Sing Your Lungs Out: a qualitative study of a community singing group for people with chronic obstructive pulmonary disease (COPD)

Long-term self-reported attendance in exercise training or lung choir and status of quality of life following initial pulmonary rehabilitation for COPD

Background

Both adherence rates to pulmonary rehabilitation (PR) programmes and long-term attendance in exercise training after PR remain a challenge. In our previous randomised controlled trial (RCT), effects were positively associated with a dose-response pattern, regardless of whether PR contained conventional physical exercise training (PExT) or Singing for Lung Health (SLH) as a training modality within a 10 weeks' PR programme for chronic obstructive pulmonary disease (COPD). However, long-term status of this RCT cohort remains unknown. In this study, we investigated whether current status (=attendance in supervised exercise training or a lung choir and scoring in quality of life (QoL)) was related to initial PR completion, randomisation, or adherence.

Methods

We collected data via telephone, using a researcher-developed questionnaire on current self-reported attendance in supervised exercise training or a lung choir and on perceived benefits of the initial RCT intervention. Additionally, we used COPD-validated questionnaires (primarily: QoL (measure: St George's Respiratory Questionnaire; SGRQ).

Results

In 2023 (i.e., mean/median 4.7 years after initial PR), surviving participants were contacted (n = 196; 73% of 270), and 160 (82% of 196) were included. Out of the included participants, 30 (19%) had not completed initial PR. Compared to the initial PR-completers, non-completers reported less current attendance in exercise training or lung choir (24% vs. 46%, p = 0.03) but SGRQ scores were comparable. Yet, those who attended exercise training or lung choir at present (n = 66/160; 41% out of 160) reported better QoL score than those with no current attendance (SGRQ; Attending: 39.9 ± 15.4; Not attending: 43.1 ± 16.7; p = 0.02). Neither having had SLH instead of PExT, nor adherence level during initial PR, was related to current attendance or to QoL scores.

Conclusion

This study indicates that long-term self-reported attendance and current QoL scores are positively related to initial completion of a PR programme. Surprisingly, neither initial PR content (PExT or SLH) nor initial PR adherence was related to long-term outcomes. We suggest that future PR programmes include special attention to those who do not complete PR to support long-term attendance and QoL status.

Prevention of Re-Hospitalization for Acute Exacerbations: Perspectives of People with Chronic Obstructive Pulmonary Disease: A Qualitative Study

Purpose

Current guidelines for prevention of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) reflect clinical understanding of the causes of exacerbations but with a limited recognition of person-specific contributing factors. As part of a randomized trial of a person-centered intervention aiming to promote self-determination, we describe personal perspectives of those with chronic obstructive pulmonary disease (COPD) on what they saw as the causes and best ways to stay well and prevent rehospitalization after an AECOPD.

Patients and Methods

Twelve participants (mean age 69.3 years, six female, six male; eight New Zealand European, two Māori, one Pacific, and one other) were interviewed about their experiences of staying well and out of hospital. Data were collected via individual semi-structured interviews one year following an index hospital admission for AECOPD and focused on the participants' views and experiences of their health condition, their beliefs about staying well, and the causes of and factors preventing further exacerbations and hospitalizations. Data were analyzed using constructivist grounded theory methods.

Results

Three main themes were identified that described participants' views on what helped or hindered them to stay well and out of hospital: 1) Being Positive: The importance of having a positive mindset; 2) Being Proactive: Practical steps to reduce the risk of, and consequences from, episodes of AECOPD; and 3) Being in Control: Feeling in command of one's life and health. Each of these was affected by Being Connected: The influence of significant others, particularly close family.

Conclusion

This research expands our understanding of how patients manage COPD and adds patient perspectives to current knowledge on how to prevent recurrent AECOPD. Programs which promote self-efficacy and positivity would be beneficial additions to AECOPD prevention strategies, as could the inclusion of family or significant others in wellbeing plans.

