Long Covid - with Highly Specialist SLT Carrie Garrett

We're discussing Long Covid and its effects on speaking and singing.
Our guest is highly specialist speech and language therapist, singer and singing teacher Carrie Garrett.
Symptoms of Long Covid (it's a looong list!)
How singing teachers can support students with Long Covid
The difference between Long Covid and post-Covid syndrome
Types of vocal exercises that are useful for Long Covid support
Differences between Long Covid and chronic conditions such as COPD or asthma
And a poem (with permission) from Michael Rosen on working with a voice therapist post-Covid

Resources mentioned in the show:
Michael Rosen's BBC Radio 4 Word of Mouth episode with Fiona Gillies 
https://www.bbc.co.uk/sounds/play/m000vp3y

The One Minute Voice Warmup App (Apple and Android) from Vocal Process

My Singer Has A Voice Problem (course) in the Vocal Process Learning Lounge https://bit.ly/VocalProcessLearningLounge

Ask us anything - submit your questions on https://speakpipe.com/Vocalprocess

British Medical Journal https://blogs.bmj.com/bmj/2021/02/19/we-need-to-do-more-to-understand-chronic-vocal-symptoms-of-covid-19/

Allied Health Professionals webinar - Long Covid Speech and Language Therapists
https://www.youtube.com/watch?v=olKyibwGiXc

NHS England National guidance for post-COVID syndrome assessment clinics https://www.england.nhs.uk/coronavirus/publication/national-guidance-for-post-covid-syndrome-assessment-clinics/

NHS Supporting your recovery after Covid19 www.yourcovidrecovery.nhs.uk

British Lung Foundation www.blf.org.uk

NHS Voice problems after Covid19 with Paul John McKenna https://youtu.be/Y9QqYuHhSkI

Transcript

Carrie: 0:00

The Long COVID diagnosis of Long COVID is usually symptoms are not explained or attribute attributable, oh, put my teeth back in, attributable to other diagnoses. I mean that there have been over 200 symptoms documented, then they go across respiratory problems, cardiovascular problems, neurological, gastrointestinal psychological symptoms, you know, and people are experiencing clusters of symptoms as well. So these these symptoms... So for example, I've had patients referred to speech and language therapy with laryngeal symptoms, which is obviously what we're sort of focusing more more on today. So they've got that sensation of lump in the throat, voice changes, but they've also got muscle pains in their legs, chronic fatigue, they're just really struggling. And like you said, the tingling, the dizziness. There's, there's not I mean, we're all learning, everybody is learning about this situation, this new diagnosis of Long COVID. And as you said, dizziness, blood pressure, maybe people aren't eating and drinking enough for other reasons linked to the Long COVID. But there's also other things to consider, such as them being too hot, they might be experiencing anxiety, or heart rate changes as well. So we've got to look at the people as a whole and to see what's actually going on for them. And I think sometimes the multi you know, go going to seek help from many professionals can possibly be the best way forward.

Announcer: 1:43

This is a voice, a podcast with Dr. Gillyanne, Kayes and Jeremy Fisher.

Jeremy : 1:53

Hello, and welcome to This Is A Voice Series three, Episode Six. And this one is on Long COVID. And we have a very special guest with us today.

Gillyanne Kayes: 2:02

Welcome Carrie Garrett, specialist speech and language therapist, voice rehab specialist, singer and singing teacher. We are so thrilled to have you here talking with us about Long COVID Because you know how important that is to the singing and the voice community?

Carrie: 2:22

Absolutely. Hello, thank you so much for having me here. It's really lovely to be here. I've come to learn as much as to share what I've been experiencing as well in my work as a speech and language therapist.

Jeremy : 2:33

Excellent. And we have so many questions that people have asked, and we've got some that we have recordings of they've sent in on speakpipe.com/vocalprocess. And there's some that we have people have sent in on Facebook, they've emailed us. So there's a lot of things going on.

Gillyanne Kayes: 2:46

And we put this together really because you know you've done a lovely pop up workshop for us called My Singer Has A Voice Problem, which is in our Learning Lounge now. But we knew that you know, when we recorded that we didn't know enough yet about the impact of Long COVID. And thank you, Carrie, because it was your idea saying, look, what why don't we have a Q&A and that you would frame your evidence based info such as we have, you know, at the moment around those questions so that we could really dig deep into it, because we're going to be dealing with this for possibly years, aren't we in terms of impact?

