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Vocal Self-Perception of Home Office Workers During the COVID-19 Pandemic

Published:October 30, 2020DOI:https://doi.org/10.1016/j.jvoice.2020.10.016

      ABSTRACT

      Objective

      To investigate the self-perception of vocal fatigue symptoms and musculoskeletal pain in home office workers before and during the coronavirus disease (COVID-19) pandemic.

      Materials and methods

      A total of 424 individuals participated in this cross-sectional, observational, and descriptive study; they were stratified into the experimental group (EG), consisting of 235 individuals working from home office during the COVID-19 pandemic; and the control group (CG), with 189 individuals who continued to work in person during this period. All participants answered the vocal fatigue index and the musculoskeletal pain investigation questionnaires. The data were analyzed in a descriptive and inferential manner.

      Results

      Participants in the EG reported more vocal fatigue symptoms and musculoskeletal pain than those in the CG before the pandemic. However, during the pandemic, the EG presented a higher frequency of pain in the posterior of the neck, shoulder, upper back, and temporal and masseter muscles, while the CG presented a higher frequency of pain in the larynx. With regard to vocal fatigue, during the pandemic, EG had an increase in scores to factors such as tiredness and voice impairment, avoidance of voice use, and total scores. No such differences were noted in the CG.

      Conclusion

      Workers who migrated to home offices during the COVID-19 pandemic are at risk of developing vocal disorders.

      Key Word

      INTRODUCTION

      At the end of 2019, an epidemic began in China, caused by the severe acute respiratory syndrome coronavirus 2, that causes the coronavirus disease (COVID-19). The disease had a rapid spread globally and has been considered a public health emergency. As a result, in 2020, the World Health Organization (WHO) declared it a pandemic.

      World Health Organization. Novel Coronavirus – China. WHO.

      Since the first diagnosed case in Brazil in February 2020, more than five million confirmed cases and more than 150,000 deaths were reported nationwide.

      OPA OP-A de S, OMS OM de S. Folha Informativa – COVID-19 (Doença Causada Pelo Novo Coronavírus). OPA; OMS.

      In view of the current scenario, individual and collective interventions are required to reduce disease transmissions, such as respiratory and hand hygiene, face mask use, and social distancing.

      OPA OP-A de S, OMS OM de S. Folha Informativa – COVID-19 (Doença Causada Pelo Novo Coronavírus). OPA; OMS.

      ,
      • Garcia LP
      • Duarte E
      Intervenções não farmacológicas para o enfrentamento à epidemia da COVID-19 no Brasil.
      Social distancing is the recommended practice of maintaining at least 6-feet space between people to reduce the spread of COVID-19.
      • Sen-Crowe B
      • McKenney M
      • Elkbuli A
      Social distancing during the COVID-19 pandemic: staying home save lives.
      It was initially recommended by the WHO,

      OPA OP-A de S, OMS OM de S. Folha Informativa – COVID-19 (Doença Causada Pelo Novo Coronavírus). OPA; OMS.

