Review Article|Articles in Press

What are the Symptoms that Characterize the Clinical Condition of Vocal Fatigue? A Scoping Review and Meta-Analysis

Published:February 02, 2023DOI:



      Vocal fatigue is a clinical manifestation associated with a perception of negative vocal adjustment. It is related to the increase in the sensation of excessive effort when speaking and the lack of conditioning of the muscles and structures that involve vocal production. Because it has a complex and multifactorial diagnosis, there is still no consensus on the symptoms most commonly found in this clinical condition.


      To review and analyze the symptoms that characterize the clinical condition of vocal fatigue.


      This study consists of a scoping review carried out in the Cochrane Library, Embase, Lilacs, and Medline databases. Observational studies or clinical trials from the last 10 years. Studies with participants younger than 18 years of age were excluded; as well as research that did not describe symptoms of vocal fatigue or that presented vocal fatigue as a symptom; studies with patients with neurological, psychiatric, syndromic conditions, or head and neck cancer. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies NHLBI-NIH scale was used to assess the methodological quality of selected observational studies and the PEDro scale for the analysis of experimental studies. The steps were performed by three blinded evaluators. Subsequently, meta-analyses of global means were executed for each factor under study; a comparison of the difference in the mean score for each factor between exposed and unexposed; a comparison of the difference in the average score, among non-professional voice users, for each factor between exposed and unexposed.


      In the searches performed, 956 articles were found and 29 articles were selected according to the eligibility criteria. Of these, 93.11% of the studies were observational and 6.89% were clinical trials. Regarding the gender and age group of the study samples, women aged between 30 and 45 years were predominant. As for the occupational use of voice, 68.97% of the samples were composed of professional voice users and 31.03% of non-professional voice users, with most professional voice users being teachers and non-professional voice users, individuals with dysphonia or vocal complaint. To assess vocal fatigue symptoms, 28 studies used the Vocal Fatigue Index (VFI) protocol, and only one study used another assessment protocol, Self-Administered Voice Rating. All studies were classified as regular, according to the scale used. As for the meta-analyses performed, the mean scores of the VFI factors were higher among professional voice users when compared to non-professional voice users and higher in dysphonic individuals compared to non-dysphonic individuals.


      The vocal fatigue symptoms found in this review were common in the populations of professional voice users and non-professional voice users and dysphonic and non-dysphonic individuals. These symptoms were related to vocal recovery after rest, physical discomfort, and restricted vocal use.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Voice
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Xue C
        • Kang J
        • Hedberg C
        • et al.
        Dynamically monitoring vocal fatigue and recovery using aerodynamic, acoustic, and subjective self-rating measurements.
        J Voice. 2019; 33: 809.e11-809.e18
        • Kang J
        • Xue C
        • Lou Z
        • et al.
        The therapeutic effects of straw phonation on vocal fatigue.
        Laryngoscope. 2020; 130: E674-E679
        • Solomon NP.
        Vocal fatigue and its relation to vocal hyperfunction †.
        Int J Speech Lang Pathol. 2008; 10: 254-266
        • Bonetti A
        • Bonetti L
        • Čipčić O.
        Self-assessment of vocal fatigue in muscle tension dysphonia and vocal nodules: a preliminary analysis of the discriminatory potential of the croatian adaptation of the vocal fatigue index (VFI-C).
        J Voice. 2021; 35: 325.e1-325.e15
        • Naderifar E
        • Moradi N
        • Farzadi F
        • et al.
        Cross-cultural adaptation and validation of the vocal fatigue index into persian.
        J Voice. 2019; 33: 947.e35-947.e41
        • Nanjundeswaran C
        • VanSwearingen J
        • Abbott KV.
        Metabolic mechanisms of vocal fatigue.
        J Voice. 2017; 31: 378.e1-378.e11
        • Mahalingam S
        • Boominathan P
        • Arunachalam R
        • et al.
        Cepstral measures to analyze vocal fatigue in individuals with hyperfunctional voice disorder.
        J Voice. 2021; 35: 815-821
        • Kitch JA
        • Oates J.
        The perceptual features of vocal fatigue as self-reported by a group of actors and singers.
        J Voice. 1994; 8: 207-214
        • Gotaas C
        • Starr CD.
        Vocal fatigue among teachers.
        Folia Phoniatr (Basel). 1993; 45: 120-129
        • Welham NV
        • Maclagan MA.
        Vocal fatigue: current knowledge and future directions.
        J Voice. 2003; 17: 21-30
        • Nanjundeswaran C
        • Jacobson BH
        • Gartner-Schmidt J
        • et al.
        Vocal fatigue index (VFI): development and validation.
        J Voice. 2015; 29: 433-440
        • Athira UR
        • Devadas U.
        Adaptation and validation of vocal fatigue index (VFI) to malayalam language.
        J Voice. 2020; 34: 810.e19-810.e24
        • Barsties V
        • Latoszek B
        • Auner M
        • et al.
        Cross-cultural adaption and validation of the vocal fatigue index in German.
        J Voice. 2021; 35: 161.e1-161.e13
        • Şirin S
        • Öğüt MF
        • Bilgen C.
        Reliability and validity of the Turkish version of the vocal fatigue index.
        Turk J Med Sci. 2020; 50: e902-e909
        • Srinivas S
        • Mahalingam S
        • Boominathan P.
        Cultural and linguistic adaptation of vocal fatigue index for tamil-speaking population (VFI-T).
        J Voice. 2021; 35: 662.e1-662.e8
        • Contreras-Regatero S
        • Vila-Rovira J
        • Verdejo C.
        Validity and reliability of Spanish version of two questionnaires of vocal fatigue in female teachers.
        J Voice. 2021; 35: 159.e1-159.e9
        • Zambon F
        • Moreti F
        • Ribeiro VV
        • Nanjundeswaran C
        • Behlau M
        Vocal Fatigue Index: Validation and Cut-off Values of the Brazilian Version.
        J Voice. 2022; 36: 434.e17-434.e24
        • Tricco AC
        • Lillie E
        • Zarin W
        • et al.
        PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation.
        Ann Intern Med. 2018; 169: 467-473
      1. National Heart, Lung, and Blood Institute; National Institutes of Health; U.S. Department of Health and Human Services.Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. 2014. Available online at (Accessed in July 5th, 2022).