Unknown: 3:28

Yeah, and I think also one of the important things to say is that it's actually raised some important health sort of aspects about things like chronic fatigue as well, and people who are experiencing chronic lung and respiratory problems as well already before COVID They were experiencing these problems. And actually the fact that COVID and Long COVID has now come into existence. I think it's raising the awareness across the board with voice professionals as to what can we do to help help these people who are experiencing these these chronic conditions? Hopefully Long COVID isn't going to be permanently chronic, as the evidence says there are there is reassuring evidence that symptoms improve over time. I want to get that in at the front. Because I think if anybody's listening to this, and actually has been experiencing ongoing symptoms, they need some reassurance that things will get better. It's just being patient and kind to themselves as well, and hopefully finding some good support from voice practitioners.

Gillyanne Kayes: 4:27

Thank you. It this seems to me a wonderful moment to play that poem from Michael Rosen because really what's happened with COVID is at the work of the speech therapist in the sort of the rehab phase, once people are out and they're off the respirators and then they're moving around and going back into the community. I think it's really brought to public notice what a speech and language therapist actually does and how important it is. Yes, Michael tells it very well.

Michael Rosen: 5:00

Fiona, the voice therapist looks out of her zoom screen and says that she can see that I'm not using my diaphragm. I say that it feels as if my voice is reedy. She's going to give me semi occluded vocal tract voice therapy. She gets me to trill my lips, sing through my teeth, hum raspberries and talk into my hand. I offer Frere Jacques, Twinkle Twinkle Little Star and Three Blind Mice, as my exercise pieces. I have to slow the notes. "Glide up and down the scales", says Fiona. She says that I should do this before I go on the radio or do a show for children. There's good empirical evidence she says to show that semi occluded vocal tract therapy works. Later, I sit in the loo and hum raspberries and sing Three Blind Mice into my hand.

Jeremy : 6:01

That's clearly working with Michael.

Gillyanne Kayes: 6:03

Absolutely. And isn't it interesting that he has been given had been given exercises that singers do?

Unknown: 6:11

Yes, absolutely. I think that was one of the things I noticed transitioning from being a singing teacher into qualifying as a speech and language therapist. When I started working with patients with the voice that very much is a crossover - voice is voice. And as my mentor said, There is nothing new under the sun. It's just applying the right thing for the right time and the right person, isn't it.

Jeremy : 6:36

So I want to go straight to Franka. Franka sent in three questions for us. I want to get to her first one because it's so relevant to what you've just said. So let's hear what Franka has to ask.

Franka: 6:47

Hello, Jeremy and Gillyanne, here are some questions for the podcast on Long COVID. My first question is, what exactly is the difference between Long COVID and for instance, COPD and asthma in terms of what is happening to the lungs? And and also, of course, following from that in in the way it should be treated?