      and among the possible measures is the closing of nonessential companies and implementation of remote work from home offices.
      • Sen-Crowe B
      • McKenney M
      • Elkbuli A
      Social distancing during the COVID-19 pandemic: staying home save lives.
      The employee can carry out his professional activities remotely in his own home, using information processing technologies and resources.
      • Garrett RK
      • Danziger JN.
      Which telework? Defining and testing a taxonomy of technology-mediated work at a distance.
      Thus, it is essential to highlight that workers who adapted to their home offices did not receive guidance or training to change their vocal use. In the remote working model, there is a greater demand for meetings vocally via digital platforms, using microphones and/or headphones. Since daily face-to-face contact is no longer a reality, it was necessary to find other means to enable interaction between employees, the company, and customers. In addition, many workers do not have suitable equipment and infrastructure at home for a professional practice that may provide adequate ergonomic conditions.
      Vocal use in inadequate ergonomic conditions, without prior vocal training, can be performed through incorrect muscle adjustments. Such adjustments, associated with excessive tension of the laryngeal musculature and scapular girdle region, can trigger an inappropriate vocal behavior
      • Rubin JS
      • Blake E
      • Mathieson L
      Musculoskeletal patterns in patients with voice disorders.
      • Roy N
      • Weinrich B
      • Gray SD
      • et al.
      Three treatments for teachers with voice disorders.
      • Braga NJ
      • de Oliveira DSF
      • Atherino CCT
      • et al.
      nodules: functional and anatomical analysis.
      • Yamasaki R
      • Behlau M
      • Brasil OOC
      • Yamashita H
      • et al.
      Anatomical and morphological differences in the vocal tract between dysphonic and normal adult women.
      • da Cunha Pereira G
      • de Oliveira Lemos I
      • Dalbosco Gadenz C
      • et al.
      Effects of voice therapy on muscle tension dysphonia: a systematic literature review.
      • Yamasaki R
      • Murano EZ
      • Gebrim E
      • et al.
      Vocal tract adjustments of dysphonic and non-dysphonic women pre- and post-flexible resonance tube in water exercise: a quantitative MRI study.
      • Barata LF
      • Madazio G
      • Behlau M
      • et al.
      Análise vocal e laríngea na hipótese diagnóstica de nódulos e cistos.
      • Balata PMM
      • Silva HJ
      • Pernambuco LA
      • et al.
      Electrical activity of extrinsic laryngeal muscles in subjects with and without dysphonia.
      • Redenbaugh MA
      • Reich AR.
      Surface EMG and related measures in normal and vocally hyperfunctional speakers.
      • Hocevar-Boltezar I
      • Janko M
      • Zargi M
      Role of surface EMG in diagnostics and treatment of muscle tension dysphonia.
      resulting in vocal fatigue symptoms
      • Zambon F
      • Moreti F
      • Nanjundeswaran C
      • et al.
      Cross-cultural adaptation of the Brazilian version of the vocal fatigue index – VFI.
      and musculoskeletal pain in regions close to the larynx.
      • Silverio KCA
      • Siqueira LTD
      • Lauris JRP
      • et al.
      Muscleskeletal pain in dysphonic women.
      ,
      • da Silva Vitor J
      • Siqueira LTD
      • Ribeiro VV
      • et al.
      Musculoskeletal pain and occupational variables in teachers with voice disorders and in those with healthy voices—a pilot study.
      It is also known that an inadequate body posture during vocal use is a predictor for the development of vocal changes.
      • Kooijman PGC
      • de Jong FICRS
      • Oudes MJ
      • et al.
      Muscular tension and body posture in relation to voice handicap and voice quality in teachers with persistent voice complaints.
      On the other hand, workers who kept their jobs in person in the usual places had to adopt the face mask as a mandatory accessory and are also subject to the vocal fatigue symptoms.
      • Ribeiro VV
      • Dassie-Leite AP
      • Pereira EC
      • et al.
      Effect of wearing a face mask on vocal self-perception during a pandemic.
      Thus, it is necessary to understand whether adaptations in professional activities resulting from the pandemic pose a risk to the voice since these new working conditions can be long-lasting, and these professionals may develop vocal disorders in the future.
      The objective of this study was to investigate the self-perception of vocal fatigue symptoms and musculoskeletal pain related to voice in home office workers before and during the COVID-19 pandemic.

      MATERIAL AND METHODS

      Design study

      This research is a cross-sectional, observational, and descriptive study.

      Ethical aspects

      The Research Ethics Committee of the Universidade Federal de Sergipe approved this study (4.071.175). Each participant signed an informed consent form before participation in the study.

      Sample

      Participants were recruited by the dissemination of the study on social networks in Brazil. For this purpose, a post was prepared and shared with an access link to complete the survey questions and questionnaires. The data collection was conducted online through Google Forms in June 2020, during the COVID-19 pandemic.
      Eligibility criteria were established to select the sample and applied based on responses to a sample questionnaire prepared by the authors and the Voice Disorders Screening Index protocol.
      • de Assis Moura Ghirardi AC
      • Piccolotto Ferreira L
      • Pimentel Pinto Giannini S
      • et al.
      Screening index for voice disorder (SIVD): development and validation.
      Brazilian individuals of both sexes, aged between 18 and 59 years, were invited to participate. Participants that reported an established diagnosis of dysphonia, undergoing otorhinolaryngological or treatments for voice or larynx at the time of the study, participants who reported hearing complaints, and/or diagnosis of COVID-19, who reported with diseases of the upper airway on the day the survey was completed, participants who already worked in home office before the pandemic, and participants who were classified in the risk range for developing dysphonia using the voice disorder screening index protocol
      • de Assis Moura Ghirardi AC
      • Piccolotto Ferreira L
      • Pimentel Pinto Giannini S
      • et al.
      Screening index for voice disorder (SIVD): development and validation.
      were excluded.
      The sample size was calculated using hypothesis testing with the t test for two independent groups of different sizes from a pilot study with 100 participants. The main outcome variability was considered for the calculation (the total domain of the vocal fatigue index [VFI]). The parameters adopted for the test were α = 5%, β = 20%, K = 80%, difference from the mean of 2.5 points (µ = 2.5) and a combined standard deviation of 8.3 (σ = 8.3). The calculated sample size was 169 participants per group.
      A total of 514 volunteers participated in the selection process, of which 89 were excluded. The sample consisted of 424 participants (252 women and 172 men) with an average age of 32 years and three months, divided into the experimental group (EG) with 235 individuals working from home office during the COVID-19 pandemic; and the control group (CG) with 189 individuals who were working at their usual workplace.

