Back in early 2020 I’d never considered having to deliver music therapy sessions in full PPE for the foreseeable future. I’d had some experience of surgical masks, gloves and aprons when working with immunocompromised patients in medical settings, but it had been occasional and somewhat of a novelty. I don’t think I even knew what PPE stood for! Fast forward to 2022 and the term PPE is a household phrase and something that comes as part of a standard clinical day.
I would like to share my experience of working in medical settings and the impact that using PPE has had on my practise so far. I will include some thoughts about how to protect ourselves from any strain as a result of wearing masks, and some of the research about singing and aerosol generation.
Managing the risk of infection
When you’re constantly donning and doffing (more new terms I learned in 2020!) PPE it is tempting to keep questioning why it’s needed with such militant precision. But then, whenever there’s a new Covid outbreak in your workplace you’re probably also thankful you are so adequatey protected.
There have been various studies into aerosol generation when singing; Stockman et al. (2021) found that the lowest risk of catching Covid-19 indoors was when singing for less than 30 minutes, whilst Alsved et al. (2020) found that singing generates more aerosols than talking and a higher volume of singing produces a higher volume of aerosol particles and droplets. They found that ‘wearing an ordinary surgical face mask reduced the amount of measured exhaled aerosol particles and droplets to levels comparable with normal talking’ (Ibid) which suggests that singing with a mask on poses no more risk than talking. These studies are useful for thinking of ways to reduce and manage the risk of infection and spread of Covid-19 in clinical settings;
- wear a mask
- sing at a low volume
- do not sing for more than 30 minutes
Voice strain when wearing a mask
To give some context; from July 2020 – March 2021 I was working 3 full days a week, all in acute medical settings and wearing full PPE for sessions: safety glasses, surgical mask, gloves and apron. My instruments had been adapted to be fully cleanable using the necessary grade cleaning solutions, which also involved removing my guitar strap. During this period, I started to suffer with some voice issues: my voice felt tight and weak, my neck was sore and aching and I often came home from work with headaches. My Speech Therapy colleagues were concerned that I had some strain and kindly suggested I explore a referral to voice therapy. I contacted my GP who screened me over the phone and referred me for a voice therapy assessment. Thankfully I was seen for a digital appointment within a few weeks and received a course of voice rehabilitation sessions with a specialist Speech Therapist. I was also referred for an ultrasound of my neck and a scope of my vocal cords to rule out any “nasties” causing the issues. With the scans and scopes coming back clear, I was diagnosed with muscle tension dysphonia. All of my treatment was through my local NHS Trust (who I also work with) and their level of expertise, care and compassion was a humbling experience. I have never been prouder to work with the NHS.
Now I knew what the problem was, I could undo the bad habits that had caused it and strengthen my vocal folds again, given exercises and training by my NHS Voice Therapist:
- Warmups and stretches – whole body
- Water-based resistance training for my vocal cords using (I used Vocal Tubes)
- Retraining my singing voice
- Retraining my posture
- Learning about the physiology and mechanics of the voice system
Using these techniques I have now made a full recovery, although sometimes I start slipping back into old habits and have to start using the exercises again.
Singing in a FFP3 Mask
I have recently been fit tested for a FFP3 mask for use with patients with or exposed to Covid-19; this mask is different because it lets absolutely no unfiltered air in or out of the mask. This makes it safe to sing at loud volumes and without the time limit of 30 minutes, however I have noticed that my voice starts to fatigue very quicky, I become very hot, I have to exert myself to project my voice, and the mask does hurt my face when singing because it is tightly secured and there is no give (this is also a positive because the mask doesn’t go in my mouth!). Therefore I would recommend the following adjustments:
- Keep very well hydrated and take longer breaks between sessions to recover
- Warm up and warm down before and after wearing the FFP3 mask
- Limit session times; shorten as needed
To manage and reduce the risk of infection and injury when singing in clinical settings, the following adjustments should be considered:
- Learn how to safely use your voice and keep good posture when working in PPE
- Agree what a safe duration and volume of singing should be with your team members in the workplace
- Increase duration in-between sessions and keep well hydrated to counter the dehydrating effect of wearing masks
Alsaved, M., Matamis, A., Bohlin, R., Richter, M., Bengtsson, P., Fraenkel, C., Medstrand, P. & Londahl, J. (2020) ‘Exhaled respiratory particles during singing and talking’ Aerosol Science and Technology, 54:11, pp1245-1248, accessed on 29.01.2022 via DOI 10.1080/02786826.2020.1812502
Stockman et al. (2021) ‘Measurement and simulations of aerosol released while singing and playing wind instruments, ACS Environ. Au, 1, 1. Pp71-84 accessed on 29.01.2022 via https://doi.org/10.1021/acsenvironau.1c00007