Carrie: 7:13

Oh Thank you Franka, that's a great question. I will reinforce I'm not a respiratory specialist, but I will endeavour to answer in my best term capacity, my best knowledge. The British Lung Foundation has some really good practical resources and guidance on this. But in my limited understanding the way we can differentiate between Long COVID and more chronic conditions such as COPD or asthma is that specialist respiratory teams and specialists would have assessed and concluded that there's no alternative cause for the symptoms the individual is experiencing. Usually Long COVID. So Long COVID can be symptoms that being experienced ongoing symptomatic symptoms that are being experienced four to 12 weeks after actually having a confirmed or suspected case of COVID. But actually the post COVID syndrome, so the really long term Long COVID is symptoms that exist 12 weeks following that. And actually, it's the 12 weeks post COVID where if they're still experiencing those respiratory problems, which are new, following having experienced COVID then they should get some assessment. Absolutely, if not before, and what we're finding is that actually people are getting normal imaging. And we have to remember that people don't just get COVID in isolation quite often people in the population have existing comorbidities such as asthma and COPD, bronchiectasis, you know, but essentially COVID acts, is a viral pneumonitis and it affects the lung tissues. Just like the other lung impairments do, it causes inflammation. There's scarring, buildup of fluids you know, and and I think the symptoms present themselves in a very similar way. It's dry cough, breathlessness, shortness of breath, people as a result of this get very weak and tired, generally feeling unwell, people might have a loss of appetite that you know, from from their tiredness and just finding it difficult to coordinate breathing and eating. Some people might experience chest pain, which could possibly be muscular or it could be an inflammation of what we call the pleura, the lining between the lung and the ribcage. So when they breathe in and out, it's very painful, and they might experience a high temperature as well. So symptoms are different between everyone. Asthma specifically because I think a lot of people, when we're teaching singing, we work with people with asthma on a very regular basis. Asthma is essentially inflammation and swelling of the airways, and a narrowing of the airways. So breathing becomes very difficult. And that that that breathing is, you know, it's aggravated as well by excess mucus secretions during the asthma event, resulting in wheezing and breathlessness and it can be very difficult. So they take different sorts of medication to try and help with that. Like I said, I'm not an expert, but I know that treatments because you asked specifically about treatments how the way it should be treated. For general lung impairments, you've got everything from antibiotics, although viral pneumonias tend to get better on their own. You've got corticosteroids which cause the immune system to slow down which lessens the amount of inflammation, you've got inhaled oxygen. And I know that Jeremy and Gillyanne, talked in previous podcasts about nasal breathing, and the increase in oxygen that that actually promotes into the, you know, the breathing system, and the body over and above open mouth breathing. So nasal breathing allows more oxygen to be absorbed. And it helps to retrain the breathing mechanism. That's something that singing teachers can be a part of. Going back to medicines, you got bronchodilators. And obviously, the way that some of these medications can be administered, is using nebulizers, which is also something else that singing teachers are familiar with, or some singing teachers. And they help by sort of managing the mucus buildup with thinning out mucus. Powerful, there are some powerful antioxidants, which also may help lung function. But I must stress that not everything is for everyone. And I think in our capacity as singing teachers and Speech and Language Therapists. If we're not an expert, and I hold my hands up, I absolutely am not an expert in respiratory matters. But these conditions are very different to each other. And everybody is different, like I said, so each person will require a personalised structured approach to treatment which is guided by specialists in their field. And I will reinforce that not everyone tolerates things like the nebulizers and the saline hypertonic saline solutions that are used in those and respiratory teams are best place for testing for this as well.

Jeremy : 12:34

It sounds like the one of the main things that just as laymen we look out for is a sudden appearance or an appearance following a COVID diagnosis. So that the the symptoms because this is almost similar

Gillyanne Kayes: 12:46

different behaviour. So a different sense of functioning. I mean, obviously Franka has talked about lung function and a number of people from our community when we said what are you finding? Lung capacity diminished, breathlessness. Tingling, which would also be a result of maybe having lower oxygen levels?

Carrie: 13:07

Yeah, absolutely.

Gillyanne Kayes: 13:08

And the other thing you talked about is fatigue, because, obviously, we use oxygen to create glucose in the body. And if that isn't happening as efficiently as normal, we're going to experience fatigue, aren't we?

Carrie: 13:22

Yes. Yeah, absolutely. I mean, they're there. They're, like I said, the Long COVID diagnosis of Long COVID is usually symptoms are not explained or attribute attributable, oh, put my teeth back in, attributable to other diagnoses. I mean, that there have been over 200 symptoms documented, then they go across respiratory problems, cardiovascular problems, neurological, gastrointestinal, psychological symptoms, you know, and people are experiencing clusters of symptoms as well. So these these symptoms, so for example, I've had patients referred to speech and language therapy with laryngeal symptoms, which is obviously what we're sort of focusing more more on today. So they've got that sensation of lump in the throat voice changes, but they've also got muscle pains in their legs, chronic fatigue, they're just really struggling. And like you said, the tingling, the dizziness. There's, there's not I mean, we're all learning everybody is learning about this situation, this new diagnosis of Long COVID. And as you said, dizziness, blood pressure, maybe people aren't eating and drinking enough for other reasons linked to the Long COVID. But there's also other things to consider, such as them being too hot, they might be experiencing anxiety, or heart rate changes as well. So we've got to look at the people as a whole and to see what's actually going on for them. And I think sometimes the multi you know, go going to seek help from many professionals can possibly be the best way forward.