      Outcomes

      The self-assessed outcomes were vocal fatigue symptoms and the frequency of musculoskeletal pain. Both outcomes were assessed twice by considering the current period—March 2020 to June 2020 (during the pandemic) and that until February 2020 (before the pandemic). However, data collection was performed in a single moment, obtaining the present and retrospective data.
      To analyze the self-perception of vocal fatigue symptoms, the VFI was used, translated, and validated in Brazilian Portuguese.
      • Zambon F
      • Moreti F
      • Ribeiro VV
      • et al.
      Vocal fatigue index: validation and cutoff values of the Brazilian version.
      The frequency of 17 vocal fatigue symptoms was analyzed on a five-point Likert scale from zero (never) to four (forever). The factors of the VFI are tiredness and voice impairment; avoidance of voice use; physical discomfort; improvement of voice symptoms with rest, and, total. The calculation of the factors was performed according to the authors' instructions.
      To investigate the frequency of pain, the "Musculoskeletal Pain Investigation Questionnaire" was used.
      • Silverio KCA
      • Siqueira LTD
      • Lauris JRP
      • et al.
      Muscleskeletal pain in dysphonic women.
      For the present study, only the larynx's proximal regions were used, and the frequency of pain was analyzed. The body parts investigated were the posterior and anterior neck, shoulders, upper and lower back, temporal region, masseter, submandibular region, and larynx. Participants rated the frequency of pain in each body region between zero and three (0 = never, 1 = rarely, 2 = sometimes, 3 = always).
      Some data from the sample questionnaire were used to characterize the sample. The participants' profession was classified according to the classification of voice and speech professions according to the demands on voice quality and vocal loading from working ability.
      • Vilkman E.
      Occupational safety and health aspects of voice and speech professions.

      Data analysis

      Data analysis was performed using the SPSS 25.0 (IBM Corporation, Armonk, NY). The descriptive analysis of the nominal qualitative variables was performed by calculating the mean values of relative and absolute frequencies, and that of the qualitative ordinal variables and quantitative variables were performed by calculating the measures of variability, central tendency, and position. The quantitative variables were subjected to a normality analysis with the Shapiro Wilk test for inferential analysis. The independent groups were compared using the Mann-Whitney test, and the dependent groups were compared using the Wilcoxon test. Nominal qualitative variables were associated with the chi-squared test. A significance level of 5% was considered.

