience between 3 and 29 years (median 12),
speech therapy only when they present high occurrence of number of students per classroom was between 8 and 40
signs and symptoms and deviated voice quality(11). However, (median 20) and daily hours lecture/work load between 1 and
little is known regarding vocal fatigue in teachers and if these 3 periods per day (median 2). Regarding the teachers that
professional seek help only when the symptom is already chronic.
were evaluated in the school, 23 were women (76.67%) and
Therefore, identifying the self-perception of these professionals
7 (23.33%) participants were men (p = 0.518), aged between
in relation to dysphonia and vocal fatigue offers data not only
25 and 48 years old (median 41.5, p = 0.459), teaching time
for speech-language pathology intervention, but also preventive
between 1 and 28 years (median 15, p = 0.695), number of
strategies for those teachers.
students per classroom between 5 and 48 (median 25; = 0.214)
Therefore, the objective of the present study was to verify
the self-perception of vocal fatigue of dysphonic teachers in and work load between 1 and 3 periods per day (median 2,
school year activity who sought speech-language pathology p = 0.486). Both groups were equivalent regarding: years of
assistance. teaching experience, numbers of students per classroom, daily
hours lecture/workload (Table 1).
METHODS Teachers self-rated their voices using a 5-point scale in
which: 1 = excellent, 2 = very good, 3 = good, 4 = reasonable
The research was accepted by the Committee for Ethics and 5 = bad.
in Research of the Universidade de Taubaté - UNITAU The Brazilian translation for the self-assessment Vocal
(CAAE: 62322516.9.0000.5501, protocol number: 122.608). Signs and Symptoms checklist, a list of 14 items proposed by

Abou-Rafée et al. CoDAS 2019;31(3):e20180120 DOI: 10.1590/2317-1782/20182018120 2/6

Table 1. Characterization of the work and information of voice use for teachers with and without vocal complaints
Groups
Characterization of the group G1 G2 P
Mean Median 25% 75% SD Média Mediana 25% 75% SD
Age of the teachers 37.900 37.5 31.75 44.25 7.729 39.166 41.5 32 46 7.134 0.459
Number of students per room 21.866 20 15 28 8.186 24.206 25 18.5 30 9.182 0.214
Years of teaching experience 13.785 12 8.25 19 7.385 14.517 15 8 23 8.671 0.695
Daily hours lectures/work load 1.733 2 1 2 0.583 1.633 2 1 2 0.614 0.486
Caption: G1 - Group of teachers who sought treatment; G2 - Group of teachers who did not seek treatment; Significant values (p≤0.05) - WILCOXON test;
SD – Standard Deviation

Roy et al.(13) was used. Among the evaluated items are: hoarseness; of deviation; 1, mild deviation; 2, moderate deviation; and
voice tires or changes quality after short use; trouble speaking 3, severe deviation. For intra-rater reliability analysis, 20%
or singing softly; difficulty projecting voice; loss of singing of the speech samples were repeated and the answers from
range; discomfort while using voice; a monotone voice; effort the judges with higher intra-rater reliability were considered
to talk; chronic throat dryness; chronic throat soreness; frequent (reliability 88.88%).
throat clearing; bitter or acid taste; swallowing difficulties and Data collection was performed between the evaluation
a wobbly or shaky voice. session and the first voice therapy session in order to eliminate
For the self-evaluation of vocal fatigue, the Brazilian possible external interference in the outcomes. Subsequently,
validated version of the Vocal Fatigue Index(9) was used. all individuals underwent conventional speech therapy in the
The Vocal Fatigue Index (VFI) consists of 19 questions Programa de Saúde Vocal do Sindicato dos Professores de São
characterized by three factors: (1) factor 1, related to Paulo (SinproSP).
tiredness of voice and voice avoidance (questions 1 to 11); Statistical analysis was performed. The Shapiro-Wilk test
(2) factor 2, related to physical discomfort associated with was used to evidence the normal distribution between the groups,
voicing (questions 12 to 16), and (3) factor 3, related to non-parametric tests, such as Wilcoxon and Z-Test were used
improvement of symptoms with rest (questions 17 to 19). for proportions.
In factors 1 and 2, higher scores represent more disadvantage,
while in factor 3, higher scores represent more improvement RESULTS
of the symptoms, i.e., less symptoms. Each question varies
from a scale of 0 to 4, where 0 = never, 1 = almost never, Regarding voice self-assessment, the group of teachers
2 = sometimes, 3 = almost always, 4 = always. The protocol who sought treatment (G1) self-rated their voice as reasonable.
is calculated by the simple sum of the answers, and the total However, the group of teachers who did not seek treatment
score varies from 0 to 76: in the subscale of tiredness of (G2), self-rated their voice as good (p = 0.015). The groups
voice and voice avoidance, from 0 to 44; related to physical studied presented mild to moderate voice deviations, with no
discomfort associated with voicing, from 0 to 20; and related significant difference between them (p = 0.119).
to improvement of symptoms with rest, from 0 to 12(9). In relation to the Vocal Signs and Symptoms Checklist
To assess the perceptual judgment of the voice quality the (Table 2), G1 had higher occurrence of symptoms when compared
participants were instructed to count the numbers 1 to 10, and to G2 (7.8 SD = 3.33 Vs 4.7 SD = 2.6, p = 0.0004). The most
to phonate the sustained vowel “é” in comfortable pitch and frequent symptoms for G1 were: tired voice, speech discomfort,
loudness. Voices were recorded directly on a computer using the monotonous voice, effort to speak, throat pain, throat clearing
Fono View (CTS computing) program, with Andrea PureAudio and wobbly or shaky voice (Table 3).
USB external sound card and Karsect HT-2 head-mounted Concerning VFI, the mean scores of tiredness of voice and
microphone positioned at 45° microphone-to-mouth angle and voice avoidance and physical discomfort associated with voicing
2 cm from the mouth of the speaker. Three speech-language were higher in the group of teachers who sought treatment. In the
pathologists perceptually judged the overall voice quality factor of improvement of symptoms with rest, no differences
using a four-point scale, in which 0 indicated the absence were found between the two groups (Table 4).