Singing Interventions in Pulmonary Rehabilitation: A Scoping Review

(1) Background: Individuals with pulmonary disease need intensive and consistent rehabilitation due to their high risk for serious illness and long-term complications. The purpose of this scoping review was to provide a comprehensive analysis of relevant research regarding the use of singing in pulmonary rehabilitation. (2) Methods: A systematic literature search was performed using the PsycINFO, CINAHL, PubMed, and Web of Science databases. A search for studies that employed singing in pulmonary rehabilitation for patients with pulmonary disease was conducted. (3) Results: Studies that met the selection criteria were summarized and analyzed. Twenty-seven studies were included in the final analysis. Results showed that research using singing in pulmonary rehabilitation generally employed an intervention with structured tasks and additional home practice or socialization time. However, the singing procedure in each intervention was not always specifically described and the findings were inconsistent. (4) Conclusions: Programmed singing interventions can support lung health and be an effective component of pulmonary rehabilitation. The therapeutic singing method in relation to respiratory exercises should be integrated into the main activity in the intervention. Overall, singing has physical and psychosocial effects, leading to improvements in symptoms, but more research is necessary to ensure that the respiratory needs of people with pulmonary disease are adequately met.

Singing for People with Advance Chronic Respiratory Diseases: A Qualitative Meta-Synthesis

Rationale: Although there remains insufficient evidence regarding singing programs as effective strategies for achieving clinically significant health outcomes, this non-pharmacological intervention appears to be subjectively low-risk and well-tolerated by people with advanced chronic respiratory diseases (CRD). Objective: This study sought to examine and synthesize the current qualitative evidence regarding the experiences of participating in singing for breathing programs by people with advanced CRD. Methods: A meta-synthesis of qualitative data was conducted. Electronic databases (Medline, CINAHL, PsycINFO, and EMBASE) were searched for published qualitative studies reporting the effects of singing programs for adults with advanced CRD and their carers. Primary qualitative data were extracted and analysed, which generated descriptive and analytical themes. Results: Themes identified from seven included studies were: anticipation and reluctance to participate; physical and psychological benefits; new sense of purpose and enjoyment; social connection and achievement; and broad views regarding program structure and content. The themes highlighted changing perspectives before, during and after engaging in the singing program, as participants transitioned from initial anxiety to mastery of their chronic condition as the singing program progressed. Participants, however, raised concerns regarding several singing technicalities, the lack of ongoing support after the singing programs’ conclusion and the social impacts of transitioning the sessions online during the COVID-19 pandemic. Conclusions: This meta-synthesis highlights the positive experiences of people with CRD who participate in singing for breathing programs. Further research, including longitudinal qualitative studies, can provide insight into the acceptability and feasibility of singing programs and inform the broader implementation of the intervention.

SINFONIA study protocol: a phase II/III randomised controlled trial examining benefits of guided online group singing in people with chronic obstructive pulmonary disease and interstitial lung disease and their carers

Background

Chronic obstructive pulmonary disease (COPD) and interstital lung disease (ILD) are incurable conditions characterised by airflow limitation, persisting respiratory symptoms, and progressive respiratory failure. People living with COPD or ILD often suffer from chronic and severe breathlessness, with limited treatment options and low engagement rates with current therapies. Group singing represents a potential community-based therapy to improve quality of life for patients with COPD or ILD and breathlessness.

Methods

This protocol papers describes SINFONIA, a parallel, double-arm, randomised, blinded-analysis, mixed-methods phase II/III trial of guided, online group singing that will be conducted over 24 months. Adults with confirmed COPD or ILD, on stable treatment for at least four weeks at time of recruitment, with a modified Medical Research Council (mMRC) dyspnoea score of two or greater, who are capable and willing to give consent, and not currently participating in pulmonary rehabilitation will be eligible to participate. Carers may optionally enrol in the trial. Data will be collected on quality of life, anxiety and depression, breathlessness, mastery of breathing, exercise tolerance, loneliness, healthcare utilisation, and carer quality of life (optional). Participants will be randomised 1:1 to intervention or control arms with intervention arm attending one 90 min, guided, online, group singing session per week for 12 weeks and control arm continuing routine care. Phase II of the trial aims to determine the feasibility and acceptability of guided, online group singing and will collect preliminary data on effectiveness. Phase III aims to determine whether guided, online group singing has an effect on quality of life with the primary outcome being a between arm difference in quality of life (36-item Short Form Survey) measured at 12 weeks.

