This study examined risk factors for voice disorders among Fado singers in Portugal. A survey of 111 Fado singers found that 40.5% reported past or current voice problems. Multivariate analysis identified several independent risk factors: nose/sinus issues or medication use increased risk 5 times; oral contraceptives or hormone therapy increased risk 5 times; previous smoking increased risk 4 times; vocal fatigue after performances increased risk 3 times. Corticosteroid use was found to decrease risk by 0.2 times, possibly due to treatment of an existing condition. The study concludes that singing Fado professionally significantly increases the risk of developing voice disorders.

1. Risk factors for voice disorders among Fado singers
Pedro Melo Pestana 1,2
Susana Vaz-Freitas 2,3
Maria Conceição Manso 2, 4, 5
1 PMP terapia – Esposende - Portugal
2 University Fernando Pessoa - Faculty of Health Sciences – Porto - Portugal
3 Speech Pathology Unit of Otolaryngology Service – Centro Hospitalar do Porto
4 Fernando Pessoa Energy, Environment and Health Research Unit (FP-ENAS), University Fernando Pessoa
5 LAQV, REQUIMTE, University of Porto, Portugal

2. Risk factors for voice disorders among Fado singers
Furthermore, a waitress!!
Different sleep-awake cycles
No formal training/learning!!
7 hours of singing per week
60 minutes of singing per day
10 songs per performance
2 to 3 performances/venues per day
(afternoon and late at night)
Simple calculations
of a living example
(still no boring statistics!!)

3. Risk factors for voice disorders among Fado singers
Introduction
• Fado is a genre of urban folk music from Portugal (UNESCO, 2011)
• Singing is a professional occupation that increases the risk of voice disorders
– conflicting evidence! (Kwok & Eslick, 2018; Mori, Francis, & Song, 2017)
• Epidemiological research (prevalence and risk) in singers is scant but
promising (Garzón García, Muñoz López, & y Mendoza Lara, 2017)
• Self-perception mirrors the impact and the importance each one gives
1

4. Risk factors for voice disorders among Fado singers
Introduction
• Fado singers – unique demands and routines
• Hints for an increased risk for voice disorders (hazards)
(Ibrahim et al., 2017; Kahle, 2012; Mendes et al., 2014; Mendes et al., 2014; Mendes et al. 2013)
• Vocal health thresholds near pathological levels
• Unhealthy lifestyles
• Performing under poor acoustic conditions
• Prevalence of voice disorders among Fado singers: 39.6% (Pestana et al., 2018)
1

5. Risk factors for voice disorders among Fado singers
Goal
To determine the associated risks and
protective factors of voice disorders in
relation to the act of singing Fado and
voice.
2
(Pestana et al, 2018)
Population
Expected sample
Final sample
411
199
111

6. Risk factors for voice disorders among Fado singers

7. Risk factors for voice disorders among Fado singers
Methods3
Cross-sectional design
A. Sample
• Convenience/Snowball sampling
• Criteria: singers of Fado de Lisboa substyle;
older than 18 years old; an active singer
B. Customized and self-administered
questionnaire
55 questions / 6 groups
111 completed
9.3% incomplete
21.7% no answer
168 recruited
1. Personal and demographic data
2. Musical experience and knowledge
3. Performance demands and habits
4. Personal and social habits
5. Vocal health and well-being
6. Strategies

8. Risk factors for voice disorders among Fado singers
Methods (cont.)
3
C. Questionnaire fulfillment
• Online; private server; individual tokens
• 21 February 2017 → 2 March 2018
D. Data analysis
• Confidence levels – 95%
• Risk and protection factors
• Associations with voice problems → univariate logistic regression (OR)
• Predict association (risk and protection) → multivariate logistic regression (OR)

9. Risk factors for voice disorders among Fado singers
Results4
A. Sample characterization
42 yo (18-74)
Past or present voice problems
40.5% (95% CI – 31.9%-49.9%)

10. Risk factors for voice disorders among Fado singers
Results (cont.)
• Multivariate logistic regression analysis of risk factors independently associated
with Voice Problems
4
5.552 (1.481-20.817)
4.955 (1.210-20.293)
3.955 (1.488-10.515)
2.868 (1.157-7.109)
0.219 (1.210-20.293)
Nose related disorders, Decongestants or Antihistamines
Oral contraception or hormone replacement therapy
Previous smoking habits
Vocal fatigue after performances
Corticosteroids

11. Risk factors for voice disorders among Fado singers
Discussion5
Nose related disorders, Decongestants or Antihistamines
5x
• Disorder or the medication intake?
• “Post nasal dripping”?
• Allergic rhinitis is commonly associated
with voice changes
• Environmental hazards: stage fog/smoke,
curtains dust, etc

12. Risk factors for voice disorders among Fado singers
Discussion5
Oral contraception or hormone replacement therapy
5x
• Primarily applied to female singers
• Hormonal fluctuation
• Contradictions are found in literature

13. Risk factors for voice disorders among Fado singers
Discussion5
Previous smoking habits
4x
• Highly destructive effect on vocal folds
• Burning effect

14. Risk factors for voice disorders among Fado singers
Discussion5
Vocal fatigue after performances
3x
Lack of vocal endurance
High vocal load
Vocal sign that suggests a broad clinical
event

15. Risk factors for voice disorders among Fado singers
Discussion5
Corticosteroids
0.2x
• Protective !?
• Who’s taking has already an established
pathology → it reduces the symptomatology
• Due to other reasons → positive effects on
vocal and/or respiratory tract

16. Risk factors for voice disorders among Fado singers
Conclusion5
• Some predictable variables were not identified (eg, amplification systems,
voice warm-up, strategies adopted to overcome voice problems)
• Demystifies some preconceptions associated with singing folk and
popular music
• Based ONLY on self-reported data → should be interpreted in the context
• FUTURE: instrumental voice analysis, vocal load assessment, suitability
of the repertoire, individual study of risk factors
To sing Fado (only Fado?) significantly increased the risk of
developing voice disorders

17. Risk factors for voice disorders among Fado singers
Obrigado!
ppestana@pmpterapia.pt