      RESULTS

      EG was significantly older than CG (P< 0.001). The groups were homogeneous in terms of daily working time (Table 1).
      Table 1Characterization of Groups According to Age and Working Time
      VariableGroupMeanSD1QMedian3QP Value
      AgeCG30.468.5124.0028.0036.00<0.001
      Mann-Whitney test.
      EG33.779.2926.0032.0039.00
      Daily workloadCG7.892.597.008.009.000.552
      EG7.861.798.008.008.00
      Abbreviations: 1Q, first quartile; 3Q, third quartile; SD, standard deviation.
      low asterisk Mann-Whitney test.
      Table 2 shows that both groups were associated with moderate quality and high loading, and moderate quality and moderate loading (P= 0.019).
      Table 2Association Between Groups and Classification of Voice and Speech Professions According to the Demands on Voice Quality and Vocal Loading From the Working Ability
      GroupP Value
      CGEG
      ClassificationHigh quality and high loadingn130.019
      Chi-squared test.
      %0.5%1.3%
      Moderate quality and high loadingn76128
      %40.2%54.5%
      Moderate quality and moderate loadingn110101
      %58.2%43.0%
      Low quality and high loadingn23
      %1.1%1.3%
      Abbreviations: %, relative frequency; n, absolute frequency.
      low asterisk Chi-squared test.
      EG showed scores significantly higher than CG for pain frequency in all regions, except submandibular (Table 3), and vocal fatigue symptoms in all factors (Table 4), both before and during the COVID-19 pandemic.
      Table 3Analysis of the Self-Perceived Frequency of Pain Before and During the Pandemic Among Individuals Who Are Working in the Home Office and Individuals Who Are Working in the Usual Workplace During the COVID-19 Pandemic
      VariableGroupMeanSD1QMedian3QP Value
      Posterior neck (prepandemic)CG0.700.870.000.001.00<0.001
      Mann-Whitney test.
      EG1.050.910.001.002.00
      Posterior neck (during pandemic)CG0.750.920.000.001.00<0.001
      Mann-Whitney test.
      EG1.231.030.001.002.00
      Shoulders (prepandemic)CG0.790.930.001.001.00<0.001
      Mann-Whitney test.
      EG1.130.960.001.002.00
      Shoulders (during pandemic)CG0.881.000.001.002.00<0.001
      Mann-Whitney test.
      EG1.331.060.001.002.00
      Upper back (prepandemic)CG0.810.950.001.001.00<0.001
      Mann-Whitney test.
      EG1.200.970.001.002.00
      Upper back (during pandemic)CG0.860.950.001.001.50<0.001
      Mann-Whitney test.
      EG1.411.050.001.002.00
      Lower back (prepandemic)CG0.931.000.001.002.00<0.001
      Mann-Whitney test.
      EG1.260.990.001.002.00
      Lower back (during pandemic)CG0.941.030.001.002.00<0.001
      Mann-Whitney test.
      EG1.371.040.001.002.00
      Temporal region (prepandemic)CG0.600.850.000.001.000.024
      Mann-Whitney test.
      EG0.780.910.001.001.00
      Temporal region (during pandemic)CG0.640.930.000.001.000.005
      Mann-Whitney test.
      EG0.880.960.001.002.00
      Masseter (prepandemic)CG0.230.530.000.000.000.025
      Mann-Whitney test.
      EG0.390.730.000.001.00
      Masseter (during pandemic)CG0.230.520.000.000.000.006
      Mann-Whitney test.
      EG0.470.820.000.001.00
      Submandibular region (prepandemic)CG0.130.380.000.000.000.138
      EG0.210.520.000.000.00
      Submandibular region (during pandemic)CG0.140.400.000.000.000.095
      EG0.240.590.000.000.00
      Larynx (Prepandemic)CG0.150.380.000.000.00<0.001
      Mann-Whitney test.
      EG0.390.700.000.001.00
      Larynx (during pandemic)CG0.210.520.000.000.000.004
      Mann-Whitney test.
      EG0.410.740.000.001.00
      Anterior neck (prepandemic)CG0.220.510.000.000.00<0.001
      Mann-Whitney test.
      EG0.480.780.000.001.00
      Anterior neck (during pandemic)CG0.280.620.000.000.00<0.001
      Mann-Whitney test.
      EG0.550.860.000.001.00
      Note: Mann-Whitney test.
      Abbreviations: 1Q, first quartile; 3Q, third quartile; SD, standard deviation.
      low asterisk Mann-Whitney test.
      Table 4Analysis of Self-Perceived Vocal Fatigue Symptoms Before and During the Pandemic Among Individuals Who Are Working in the Home Office and Individuals Who Are Working in the Usual Workplace During the COVID-19 Pandemic
      VariableGroupMeanSD1QMedian3QP Value
      Tiredness and voice impairment (prepandemic)CG3.494.640.001.006.50<0.001
      Mann-Whitney test.
      EG5.696.130.004.008.00
      Tiredness and voice impairment (during pandemic)CG3.634.670.002.006.00<0.001
      Mann-Whitney test.
      EG6.596.051.005.009.00
      Avoidance of voice use (prepandemic)CG1.832.360.001.003.00<0.001