        • Morton NA.
        The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study.
        Aust J Physiother. 2009; 55: 129-133
        • Shiwa SR
        • Costa LOP
        • Moser ADL
        • et al.
        PEDro: The physiotherapy evidence database.
        Fisioter Mov. 2011; 24: 523-533
        • Banks RE
        • Bottalico P
        • Hunter EJ
        The effect of classroom capacity on vocal fatigue as quantified by the vocal fatigue index.
        Folia Phoniatr Logop. 2017; 69: 85-93
        • Hunter EJ
        • Banks RE
        Gender differences in the reporting of vocal fatigue in teachers as quantified by the vocal fatigue index.
        Ann Otol Rhinol Laryngol. 2017; 126: 813-818
        • Abou-Rafée M
        • Zambon F
        • Badaró F
        • et al.
        Vocal fatigue in dysphonic teachers who seek treatment.
        Codas. 2019; 31e2018120
        • Anand S
        • Bottalico P
        • Gray C.
        Vocal fatigue in prospective vocal professionals.
        J Voice. 2021; 35: 247-258
        • Cercal GCS
        • Paula AL
        • Novis JMM
        • et al.
        Vocal fatigue in professors at the beginning and end of the school year.
        Codas. 2019; 32e20180233
        • De Paula AL
        • Cercal GCS
        • Novis JMM
        • et al.
        Perception of fatigue in professors according to the level of knowledge of vocal health and hygiene.
        Audiol. Commun. Res. 2019; 24: e2163
        • Depolli GT
        • Fernandes DNS
        • Costa MRB
        • et al.
        Fadiga e Sintomas Vocais em Professores Universitários.
        Distur. da Comunic. 2019; 31: 225-233
        • Moghtader M
        • Soltani M
        • Mehravar M
        • et al.
        The relationship between vocal fatigue index and voice handicap index in university professors with and without voice complaint.
        J Voice. 2020; 34: 809.e1-809.e5
        • Cantor-Cutiva LC
        • Banks RE
        • Hunter EJ
        The effect of upper airway ailments on teachers’ experience of vocal fatigue.
        J Voice. 2020; 36: 226-231
        • Enclade HX
        • Chow MS
        • Sund LT
        • et al.
        Pilot evaluation of community-based vocal health screenings.
        J Voice. 2021; 35: 666.e1-666.e5
        • Erkan SO
        • Tuhanioglu B.
        Vocal fatigue in doctors: evaluation with subjective and objective acoustic parameters.
        Logoped Phoniatr Vocol. 2021; 46: 35-41
        • Hunter EJ
        • Maxfield L
        • Graetzer S.
        The effect of pulmonary function on the incidence of vocal fatigue among teachers.
        J Voice. 2020; 34: 539-546
        • Lei Z
        • Fasanella L
        • Martignetti L
        • et al.
        Investigation of vocal fatigue using a dose-based vocal loading task.
        Appl Sci (Basel). 2020; 10: 1-16
        • Ribeiro VV
        • Dassie-Leite AP
        • Pereira EC
        • et al.
        Effect of wearing a face mask on vocal self-perception during a pandemic.
        J Voice. 2020; 36: 878.E1-878.E7
        • Siqueira LTD
        • Santos APD
        • Silva RLF
        • et al.
        Vocal self-perception of home office workers during the COVID-19 pandemic.
        J Voice. 2020; 37: 144.e15-144.e22
        • Vermeulen R
        • van der Linde J
        • Abdoola S