Discussion

SINFONIA is the first study is the first of its kind in Australia and to our knowledge, the first to deliver the singing intervention program entirely online. Determining the feasibility, acceptability, and effectiveness of guided, online group singing is an important step towards improving low-cost, low-risk, community-based therapeutic options for patients living with COPD or ILD and breathlessness.

Trial registration: Phase II—ACTRN12621001274864, registered 20th September 2021; Phase III—ACTRN12621001280897, registered 22nd September 2021.

Playing the harmonica with chronic obstructive pulmonary disease. A qualitative study

Objectives: To investigate the experience of playing the harmonica for individuals with COPD.

Methods: A qualitative, phenomenological study using semi-structured interviews and reflexive thematic analysis.

Results: Eight people living with COPD (six females, two males) were recruited, who had attended at least six weeks of harmonica group sessions, either face-to-face prior to the COVID-19 pandemic or remotely. Five themes were generated. Themes included ‘hard in the beginning’, ‘holding the condition’, ‘breathing control’, ‘gives you a high’ and ‘needing the Zoom class’.

Discussion: Playing the harmonica with COPD is difficult at first, particularly drawing a breath through the harmonica. With practice, experience in a fun activity and quality teaching, individuals were able to become more attuned and embodied with their breathing, and playing the harmonica offered a breathing control strategy. Songs, rather than breathing, became the focus, and participants were able to escape living with respiratory disease when playing. Participants reported the harmonica helped mucous expectoration. The group was a priority in the weekly lives of participants, even though the ‘buzz’ of being part of a group was lost when participating online. Further mechanistic studies and randomised controlled trials are needed to investigate the biopsychosocial benefits of playing the harmonica with COPD.

"It's Not the Same": A Comparison of the Psychological Needs Satisfied by Musical Group Activities in Face to Face and Virtual Modes

According to the social identity approach to health, group memberships influence people’s mental health to the extent that they identify with their group. Emerging evidence suggests that music groups, such as choirs, enhance mental health via group identification and the satisfaction of various psychological needs; however, more research is required to understand these processes in other types of music groups. Furthermore, the coronavirus disease 2019 (COVID-19) social distancing restrictions in 2020 prevented music groups from meeting face to face (F2F). Some music groups adapted virtually, but the rate of adaptation of various music activities is unknown, as is the impact of such adaptations on participants’ group identification, psychological need satisfaction, and mental health. We explored these questions using a cross-sectional survey with 257 participants (M_age = 46 years, 78% female) of singing (n = 172), instrumental (n = 48), and dance groups (n = 37). Participants rated group identification and psychological needs satisfaction retrospectively for their music group in F2F mode and then for the group in adapted mode, along with mental health 12-item short form health survey (SF-12). Results showed that instrumental groups (60%) were less commonly adapted to virtual mode than singing (83%) and dance (86%) groups. Group identification and average psychological needs satisfaction (M = 4.04 and 3.50 out of 5) scores were significantly lower for groups in virtual mode than in F2F mode (M = 4.53 and 4.14, respectively). Psychological needs satisfaction did not mediate the relationship between group identification and SF-12 mental health. Despite this, values on group identification and psychological need satisfaction remained high, which suggests that virtual music groups may be beneficial during the COVID-19 pandemic and in contexts where F2F groups are less accessible.

The role of social capital in participatory arts for wellbeing: findings from a qualitative systematic review

BACKGROUND

Social capital is often cited as shaping impacts of participatory arts, although the concept has not been systematically mapped in arts, health and wellbeing contexts. In wider health inequalities research, complex, differential, and sometimes negative impacts of social capital have been recognised.

METHODS

This paper maps of social capital concepts in qualitative research as part of the UK What Works for Wellbeing evidence review programme on culture, sport and wellbeing.