Table 2. Total value of vocal signs and symptoms for teachers with and without vocal complaints
Signs and Symptoms
Groups Mean Median 25% 75% SD P Value
G1 7.833 9 5 10 3.333
0.0004*
G2 4.766 5 3 7 2.686
*Statistically significant difference
Caption: G1 - Group of teachers who sought treatment; G2 - Group of teachers who did not seek treatment; Significant values (p≤0.05) - WILCOXON test;
SD – Standard Deviation

Abou-Rafée et al. CoDAS 2019;31(3):e20180120 DOI: 10.1590/2317-1782/20182018120 3/6

Table 3. Individual value of vocal signs and symptoms for teachers with and without vocal complaints
Groups
Symptoms G1 G2 P Value
N % N %
Hoarseness 22 73.33 16 53.33 0.1080
Voice tires or changes quality after short use 24 80.00 13 43.33 0.0035*
Trouble speaking or singing softly 20 66.67 13 43.33 0.0693
Difficulty projecting voice 19 63.33 13 43.33 0.1205
Loss of singing range 20 66.67 18 60.00 0.5921
Discomfort while using voice 17 56.67 7 23.33 0.0084*
A monotone voice 9 30.00 0 0.00 0.0011*
Effort to talk 20 66.67 11 36.67 0.0201*
Chronic throat dryness 21 70.00 17 56.67 0.2839
Chronic throat soreness 19 63.33 11 36.67 0.0389*
Frequent throat clearing 19 63.33 9 30.00 0.0097*
Bitter or acid taste 12 40.00 9 30.00 0.4168
Swallowing difficulties 4 13.33 3 10.00 0.6876
A wobbly or shaky voice 4 33.33 3 10.00 0.0283*
*Statistically significant difference
Caption: G1 - Group of teachers who sought treatment; G2 - Group of teachers who did not seek treatment; Significant values (p≤0.05) - Z-test for proportions;
N – Number of participants

Table 4. VFI scores for teachers with and without vocal complaints, by domain
Groups
Factors G1 G2 P
Mean Median 25% 75% SD Mean Median 25% 75% SD
Vocal Restriction 24.833 27 19 32 9.663 16.666 15 12 21 6.477 0.0007*
Physical Discomfort 7.733 6.5 2 13.25 5.514 4.500 4.5 1 7.25 3.235 0.0372*
Recovery (without inversion) 9.066 10 6 12 2.935 8.866 9 7 10 2.473 0.5633
Total 35.500 37 28.28 44.5 12.880 23.833 23.5 18 30.25 8.440 0.0003*
Recovery (with inversion) 2.933 2 0 6 2.935 2.666 2.5 2 3 1.988 0.8685
*Statistically significant difference
Caption: G1 - Group of teachers who sought treatment; G2 - Group of teachers who did not seek treatment; Significant values (p≤0.05) - WILCOXON test;
SD – Standard Deviation; VFI – Vocal Fatigue Index