      Mann-Whitney test.
      EG2.772.910.002.004.00
      Avoidance of voice use (during pandemic)CG1.942.280.001.003.00<0.001
      Mann-Whitney test.
      EG3.302.791.003.005.00
      Physical discomfort (prepandemic)CG1.001.770.000.002.00<0.001
      Mann-Whitney test.
      EG2.303.530.000.004.00
      Physical discomfort (during pandemic)CG0.941.950.000.001.00<0.001
      Mann-Whitney test.
      EG2.363.190.001.004.00
      Improvement of voice symptoms with rest (prepandemic)CG2.293.530.000.003.50<0.001
      Mann-Whitney test.
      EG4.204.420.003.008.00
      Improvement of voice symptoms with rest (during pandemic)CG2.363.320.000.004.00<0.001
      Mann-Whitney test.
      EG4.394.080.003.007.00
      Total (Prepandemic)CG16.036.5412.0013.0019.000.003
      Mann-Whitney test.
      EG18.579.4212.0016.0023.00
      Total (during pandemic)CG16.156.2812.0014.0019.00<0.001
      Mann-Whitney test.
      EG19.869.2813.0018.0024.00
      Note: Mann-Whitney test.
      Abbreviations: 1Q, first quartile; 3Q, third quartile; SD, standard deviation.
      low asterisk Mann-Whitney test.
      When comparing the moments before and during a pandemic, the EG showed an increase in the frequency of pain in the posterior regions of the neck (P= 0.001), shoulders (P< 0.001), upper back (P< 0.001), temporal (P= 0.027) and masseter (P= 0.030), and the CG in the larynx region (P= 0.023) during the pandemic (Table 5). EG showed an increase in tiredness and voice impairment scores (P= 0.008), avoid of voice use (P< 0.001), and total (P = 0.027) during the pandemic to the moment before the pandemic (Table 6).
      Table 5Analysis of the Self-Perceived Frequency of Pain in Individuals Who Are Working in the Home Office and Individuals Who Are Working in the Usual Workplace During the COVID-19 Pandemic Between the Moments Before and During the Pandemic
      VariableGroupPrepandemicDuring PandemicP Value
      MeanSD1QMedian3QMeanSD1QMedian3Q
      Posterior neckCG0.700.870.000.001.000.750.920.000.001.000.326
      EG1.050.910.001.002.001.231.030.001.002.000.001
      Wilcoxon test.
      ShouldersCG0.790.930.001.001.000.881.000.001.002.000.062
      EG1.130.960.001.002.001.331.060.001.002.00<0.001
      Wilcoxon test.
      Upper backCG0.810.950.001.001.000.860.950.001.001.500.321
      EG1.200.970.001.002.001.411.050.001.002.00<0.001
      Wilcoxon test.
      Lower backCG0.931.000.001.002.000.941.030.001.002.000.721
      EG1.260.990.001.002.001.371.040.001.002.000.060
      Temporal regionCG0.600.850.000.001.000.640.930.000.001.000.387
      EG0.780.910.001.001.000.880.960.001.002.000.027
      Wilcoxon test.
      MasseterCG0.230.530.000.000.000.230.520.000.000.000.960
      EG0.390.730.000.001.000.470.820.000.001.000.030
      Wilcoxon test.
      Submandibular regionCG0.130.380.000.000.000.140.400.000.000.000.835
      EG0.210.520.000.000.000.240.590.000.000.000.199
      LarynxCG0.150.380.000.000.000.210.520.000.000.000.023
      Wilcoxon test.
      EG0.390.700.000.001.000.410.740.000.001.000.560
      Anterior neckCG0.220.510.000.000.000.280.620.000.000.000.060
      EG0.480.780.000.001.000.550.860.000.001.000.080
      Note: Wilcoxon test.
      Abbreviations: 1Q, first quartile; 3Q, third quartile; SD, standard deviation.
      low asterisk Wilcoxon test.
      Table 6Analysis of Self-Perceived Vocal Fatigue Symptoms in Individuals Who Are Working in the Home Office and Individuals Who Are Working in the Usual Workplace During the COVID-19 Pandemic Between the Moments Before and During the Pandemic
      VariableGroupPrepandemicDuring PandemicP Value
      MeanSD1QMedian3QMeanSD1QMedian3Q
      Tiredness and voice impairmentCG3.494.640.001.006.503.634.670.002.006.000.144
      EG5.696.130.004.008.006.596.051.005.009.000.008
      Wilcoxon test.
      Avoidance of voice useCG1.832.360.001.003.001.942.280.001.003.000.301
      EG2.772.910.002.004.003.302.791.003.005.00<0.001
      Wilcoxon test.
      Physical discomfortCG1.001.770.000.002.000.941.950.000.001.000.298
      EG2.303.530.000.004.002.363.190.001.004.000.845
      Improvement of voice symptoms with restCG2.293.530.000.003.502.363.320.000.004.000.280
      EG4.204.420.003.008.004.394.080.003.007.000.375
      TotalCG16.036.5412.0013.0019.0016.156.2812.0014.0019.000.478
      EG18.579.4212.0016.0023.0019.869.2813.0018.0024.000.027
      Wilcoxon test.
      Note: Wilcoxon test.
      Abbreviations: 1Q, first quartile; 3Q, third quartile; SD, standard deviation.
      low asterisk Wilcoxon test.