RESULTS

Studies often cite positive impacts of bonding and, to a lesser extent, bridging social capital. However, reported challenges suggest the need for a critical approach. Forms of linking social capital, such as reframing and political engagement to address social divisions, are less often cited but may be important in participatory arts and wellbeing.

CONCLUSIONS

Future research should further specify dimensions of social capital as well as their nuanced effects in arts, and wellbeing contexts.

Effectiveness of oral motor respiratory exercise and vocal intonation therapy on respiratory function and vocal quality in patients with spinal cord injury: a randomized controlled trial

Singing, as a method of combining respiratory function exercise and vocal intonation therapy, provides a new direction for respiratory function exercise in patients with spinal cord injury. This randomized controlled trial investigated the effects of oral motor respiratory exercise and vocal intonation therapy on respiratory function and vocal quality in patients with spinal cord injury. Among 31 included patients with spinal cord injury, 18 completed the treatment. These 18 patients were randomly assigned to undergo music therapy (intervention group, 30 min/d, 5 times a week, for a total of 12 weeks; n = 9, 7 males and 2 females; 30.33 ± 11.74 years old) or normal respiratory training (control group, n = 9; 8 males and 1 female; 34.78 ± 11.13 years old). Both patient groups received routine treatment concurrently. Before and at 6 and 12 weeks after intervention, a standard respiratory function test, a voice test, the St. George's Respiratory Questionnaire, and a quality of life questionnaire were administered. The results showed that the inspiratory capacity, forced expiratory volume in 1 second, forced vital capacity, maximal mid-expiratory flow rate, sing-loud pressure level, and sustained note length were significantly increased in the intervention group compared with the control group. The St. George's Respiratory Questionnaire and quality of life results of patients in the intervention group were significantly superior to those in the control group. These findings suggest that oral motor respiratory exercise and vocal intonation therapy, as respiratory training methods in music therapy, are effective and valuable for improving respiratory dysfunction and vocal quality in patients with spinal cord injury. This study was approved by the Ethics Committee of China Rehabilitation Research Center (approval No. 2019-78-1) on May 27, 2019 and was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR1900026922) on October 26, 2019.

'To more than I can be': A phenomenological meta-ethnography of singing groups for people with chronic obstructive pulmonary disease

Anecdotal experience and qualitative accounts suggest that singing groups, classes or choirs specifically for people with COPD (henceforth referred to as COPD-SGs) are effective in improving health. However, this is not reflected in the quantitative evidence. This meta-ethnography deployed phenomenological methods to explore this discrepancy. Analysis identified the phenomena of being together, being uplifted and being involved as central benefits of COPD-SGs. When viewed through the phenomenological lens of body-social as distinct from body-subject and body-object, findings demonstrated that the qualitative effectiveness of COPD-SGs is greatest on a collective basis. Qualitative research into the effectiveness of COPD-SGs offers more favourable results because phenomenological approaches can identify collective benefits that quantitative methods cannot. COPD-SGs should seek to maximise these collective benefits by rediscovering their cultural and artistic heritage within the national and global Arts in Health (AiH) movement, which has long emphasised the radical creative and healing power of group activity.

Heterogeneity in Danish lung choirs and their singing leaders: delivery, approach, and experiences: a survey-based study

OBJECTIVES

Singing is considered a beneficial leisure time intervention for people with respiratory diseases, and lung choirs have gained increasing attention. However, there is no available guideline on preferred methodology, and hence, outcomes, delivery, and benefits are unclear. The present study investigated for the first time ever emerged delivery, approach, and experiences in Danish lung choirs and their singing leaders, hypothesising the array to be heterogeneous, without disease-specific approach, and a challenging field to navigate for the singing leaders.

SETTING

An online survey comprising 25 questions was performed individually, May 2017, in Denmark.