Gillyanne Kayes: 14:58

That's great. Yes. And speaking personally, I know that tingling can be related to anxiety. And it's noted as that. So it doesn't necessarily mean there's anything else wrong. Carrie wants to pick up on one thing which surprised me, which is just correct me if I've misunderstood. Long COVID is less long than post COVID syndrome. A longer timeline is weird. Is that right?

Carrie: 15:26

No, no. So Long COVID is an umbrella term, I would I would probably call it. It's one of those terms which is being used and has had been used. When when COVID struck the UK, we started to have people who had ongoing symptoms that presented beyond four weeks of them. So I'm talking about people who aren't hospitalised here, let's put it into community context, people who have - contract COVID and manage the symptoms at home. So they've not had any sort of intubation or anything more severe than extra ventilation or anything. They, the Long COVID term can be used, anybody who's experiencing those prolonged symptoms from four to 12 weeks. So lots of people in the literature in research are calling that Long COVID. And now the medic, the health care professions, so the NHS is starting to call 12 weeks and beyond. So if you're experiencing symptoms that exist 12 or more weeks following, experiencing a confirmed or suspected case of COVID-19 that is being termed post COVID syndrome. So it's now the that is the term which is being used for people who can access health care, extra healthcare support as well from the NHS. So for example, in the trust which I work in the Herefordshire, Herefordshire and Worcestershire Health and Care NHS Trust, we have had a post COVID syndrome service that's has set up from October, late October this year, many, many, many months since people have been experiencing this. If you think the first people who experienced COVID were sort of February, March time in 2020, and are still experiencing symptoms, then they very much fall into post COVID syndrome.

Gillyanne Kayes: 17:20

So in the UK, there is a system where you can go for help. That is NHS based if it's within your trust, or

Carrie: 17:31

yes, yeah, absolutely. And I think it's really important if you are listening to this podcast, and you're thinking that you or anyone you love or anyone you're working with, is continuing to experience symptoms, which have no other they're not explained by anything else. And you know, even some people might be feeling like they're not being believed, because symptoms can relapse and remit. So they, they're there on one week, and then they you're totally fine the next week. You know, it's really hard to pin down whether somebody has Long COVID Or even post COVID syndrome. So yeah, it's really important to find... speak to your GP, find out if you are concerned find out what services exist in your local area. There is there are some brilliant national resources, there is a fantastic Your COVID Recovery NHS site, which is www.yourCOVIDrecovery.nhs.uk which anybody can access and it takes you through all the symptoms and provides reassurances and signposts people to where they might be able to find further resources.

Jeremy : 18:40

And we'll put that in the show notes.

Carrie: 18:42

That's brilliant.

Jeremy : 18:44

You've actually I think, hopefully this is answered Rachel Lines's a question. Rachel is at SingSpace.

Gillyanne Kayes: 18:52

Am I going to be talking to Rachel, aren't we in January, we are doing a q&a for her community. So

Jeremy : 18:58

She said "I'm pretty ignorant here. So we'd like to understand a breakdown of effects from long COVID". I think you've probably covered that, "to understand the components. So we're not trying to tackle an overwhelming beast", which is a fair point."And when as vocal coaches we know when to step back and refer on and when singing can help." And actually, that goes with Franka's second question as well. So I'm just going to play Franka's second question.

Franka: 19:23

The second question is, what specific exercises can I as a singing teacher give to somebody who's suffering from Long COVID? I've heard some things about, like, easy, ballad nursery kind of songs that don't ask or demand too much from a body that's recovering from COVID. But I can imagine that there were a lot is that there was a lot more to say about that.