      DISCUSSION

      The COVID-19 pandemic has changed the style, leisure, routine of life, and work for people globally. WHO

      OPA OP-A de S, OMS OM de S. Folha Informativa – COVID-19 (Doença Causada Pelo Novo Coronavírus). OPA; OMS.

      recommended social detachment during the pandemic, which forced workers to discontinue visiting their usual workplaces in companies and adapt to perform their functions from their home offices
      • Phelipe A
      • Medeiros I.
      Covid-19 muda a rotina do mercado de trabalho com o home office.
      to maintain work activities. A recent study by the American company Deloitte, published in The Wall Street Journal,
      • Mattioli D
      • Putzier K.
      Someday the coronavirus pandemic will release its grip on our lives and we will return to the workplace. The question is: Will there be an office to go back to when this is all over?.
      showed that with the technological advancements, this could continue even after the pandemic ends. Thus, it is necessary to know the new vocal use profile in individuals working from remote modes and obtain evidence about the possible vocal fatigue symptoms and musculoskeletal pain related to vocal production before and during the pandemic. This would help assess the risk to these workers' vocal health in the home office work modality.
      In the present study, we observed that when comparisons were made before and during the pandemic, the EG presented more vocal fatigue symptoms and musculoskeletal pain than the CG, except in the submandibular region. However, when the workers switched to working from home offices during the pandemic, the EG showed an increase in the frequency of musculoskeletal pain in most regions, and the scores of most factors of vocal fatigue, while in the CG, whose participants maintained their activities in the usual place of work, there was only an increase in muscle pain in the laryngeal region.
      It is believed that the increase in pain in the laryngeal region in the CG can be due to the use of face masks for professional activities, which is mandatory by law for all workers who keep working in the usual place. Such a measure seeks to prevent the spread and contamination by the new coronavirus.
      • Garcia LP
      • Duarte E
      Intervenções não farmacológicas para o enfrentamento à epidemia da COVID-19 no Brasil.
      ,
      • Howard J
      • Huang A
      • Li Z
      • et al.
      Face mask against COVID-19: an evidence review.
      The use of masks can attenuate the sound of the voice between 3 and 12 dB, mainly at frequencies between 2000 and 7000 Hz.
      • Goldin AG
      • Weinstein B
      • Shiman N
      Speech blocked by surgical masks becomes a more important issue in the era of COVID-19.
      This can compromise communication, as the interlocutor cannot hear the message clearly and accurately. In addition, the listener's visual feedback for orofacial reading becomes difficult, along with the limitation of articulatory movements in some cases. The use of the face mask can also decrease the inspiratory flow and impact the expiratory flow, which can further lead to pneumophonic incoordination.
      • Ribeiro VV
      • Dassie-Leite AP
      • Pereira EC
      • et al.
      Effect of wearing a face mask on vocal self-perception during a pandemic.
      Thus, compensatory adjustment is made by increasing vocal intensity, which can generate overload at the glottic level,
      • Ribeiro VV
      • Dassie-Leite AP
      • Pereira EC
      • et al.
      Effect of wearing a face mask on vocal self-perception during a pandemic.
      increasing the muscle tension and causing pain perception in the laryngeal region.
      The EG showed an increase in the frequency of pain in the posterior regions of the neck, shoulders, upper back, and temporal regions during professional practice in the home office in the pandemic. These findings can be attributed to work ergonomics implemented at home, which may not be the most appropriate, and maintain the same inadequate physical body position for long periods. Posture imbalances associated with vocal use are considered predictors of vocal disorders.
      • Kooijman PGC
      • de Jong FICRS
      • Oudes MJ
      • et al.
      Muscular tension and body posture in relation to voice handicap and voice quality in teachers with persistent voice complaints.
      In addition to muscle fatigue, the effects of inadequate body posture, in the long run, can cause overload to the respiratory system, edema, varicose veins, and joint disorders, osteoarthritis, deformities in the spine, among others,
      • Salve M
      Introdução.
      also manifesting through the body pain, as seen in this study.
      There was also an increase in vocal fatigue in EG, comparing the time before and during the pandemic. Vocal fatigue is defined as a self-reported sensation of phonatory effort due to increased vocal load,
      • Solomon NP
      Vocal fatigue and its relation to vocal hyperfunction.
      • McCabe DJ
      • Titze IR.
      Chant therapy for treating vocal fatigue among public school teachers: a preliminary study.
      • Cercal GCS
      • de Paula AL
      • Novis JMM
      • et al.
      fatigue in professors at the beginning and end of the school year.
      which generates symptoms of vocal, laryngopharyngeal, and bodily discomfort, such as the presence of musculoskeletal pain.
      • dos Santos AP
      • Silverio KCA
      • Dassie-Leite AP
      • Costa C da C
      • Siqueira LTDS
      Relation between musculoskeletal pain and voice self-assessment in tele-operators.
      However, it is possible that there are no vocal changes audible or measured acoustically or physically.
      • Solomon NP
      Vocal fatigue and its relation to vocal hyperfunction.