PARTICIPANTS

Current singing leaders of Danish lung choirs, identified by hand searches on the internet. In total, 33 singing leaders in formal and informal settings were identified and 20 (67%) responded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Distribution in content, delivery, and approach; level of disease-specific knowledge and modification; experience of challenges and benefits. Quantitative variables were counted, and an inductive content analysis approach was used for the qualitative study component.

RESULTS

The lung choirs were heterogeneous concerning setting, duration, and content. The approach was traditional without disease-specific content or physical activity. Most singing leaders held various academic degrees in music, but lacked skills in lung diseases. However, they experienced lung choirs as a highly meaningful activity, and reported that participants benefited both musically, psychosocially, and physically. Singing leaders were enthusiastic regarding potentials in the 'arts-and-health' cross-field and experienced an expansion of their role and overall purpose, professionally as well as personally. However, they also experienced insecurity, inadequacy, and isolation, and requested methodological guidelines, formal support, and peer network.

CONCLUSION

Danish lung choirs are led without any disease-specific guideline or methodological approach. Further studies are needed to develop and distribute a preferred methodological approach.

TRIAL REGISTRATION NUMBER

This study is linked to clinical trial number NCT03280355 and was performed prior to data collection and results of the clinical trial.

Dance for people with chronic breathlessness: a transdisciplinary approach to intervention development

Objectives

A transdisciplinary research approach was used to develop a holistic understanding of the physical and psychosocial benefits of dance as an intervention for people living with chronic breathlessness.

Methods

The dance programme was developed in collaboration with British Lung Foundation Breathe Easy members in NE England (Darlington) and London (Haringey). Members of the Darlington group were invited to participate in the programme. An exercise instructor, trained and mentored by a dance facilitator delivered 60–90 min dance classes for 10 consecutive weeks. Exercise capacity, mobility, quadriceps strength, health status, mood and interoceptive awareness were assessed at baseline and after the 10-week programme. Second-to-second heart rate (HR) monitoring was conducted during one of the classes.

Results

Ten individuals were enrolled (n=8 women). Mean (SD) age was 70 (24); Body Mass Index 29.7 (8.1) kg/m²; one participant used oxygen and one a walking aid. Seven completed the dance programme. Improvements in all outcome measures were detected, with the exception of the Multidimensional Assessment of Interoceptive Awareness, which individuals found hard to comprehend. Eight participants wore HR monitors during one dance class and spent on average 43.5 (21.8) min with HR corresponding to at least moderate intensity physical activity (≥64% HRmax). People found the dance classes enjoyable and those with relevant past experiences who are optimistic, committed to staying well and playful readily adopted the programme.

Conclusion

A dance programme bringing both physical and psychosocial benefits for people with chronic breathlessness is acceptable when coproduced and evaluated through a transdisciplinary approach.

How Participatory Music Engagement Supports Mental Well-being: A Meta-Ethnography

Participatory music engagement has the capacity to support well-being. Yet, there is little research that has scrutinized the processes through which music has an effect. In this meta-ethnography [PROSPERO CRD42019130164], we conducted a systematic search of 19 electronic databases and a critical appraisal to identify 46 qualitative studies reporting on participants' subjective views of how participatory music engagement supports their mental well-being. Synthesis of first-order and second-order interpretations using thematic coding resulted in four third-order pathways that account for how participatory music engagement supports mental well-being: managing and expressing emotions, facilitating self-development, providing respite, and facilitating connections. Our interpretation suggests that people benefit from participatory music engagement by engaging with specific and multiple processes that meet their individual needs and circumstances. These findings inform research directions within the field of music and well-being, as well as guiding the development and delivery of future music interventions.

Taking Charge: A Proposed Psychological Intervention to Improve Pulmonary Rehabilitation Outcomes for People with COPD

Pulmonary rehabilitation (PR) is an important, evidence-based treatment that improves outcomes for people with COPD. Individualized exercise programmes aim to improve exercise capacity; self-management education and psychological support are also provided. Translating increased exercise capacity into sustained behavioural change of increased physical activity is difficult. Other unresolved problems with PR programmes include improving uptake, completion, response and sustaining long-term benefit. We offer a different perspective drawn from clinical experience of PR, quantitative and qualitative studies of singing groups for people with COPD, and stroke rehabilitation research that gives psychological factors a more central role in determining outcomes after PR. We discuss Take Charge; a simple but effective psychological intervention promoting self-management--that could be used as part of a PR programme or in situations where PR was declined or unavailable. This may be particularly relevant now when traditional face-to-face group programmes have been disrupted by COVID-19 precautions.