        • et al.
        The effect of superficial hydration, with or without systemic hydration, on voice quality in future female professional singers.
        J Voice. 2020; 35: 728-738
        • Dos Santos AP
        • Silverio KCA
        • Dassie-Leite AP
        • et al.
        Relation between musculoskeletal pain and voice self-assessment in tele-operators.
        J Voice. 2019; 33: 948.e11-948.e21
        • Moradi N
        • Beidokhti MH
        • Moghtader M
        • et al.
        Comparison of vocal fatigue in speech therapists with other rehabilitation therapists.
        J Voice. 2021; (S0892-1997(21)00014-X)
        • Nallamuthu A
        • Boominathan P
        • Arunachalam R
        • et al.
        Outcomes of vocal hygiene program in facilitating vocal health in female school teachers with voice problems.
        J Voice. 2021; (S0892-1997(21)00018-7)
        • Marques da Rocha L
        • Behlau M
        • Dias de Mattos Souza L.
        Behavioral dysphonia and depression in elementary school teachers.
        J Voice. 2015; 29: 712-717
        • 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.
        J Voice. 2018; 32: 546-552
        • Martins RH
        • do Amaral HA
        • Tavares EL
        • et al.
        Voice disorders: etiology and diagnosis.
        J Voice. 2016; 30 (761.e.1-761.e.9)
        • Dejonckere PH.
        Gender diferences in the prevalence of ocupacional voice disorders. organizador.
        in: Dejonckere PH Occupacional Voice: Care and Cure. v.1. Kugler Publications, The Hague2001: 11-20
        • Butler JE
        • et al.
        Gender-related differences of hyaluronic acid distribution in the human vocal fold.
        Laryngoscope. 2001; 111: 907-911
        • Behlau M
        • Zambon F
        • Madazio G.
        Managing dysphonia in occupational voice users.
        Curr Opin Otolaryngol Head Neck Surg. 2014; 22: 188-194
        • Bassi IB
        • Assunção AÁ.
        Diagnosis of dysphonia among municipal employees: individual and work factors.
        J Voice. 2015; 29 (389.e19-26)
        • Sliwinska-Kowalska M
        • Niebudek-Bogusz E
        • Fiszer M
        • et al.
        The prevalence and risk factors for occupational voice disorders in teachers.
        Folia Phoniatr Logop. 2006; 58: 85-101
        • Lindstrom F
        • Waye KP
        • Södersten M
        • et al.
        Observations of the relationship between noise exposure and preschool teacher voice usage in day-care center environments.
        J Voice. 2011; 25: 166-172
        • Martins RH
        • Pereira ER
        • Hidalgo CB
        • et al.
        Voice disorders in teachers. A review.
        J Voice. 2014; 28: 716-724
        • Hunter EJ
        • Cantor-Cutiva LC
        • van Leer E
        • et al.
        Toward a consensus description of vocal effort, vocal load, vocal loading, and vocal fatigue.
        J Speech Lang Hear Res. 2020; 63: 509-532
        • D'haeseleer E
        • Behlau M
        • Bruneel L
        • et al.
        Factors involved in vocal fatigue: a pilot study.
        Folia Phoniatr Logop. 2016; 68: 112-118
        • Van Houtte E
        • Van Lierde K
        • Claeys S.
        Pathophysiology and treatment of muscle tension dysphonia: a review of the current knowledge.
        J Voice. 2011; 25: 202-207