      Several factors favor the appearance of vocal fatigue, including physical, psychological, organizational, and environmental factors.
      • Jones K
      • Sigmon J
      • Hock L
      • et al.
      Prevalence and risk factors for voice problems among telemarketers.
      The literature states that three mechanisms influence the development of vocal fatigue: muscular, mucous, and mental fatigue.
      • Solomon NP
      Vocal fatigue and its relation to vocal hyperfunction.
      These mechanisms can explain the findings of the present study. Muscle fatigue, which affects the vocal muscles, corresponds to neuromuscular adjustments, both in the cervical musculature and the extrinsic and intrinsic muscles of the larynx. This can be due to a series of adjustments or compensations for postural deviations of the head, neck, and trunk.
      • Solomon NP
      Vocal fatigue and its relation to vocal hyperfunction.
      These modifications allow bodily adaptations that cause morphophysiological and postural changes in the larynx and excessive use of the entire body musculature, emphasizing the extrinsic musculature of the larynx and the cervix, with the appearance of symptoms of discomfort and musculoskeletal pain.
      • Silverio KCA
      • Siqueira LTD
      • Lauris JRP
      • et al.
      Muscleskeletal pain in dysphonic women.
      ,
      • Menoncin LCM
      • Jurkiewicz AL
      • Silvério KC
      • et al.
      Muscular and skeletal changes in cervical dysphonic in women.
      • Zielińska-Bliźniewska H
      • Pietkiewicz P
      • Miĺoński J
      • et al.
      Acoustic and capacity analysis of voice academic teachers with diagnosed hyperfunctional dysphonia by using DiagnoScope Specialist software.
      • Cielo CA
      • Christmann MK
      • Ribeiro VV
      • et al.
      Musculoskeletal stress syndrome, extrinsic laryngeal muscles and body posture: theoretical considerations.
      • Ramos AC
      • Floro RL
      • Ribeiro VV
      • et al.
      Musculoskeletal pain and voice-related quality of life in dysphonic and non-dysphonic subjects.
      • Behlau M
      • Zambon F
      • Moreti F
      • et al.
      Voice self-assessment protocols: different trends among organic and behavioral dysphonias.
      In addition, poor postural and muscular adaptations of these regions can promote excessive tension of the intrinsic muscles of the larynx. The adductor muscles are utilized excessively, simultaneously exerting adduction and abduction forces or stretching and shortening the vocal folds. Thus, the inefficient and excessive use of intrinsic musculature associated with phonatory effort leads to vocal fatigue.
      • Solomon NP
      Vocal fatigue and its relation to vocal hyperfunction.
      A study conducted in telemarketers to assess the relationship between musculoskeletal pain and vocal fatigue symptoms found that the greater the sensation of pain, the more vocal fatigue symptoms.
      • dos Santos AP
      • Silverio KCA
      • Dassie-Leite AP
      • Costa C da C
      • Siqueira LTDS
      Relation between musculoskeletal pain and voice self-assessment in tele-operators.
      In the present study, the correlation of these variables was not investigated, but it was observed that both fatigue and muscle pain symptoms increased with the new work modality, corroborating the relationship found in the study mentioned above. Thus, it is believed that muscle fatigue also favors the appearance of fatigue of the vocal fold mucosa. This can occur because of the prolonged use of the voice, in which each glottic cycle during phonation increases the friction of the vibrating portion, generating increased heat dissipation and increased tissue viscosity,
      • Solomon NP
      Vocal fatigue and its relation to vocal hyperfunction.
      which creates biomechanical tension and stress. Therefore, this fatigue of nonmuscular tissue can cause long-term damage to the laryngeal mucosa.
      • Titze IR
      Vocal fatigue: Some biomechanical considerations. In: Transcripts of the twelfth symposium: Care of the professional voice.
      In the present study, it was observed that in the new occupational scenario in times of pandemic, professionals had to adapt to the workplace within their homes. Such a fact may have produced an increase in local noise and, consequently, when communicating, professionals end up being loud. The literature reports that vocal overload or increased phonation in relation to the intensity and frequency of the voice for long periods are aspects that influence vocal fatigue.
      • Vilkman E.
      Occupational safety and health aspects of voice and speech professions.
      However, these workers were not vocally prepared and conditioned to use their voices for long periods. In addition, they did not have any guidance and training on how to communicate in front of the cameras and how to use vocal, gestural, and facial expressions and resources.
      Muscle fatigue and mucosal fatigue
      • Solomon NP
      Vocal fatigue and its relation to vocal hyperfunction.
      ,
      • Titze IR
      Vocal fatigue: Some biomechanical considerations. In: Transcripts of the twelfth symposium: Care of the professional voice.
      are mediated by peripheral nerves and the muscles interface. However, the other factors are centrally mediated, which would fall into "mental" fatigue. Mental fatigue involves increased self-perceived effort that can occur with prolonged activity.
      • Solomon NP
      Vocal fatigue and its relation to vocal hyperfunction.
      Therefore, in the current situation in which remote workers find themselves, mental fatigue is even more prominent. Home office work requires greater concentration during communication, more time looking at the computer screen,

