Title: Pelvic floor status in opera singers. A pilot study using transperineal ultrasound
Version: 1 Date: 08 Nov 2023
Reviewer:  Ketaki Vasant Phadke
Reviewer's report:
Pelvic floor status in opera singers. A pilot study using transperineal ultrasound
Summary and general comments: The authors aim at investigating whether the Transperineal
Ultrasound technique can be used to assess the functioning of pelvic floor muscles during singing
among opera singers and its influence on their breathing patterns while singing. This study
holds great interest and adds valuable insights to the field of singing, providing singers with
the opportunity to enhance their vocal abilities while gaining better control over their body and
muscle functions for more effective singing.
I kindly request the authors to take into consideration the following inquiries and make any
necessary additions, deletions, or modifications to their manuscript. This will contribute to
a clearer understanding and the overall improvement of the information presented in the
document.
Background: I request the authors to elaborate more on the first point and give us the significance
of controlling pelvic floor muscles (PFM) in relation to breath support in opera singing and its
relation to improvement in vocal performances?
Method:
1. It would be better if the method is split between subheading (Participants, inclusion exclusion
criteria, ethical approval, procedure etc.) rather than connected paragraphs for enhanced
readability.
2. Please mention the age range information in the method section not in results section.
3. Can natural or c-section delivery have an effect on PFM anatomic positioning? Can this further
affect its functioning?
4. In the sentence “supine position with hips and knees semi-flexed”, is there any significance to
this? Could there be any differences with anatomical positions with flexion? Can flexion cause
any muscle contraction at the target.
5. Please elaborate this in brackets “Valsalva maneouvre”. Not everyone will be aware.
6. Please mention the reason for 6 months gap between administration and data analysis, since
both are done by the same author. It would have been better if the analysis was done by same
and one another for reliability on measurements. Is this still possible?
7. “Previously validated ultrasound contraction scale” Please mention reference. Is it same as
reference 14?
8. Statistics: Was there homogeneity of variance in the paired observations for all four conditions
(rest, contraction, upright standing, and singing)?
Discussion: The authors present their findings regarding the ten classical singers, comparing
different conditions, including rest and singing positions. To assess the percentage of contraction
in various areas, they utilized a previously validated ultrasound contraction scale.
1. Could the authors clarify whether this contraction scale has been validated on both non-singers
and singers? It would be valuable for the authors to consider conducting transperineal ultrasound
assessments on a group of ten non-singers and individuals without formal vocal training to
determine whether similar contractions are observed in this population. This information is
of significant importance as it may yield diverse interpretations concerning the relationship
between effective breathing patterns and vocal performance. Would the authors consider
including this additional investigation in their study?
2. Could you explain the significance of the changes in hiatal area and AP diameter, and what
the implications of these changes are for the singers' pelvic floor muscle function?
3. What do the findings of the two parous women with unilateral levator avulsion reveal about the
impact of this condition on pelvic floor muscle function in comparison to the other participants?
4. Can you discuss the potential reasons behind the non-significant descent of the bladder neck
during singing and how it might relate to pelvic floor muscle function?
5. What is the clinical significance of the proportional change in levator hiatal AP diameter from
rest to contraction? How might this information be useful in a clinical context?
6. Can you provide more context for the observed differences in contraction between parous and
nulliparous women in the supine position and during singing?
7. How do you interpret the moderate positive correlation between BMI and the proportional
change in levator hiatal AP diameter from rest to contraction? What are the potential implications
of this correlation?
8. This last question is just a thought:
Did the authors make an effort to inquire about participants' post-study awareness of any
sensations or changes in the lower waist and pelvic floor region? Additionally, did they explore
whether participants had adopted specific techniques or strategies to enhance their singing
control in relation to these sensations?
Significance: This question is vital for understanding the extent to which the study participants
were conscious of physiological changes in their lower waist and pelvic floor areas and how
these changes might have influenced their singing techniques. It sheds light on the potential
connections between bodily awareness and singing performance strategies, providing insights
into the interplay of physical sensations and vocal control.