DISCUSSION The present research showed worse vocal self-evaluation

in the dysphonic teachers who sought treatment. The literature
Vocal fatigue is a common complaint among teachers(1,5), indicates that teachers with dysphonia have worse vocal
mainly because these professionals spend continuous hours self‑assessment(16), while other teachers, even with altered voice
teaching, with little time to rest their voice(1). It can be described quality, rate their voices as good(10). Probably, the worse vocal
as a symptom of voice change of functional or organic etiology(14) self-perception in teachers who participated in this research
or it may be associated with compensatory behaviors that influenced the search for treatment.
predispose to a phonotrauma and development of a pathology On the other hand, considering the number of signs and
in the larynx(3). symptoms, it was observed that the teachers who sought
It is known that teachers tend to seek specialized help when treatment had almost twice as many symptoms as teachers who
they already have a high number of symptoms and significant did not seek treatment (Table 2). The mean number of symptoms
voice quality deviations(11,15), only few teachers seek preventive that motivated teachers to seek treatment is 8.6(11), which is in
treatment or just after the symptoms begin. However, the literature accordance to findings of the present research.
presents inconsistent findings related to vocal fatigue treatment A Brazilian study evaluated 3,265 teachers and the results
and its influence on the seek for vocal care. showed that the vocal symptoms were directly related to
Therefore, the present study had the objective to verify the the occupational voice use. Teachers presented an average
self-perception of vocal fatigue of dysphonic teachers during of 3.6 symptoms compared to 2.3 symptoms of the general
school year who sought voice care. To understand teachers’ population. Among the reported symptoms were vocal fatigue,
perception of vocal fatigue, a self-assessment protocol was discomfort and greater effort to speak(17).
used to investigate three factors related to tiredness of voice and The literature also indicates that teachers with vocal complaints
voice avoidance, physical discomfort associated with voicing, present an average of 7.8 symptoms, while teachers without
and improvement of symptoms with rest(9,10). vocal complaint have an average of 2.5 symptoms. The most

Abou-Rafée et al. CoDAS 2019;31(3):e20180120 DOI: 10.1590/2317-1782/20182018120 4/6

common symptoms are hoarseness, dry throat, sore throat and treatment, indicating that discomfort in the vocal tract region
difficulty to speak(15). The present study also found common favors the effort to phonation and, therefore, generates vocal
symptoms of dry throat, neck pain and, in addition to these, fatigue complaint.
there was also vocal fatigue, discomfort to speak, monotonous Regarding the factor of improvement of symptoms with
voice, effort to speak, throat pain, throat clearing and voice rest, there was no difference between the two groups (Table 4).
instability (Table 3). In addition, the scores found in the present research are above
The similarity of the results of the present study with previous the scores found for dysphonic individuals(9), which may indicate
published articles confirms that teachers have approximately a greater recovery of symptoms in the two groups studied,
twice as many vocal problems as non-teachers. In addition to the an aspect that favors teachers to continue to teach, even with
risks of the profession itself, another factor that may contribute vocal alterations. However, there may be inconsistency in the
to the high prevalence of vocal alterations in teachers is the responses regarding this domain, since it may be difficult to
predominance of women teachers. It is known that women for the individuals to answer about the recovery of something
have greater chances of developing voice problems(18,19) due that they do not feel.
to anatomical differences and glottic proportions in the female A recent study(22) analyzed the VFI protocol using the Mokken
larynx. scale, a scale used to understand the relationship between
Considering that the two groups studied had deviated voice VFI items and to develop the hierarchical understanding of
quality, it is believed that the average number of signs and self‑reported trait of vocal fatigue. The authors of the study
symptoms may have helped the group with vocal complaint to indicated that although the third factor does not meet the criteria
seek speech therapy treatment. Perhaps, the presence of more of the scale in relation to the Loevinger H coefficient, which is
symptoms influences the teachers’ work activity and may imply an indicator of homogeneity of the items, in other words items
limitations in their vocal performance, therefore, their professional easier to understand are related to less severe symptoms, while
performance. In this sense, it would be interesting for teachers items more difficult to understand are related to more severe
to be instructed and able to identify initial vocal deviations and symptoms, the reliability between the three scales was high. This
to recognize that teaching with many vocal symptoms may be
data reinforces the hypothesis that the participants probably had
a risk factor for vocal alteration.
difficulty responding to the third factor due to the high complexity
Regarding vocal fatigue, teachers who sought treatment
of the symptoms experienced. In addition, it corroborates the
had higher scores in the factor of tiredness of voice and voice
concept that rest and voice recovery significantly influence the
avoidance and the factor related to physical discomfort associated
vocal fatigue sensation, that is, the recovery is probably related
with voicing (Table 4). In addition, these teachers presented
to the chronicity of fatigue.
scores above the dysphonic teachers found in literature.
The vocal fatigue is highly influenced by vocal loading and
The group of teachers with vocal complaints who did not
high vocal loudness over long periods of time(4). Therefore, if
seek treatment had lower scores in the factors of tiredness of
vocal fatigue is identified in early stages, it could guarantee
voice and voice avoidance and the factor related to physical
an early intervention and prevent long-term adverse effects
discomfort associated with voicing outcoming the dysphonic
patients previously reported in the literature(9). This suggests and inadequate vocal compensations. Vocal warm-up before
that a high number of symptoms is necessary for teachers to the voice use and the need to emphasize vocal hygiene in the
perceive fatigue and seek treatment, since both groups had curriculum of school teachers and other professional voice users
deviated voice quality. In this way, prevention strategies are also extremely important(7).
and vocal training are important for these professionals to Voice awareness strategies, as well as adequate training, are
recognize the symptoms early and to seek voice care before fundamental for these professionals, as they can help them in
the limitations and vocal discomfort are stablished. Moreover, the preventive search for professional help and early diagnosis.
if teachers have a better perception of their vocal symptoms, Educational campaigns that include guidance on the symptoms
they will have better self-awareness to reduce the vocal loading of vocal fatigue may favor the chances of treatment and decrease
and therefore, avoid future vocal problems. the prevalence of signs and symptoms and vocal alteration in
Dry throat, voice breaks, throat discomfort and hoarseness these professionals. Thus, the teachers will be more aware of
are some symptoms usually related to vocal fatigue(7,20,21). their vocal symptoms and therefore it will be able to reduce the
In addition, the presence of other symptoms that manifest vocal load to avoid a voice alteration(10).
themselves in vocal quality, vocal dynamics, respiratory support Future research could investigate the relationship between
for phonation, level of discomfort and muscular tension, vocal vocal fatigue and other vocal changes, or even analyze the
control mechanism and level of vocal effort is also observed(2). variation of individual responses regarding this complaint
Professionals who have high vocal demand, such as actors and verify which aspects should be considered to propose an
and singers, report an increase in tension and discomfort in effective prevention program. In addition, it would be important
the throat, neck and mandible regions when they are vocally to investigate the relationship between the physical discomfort
fatigued(6). This data corroborates the findings of the present associated with vocal fatigue and the level of physical inactivity
study regarding the physical discomfort associated with vocal and life habits of the teachers using specific protocols. This
fatigue and the signs and symptoms of discomfort to speak, could help verify if the countless hours of vocal use interfere
effort to speak and throat pain reported by teachers who sought in the increase of the vocal fatigue