      Negócios PEG. Como minimizar a fadiga por videochamadas no home office. Published online 2020.

      and the use of headphones (may favor an increase in loudness), which generates visual, auditory, vocal, and mainly mental overload, as there are many elements simultaneously composing online communication. In addition, factors such as distortions and interruptions of videos and/or audio, connection failures, and interference from electronic equipment can recruit more cognitive resources to concentrate and understand information, generating greater auditory and mental effort.
      • Ferran C
      • Watts S.
      Videoconferencing in the field: a heuristic processing model.
      ,
      • Alhanbali S
      • Dawes P
      • Millman RE
      • et al.
      Measures of listening effort are multidimensional.
      It is important to consider that several factors related to the current GE work modality, such as the maintenance of the same body position for an extended period, with consecutive virtual meetings, in a closed environment, and with insufficient infrastructure, without face-to-face social communication, can generate mental tiredness.

      Negócios PEG. Como minimizar a fadiga por videochamadas no home office. Published online 2020.

      Vocal fatigue symptoms commonly decrease with adequate vocal rest,
      • Solomon NP
      Vocal fatigue and its relation to vocal hyperfunction.
      ,
      • Kitch JA
      • Oates J.
      The perceptual features of vocal fatigue as self-reported by a group of actors and singers.
      ,
      • Kostyk B.E.
      • Rochet AP.
      Laryngeal airway resistance in teachers with vocal fatigue: a preliminary study.
      as happened in the present study. This finding shows that although vocal fatigue increased during the pandemic, it still shows acute symptoms. Despite this, as there is no forecast for the "new normal" return, it is necessary to carry out long-term follow-ups to verify whether chronic vocal fatigue cannot be installed during the pandemic.
      As limitations of the present study, the absences of assessment of vocal quality and larynx stands out, which was not possible, given the restrictions on the collection of face-to-face data resulting from the pandemic, and it was not possible to collect workers in the CG who did not use a face mask, since its use is mandatory by law. In addition, there was a risk of reporting bias as participants were asked to respond to data before the pandemic. Another limiting factor was the scarcity of studies in the literature that have investigated vocal conditions in this population of workers, which made it difficult to discuss our findings. It is suggested to carry out future studies that can raise the sociodemographic and occupational characteristics of professionals working in the home office during the pandemic and investigate possible relationships with fatigue and vocal self-perception.
      In summary, it can be considered from the above results that workers who are working from home offices during the pandemic are performing their professional activities with the risk of developing vocal changes in the future if they continue using their voice without adequate preparation. In addition, it is known that many professionals, after the pandemic, will continue to exercise their professional/position in this modality or that many occupational activities will be carried out remotely. Therefore, the evidence about the presence of vocal fatigue symptoms and musculoskeletal pain associated with voice alerts to the importance of early intervention with educational and vocal conditioning programs as well as improving communicative competence as a necessity for this population, in order to promote the optimization of vocal use and prevent future vocal disorders.
      • Abou-Rafée M
      • Zambon F
      • Badaró F
      • et al.
      Vocal fatigue in dysphonic teachers who seek treatment.

      CONCLUSION

      Individuals who started to work from their home offices during the COVID-19 pandemic showed increased vocal fatigue symptoms and musculoskeletal pain in the cervical region during the pandemic. In contrast, individuals who continued to work in their usual location showed increased pain in the laryngeal region during the pandemic. Thus, workers who migrated to their home offices during the COVID-19 pandemic are at risk of developing vocal disorders.

      Conflict of Interest

      There are no conflicts of interest to declare.

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