Carrie: 19:59

Oh, thank you. began yet great question. I think the easy ballad kind of nursery songs are being used by the English National Opera in their ENO breath programme. They have a breathing and well being programme for people recovering from the effects of COVID-19, which is a free online programme focusing upon retraining breathing through singing. And it focuses upon reducing breathlessness and anxiety through developing self management skills of the individual. So you don't have to ever have some before you don't have to be a singer. But it's obviously helps to develop those skills again, following COVID. I think in terms of what what can singing teachers do, absolutely warm ups. SOVT, you know, managing the sessions according to how the individual is on that particular day, being responsive to the individual's needs is absolutely paramount, encouraging providing a safe space in your lessons and sessions to encourage them to share how they're feeling. Because like I said, these symptoms are relapsing and remitting, they're there, sometimes they change, then they don't stay the same, they are completely baffling. But we, I think in our role as singing teachers, speech and language therapist, voice practitioners, we can respond by being supportive regarding their symptoms, and how their symptoms are affecting what it is they're trying to do.

Gillyanne Kayes: 21:35

So Carrie, if somebody were to come for a singing lesson, you know, once a week, on week three, it's worse than it was in weeks one and two, as far as the, you know, the student is concerned, what you need to do is work exactly with where the client is, at that moment, you know, if they're having a bad day, you work from that point of view, which actually what we should all be doing all the time anyway. But I think it's, it's even more so.

Carrie: 22:06

Absolutely. And I think one of the things to appreciate is that they, they, the student themselves may not in that session be seeking to progress, they may just be there to participate and be in a moment in time, which is providing some relief from just the symptoms they've been experiencing the illness, the, the you know, we all go we do singing for other reasons than just to get better technically, you know, there's so much more involved in that. It's a welcome relief from the pressures of life. You know, when people join a choir or do individual lessons, it's a bit of a social life as well, isn't it so

Jeremy : 22:44

That's so important, knowing what you're saying is so important, because actually, it also defines the role of the singing teacher, which is you are not always there to make people better. You are sometimes there just to hold the space so that they can experience.

Gillyanne Kayes: 22:56

And also, I mean, actually, thank you so much for saying that because, you know, we know about the wider therapeutic benefits of singing. And there are millions of singers out there who are avocational singers. And actually, they do want to do their best within the context of what they're working on. But it's to understand that our role is actually much more than being technicians, and even performance coaches. I mean, you know, we do cover that role, but many, many singing teachers are working with avocational singers and supporting them, many choir leaders are doing that.

Carrie: 23:33

Absolutely, I mean, I think Franka asks, ask a great question in terms of what should I be doing? But to be honest, my honest answer is nothing more than you would normally be doing. You may find that with people that you've been training and working with for long periods of time, so you know them, they may not be at the standard that they all you expect them to be. So it may be just, again, being kind to them, them being kind to themselves, providing those reassurances that this is okay, normalise their experiences, and manage, you know, in terms of direct exercises and technique that you can do with them. Same as ever. If you're doing managing unhelpful muscle tension by doing stretches and a decent warm up and things like that, that's great, that's going to do them some good if they say it's painful, or it's not doing them any favours, then move on. It's following what they want. You may find that the anything you do to retrain their breathing to reduce breathlessness and restore diaphragmatic function and increase their lung capacity again, back to their baseline as as you had previously known them would be really beneficial. And obviously, you've got all the usual vocal exercises, which you would use to rehabilitate what would normally you'd be habilitating the voice wouldn't you know in your singing teacher vocal coach role, habilitating the voice to develop and progress a voice. But actually, it may be that you've stepped into a rehabilitation role just for a short period of time while they're recovering from Long COVID and the symptoms of Long COVID. And so you're rehabilitating, range, tone, stamina, flexibility, and general coordination of the whole vocal mechanism. The warm ups are really important. SOVT, really important,

Jeremy : 25:29

We're going to go into SOVT in more depth in a moment, I just want to, I want to pick up one point, which is if you already have a student or client that you work with, and they come to you having gone through COVID, and being in Long COVID situations or post COVID situations, you already know how their voices are, you already have a memory of what standard they are, how they normally deal with things. And so you will be noticing that things aren't working in the same way. And I think it's really important for you not to think that you can get them back up to that original point immediately.

Gillyanne Kayes: 26:05

It's about adapting, isn't it? It's, you know, this reminds me of going to a yoga class. And you know, she asks every class, if anything is going on for you, you've got any aches and pains, let me know. So that you adapt so that if you don't feel like you can bend forward all the way down to the floor, you adapt with a chair.

