Osteopath and former West End performer, Jennie Morton, talks about the most common issue she treats in singers. The cause of a hoarse voice may arise from an unexpected source. The Osteopathic philosophy views the body as a completely integrated system and Osteopathic treatment is aimed at facilitating the body’s self-healing mechanisms through the use of manual therapy. As Osteopaths, we do not separate the mind and body – they are interdependent systems – and in my work with treating singers, I feel this is nowhere more apparent than in the manifestation of vocal issues. The voice is an organic instrument and a vital part of our means of expression, whether we are professional voice users or not, and therefore treatment must encompass both the physical and emotional states in order to find resolution. The majority of issues I see with singers fall into the broad category of Muscle Tension Dysphonia (MTD). This is where increased tension in the vocal musculature leads to a variety of symptoms which can include breathiness, hoarseness, pitch changes, breaks, weakness etc., and can manifest with or without pain or discomfort. Usually there is no frank damage to the cords themselves, although this can be a sequela in extreme cases. So what can lead to this muscle tension? If we look at where the vocal apparatus sits in the context of the whole body, then we can start to understand this better. The vocal apparatus is made up of the larynx (housing the vocal cords), the thyroid and cricoid cartilages and the hyoid bone, which serves as an attachment point for many of the extrinsic muscles associated with phonation. The hyoid is a unique bone in the body in that it does not articulate (join with) any other bone – it is literally suspended in space by the sling of muscles that surrounds it. Coupled with its location at the front of the neck (one the most mobile areas of the body), it is therefore very reflective of any postural asymmetries coming from structures below. Humans are programmed by nature always to keep the eyes level: this is a primitive survival mechanism that allows us to judge distances more accurately – useful when being approached by a predator! If we take the example of someone with a dropped arch on one foot, this will pull the corresponding leg downwards leading to a sideways tilt at the pelvis, which could potentially begin a ‘list’ in the spine. The body will then set up a compensatory pattern where muscles will correct alternatively right and left in a ‘zig-zag’ fashion up the back until the final point of correction at the top of the neck to bring the eyes level. This will result in an asymmetrical pull through the hyoid muscles leading to imbalance and potentially to vocal strain. Neutral pelvic positioning is also key to optimal respiratory mechanics via the abdominal and respiratory muscles. Sub-optimal pelvic alignment can serve to tighten or slacken the surrounding muscles, which may affect our ability to receive a sufficient in-breath. This will then lead to a lack of sub-glottal pressure which, when aiming for higher pitches or greater volume, may lead the singer to overuse the muscles above the hyoid to achieve this. This can lead to tension and strain of the vocal muscles and the symptoms of MTD. Any singer who has experienced vocal issues will know that it can be a very stressful situation. Anxiety has its own postural pattern that includes shoulder and neck tension and high, shallow breathing. This will also adversely affect sub-glottal pressure and vocal muscle tension – the more we worry, the worse it gets! So stress-management is also a central part of regaining the voice. To summarise, the majority of vocal issues I see usually have their origin in postural alignment, leading to inefficient muscle use and strain. Vocal issues are often put down to ‘poor technique’. but it is my belief that many such technical problems arise because the singer finds himself or herself fighting their own anatomy. Once an optimal neutral posture is found and the muscle function is better understood, much of this strain disappears. Losing one’s voice is a loss of self, so vocal issues can often lead to the voice becoming ‘dissociated’ from the rest of the body. By working from the feet up, we can reintegrate the voice into the body and allow for the freedom of expression, which serves as the inspiration for all singers.