Abou-Rafée et al. CoDAS 2019;31(3):e20180120 DOI: 10.1590/2317-1782/20182018120 5/6

CONCLUSION 9. Nanjundeswaran C, Jacobson B, Gartner-Schmidt J, Verdolini Abbott K. Vocal
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Teachers with vocal complaints and those who sought
10. Zambon F. Fadiga vocal em professores e sua relação com fadiga geral ao
treatment presented greater sensation of vocal fatigue, especially longo de um ano letivo [doutorado]. São Paulo (SP): Universidade Federal
in the factors of tiredness of voice and voice avoidance and de São Paulo; 2015. 77 p.
related to physical discomfort associated with voicing of the 11. Zambon F, Moreti F, Behlau M. Coping strategies in teachers with
VFI. In addition, they also reported greater number of symptoms vocal complaint. J Voice. 2014;28(3):341-8. http://dx.doi.org/10.1016/j.
jvoice.2013.11.008. PMid:24495425.
and worse vocal self-assessment compared to those who did not
seek treatment, although both groups had vocal complaint and 12. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Resolução
no 466, de 12 de dezembro de 2012 [Internet]. Diário Oficial da União;
deviated voice quality. In this way, many teachers with vocal Brasília; 12 dezembro 2012 [citado 2019 Abr 27]. Disponível em: http://
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The results of the present study can be used to follow‑up and the general population. J Speech Lang Hear Res. 2004;47(3):542-51.
http://dx.doi.org/10.1044/1092-4388(2004/042). PMid:15212567.
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I am deeply grateful to my counselors for assisting me in the 2013;27(4):473-80. http://dx.doi.org/10.1016/j.jvoice.2013.01.005.
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execution, follow-up and conclusion of this research. To CEV
16. Köhle J, Nemr K, Leite GCA, Santos AO, Lehn CN, Chedid HM. Ação
for allowing me to develop as a person and professional, and de proteção de saúde vocal: perfil da população e correlação entre auto-
to SinproSP for opening the doors so that we can develop avaliação vocal, queixas e avaliação fonoaudiológica perceptivo-auditiva
more and more studies in the area and enable evolution in e acústica. Distúrb Comun. 2004;16(3):333-41.
patient care. 17. Behlau M, Zambon F, Guerrieri A, Roy N. Epidemiology of voice disorders
in teachers and Nonteachers in Brazil: prevalence and adverse effects. J
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