Carrie: 26:28

Absolutely, yes, we're human beings, we have so many things. I mean, as a voice therapist, we already know that looking at a voice is multifactorial, it's holistic, we have to look at everything. It's the it's the biology, it's pathology, it's, you know, it's the psychological situation that that person is in on that day. It's their environmental situation, their social context, what do they use their voice for? There is so much more involved in working with a person. I think another thing that singing teachers can really help with is the general just revising general education on voice production, for reassurance and voice care, because I think a lot of the time people go through COVID. And don't really recognise that actually, they aren't as energetic as they have been. They aren't sort of as vocally clean if that's a term. You know, they may have a persistent cough or dry cough, they may be feeling like they've got more phlegm. That's, that's, you know, hanging around and things and, and that's different from before. So all that usual stuff of educational voice production and voice care is really important as well.

Gillyanne Kayes: 27:49

That's lovely. Thank you. Should we talk SOVT?

Jeremy : 27:52

Just before we do, I just want to make this one question that Georgia Elizabeth Welton has made also from SingSpace. "Awesome topic. I have a question. How should we address students differently suffering with Long COVID?" We sort of covering that at the moment?

Carrie: 28:08

Yeah, absolutely. chat with them. Absolutely chat with them structure that. I mean, as a speech and language therapist, I very much we very much have sort of structure to our medical case history taking. So we really get in depth view on what's going on for that person. I think as singing teachers, you have this wonderful, unique perspective, where you are involved in part of their life. I mean, I always say singing teaching is part coaching and mentoring as well. You got wider issues in the context of music and singing, if not their actual, wider life as well. You, you know, people share because it's a safe space in singings. People share information about their emotions and what they've been experiencing. And I think providing reassurances about what they're experiencing and discussing what they can expect from themselves moving forwards, and being kind to themselves is is really important. And like you said, hopefully today's chat will have provided that rounder picture of what the symptoms are, and things that we might be able to expect. I want to say just the singing teacher side of things, I think, really important and not to be undervalued is actually providing those opportunities for singing. Because if if you use it or you lose it as ever with voice that is that is always an underlying thing. With voice care and voice work. You've got to be able to use it and I think when people went into lockdown, we weren't interacting as frequently. We weren't singing, absolutely we weren't singing as frequently unless you're highly motivated and had a space within your home to actually sing in, many, many people didn't sing because they had family members. They had people, homeschooling they had people trying to work from home. And those opportunities for singing, were very much diminished. And so now we've opened up providing opportunities as a singing teacher is really important, discussing career plans, discussing auditions, rehearsals, the work pressures that people might have outside of singing, and also singing work pressures, if they are professional singers, and voice users. You know, we've got a lot we can contribute song selection, advice about musical decisions, and obviously technique as well.

Gillyanne Kayes: 30:38

I love that. And the way you've spoken about that, and I think it's absolutely true that, you know, particularly what might have happened to people who are working more on a professional level is, just as you said, they hadn't been able to maybe even practice for months, because of disturbing other people in the household or the neighbours or whatever. And then suddenly, they go into a performance situation. And it's a bit like, Well, I haven't been training in the gym, and now I've got to run a marathon. Yeah. And it's very, very easy to get into difficulties there. Yeah, I just wanted to share one thing, which might be a helpful example for Georgia's question, which is, how do we address the students - Carrie you've talked about listening. Maybe a student comes in one day, and says, Actually, I can't seem to get through my phrases this week. I don't don't know what it is. You know, my breath doesn't last as long. That's a signal for you. When you do your warm up exercises. You do short ones, you take a breath between each note, you do one note and repeat it three times. And you allow time for space for the in breath. These are the kinds of things that we do we listen, we adapt. Yes, Jeremy, you have a point to make

Jeremy : 31:56

We're going to just take a little moment because we are sponsored for this and we're going to play a little advert from our sponsor. Oh

Announcer: 32:04

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Jeremy : 32:36

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Gillyanne Kayes: 32:44

Excellent. Where shall we go next?

Jeremy : 32:47

We're going to hold it there. There is so much coming up that we're going to split this podcast into two so we'll see you next time for Series three Episode seven. Long COVID continued This Is A Voice, a podcast with Dr. Gillyanne Kayes and Jeremy Fisher.