What are the barriers to, and enablers of, working with people with lived experience of mental illness amongst community and voluntary sector organisations? A qualitative study

There is increasing emphasis on psychological and social approaches to managing and treating mental illness, including a growing evidence base on the effectiveness of community-based social interventions including arts and heritage activities, library programmes, volunteering schemes, nature-based activities and community groups. However, there is a gap in understanding of what the barriers to, and enablers of, working with individuals with mental illness might be for the community and voluntary sector. A qualitative approach was used involving focus groups with non-profit organisations delivering social activities within communities across the United Kingdom. Behaviour Change Theory, the COM-B model and the Theoretical Domains Framework, were employed as the theoretical framework, to develop interventions to address the barriers raised. Representatives of the organisations reported being motivated by the mental health needs of others, and by seeing the benefits of participation. Further motivations included expanding inclusion, and economic motivation to ensure sustainability. Strengths identified included offering innovative, responsive services that were distinct from conventional mental health services. Running these services demanded new and potentially challenging skills, such as understanding statutory responsibilities, and being able to train and support staff. Further challenges included maintaining boundaries between their roles as community organisations and clients' mental health needs and avoiding burn-out. Ability to deliver this work was enhanced by support of peer organisations and opportunities to share practice. However, funding was often short term, and complex to obtain, which could destabilise organisations' sustainability. Lack of transparency around the process, differences in language between the community and health sectors, and confusion around commissioning pathways undermined the potential opportunity offered by social prescribing policy. Interventions to address these barriers were identified, including long term funding to support core costs, training on engaging with the commissioning process, around mental health support and safeguarding, and developing mentoring schemes and local co-operatives of organisations for developing partnerships with the health sector.

Recollection of participating in a trial: A qualitative study of patients with severe and very severe chronic obstructive pulmonary disease

BACKGROUND

Despite having similar palliative needs to patients with lung cancer, advanced chronic obstructive pulmonary disease (COPD) patients are less likely to receive palliative care. To evaluate the effect of introducing specialized palliative care with severe to very severe COPD patients, a randomized controlled trial (RCT) was conducted in Switzerland.

AIM

To explore COPD patients' recollection of the trial, their needs and the usefulness of the palliative care interventions.

DESIGN AND SETTING

Qualitative study with advanced COPD patients who participated in a specialized palliative care intervention, conducted in a general hospital.

METHOD

Eighteen patients with severe to very severe COPD were interviewed about their experiences. Interviews were transcribed and thematic content analysis was performed.

RESULTS

Patients had poor recollection of the trial and difficulties understanding the palliative care intervention. No major differences were observed between patients who received the specialized intervention and those who did not. Content analysis emphasized that although they experienced disabling symptoms, participants tended to attribute their limitations to problems other than COPD and some declared that they were not sick. Patients reported restrictions due to oxygen therapy, and the burden of becoming dependent on it. This dependence resulted in intense anxiety, leading participants to focus on the present only. A strong feeling of perceived helplessness emerged from the patients' interviews.

CONCLUSIONS

Our findings suggest that poor recollection and understanding of the palliative care intervention act as barriers to the conduct of clinical trials with severe and very severe COPD patients. Their cognitive difficulties, perception of COPD, functional limitations, overwhelming anxiety, focus on the present and perceived helplessness also seem to hinder the implementation of such care.

Singing for Lung Health: service evaluation of the British Lung Foundation programme

AIMS

Singing for Lung Health (SLH) is a novel intervention for individuals with respiratory disease. Qualitative results suggest benefits to physical, mental and emotional health. Limited data also suggest objective improvements in measures of quality of life with SLH are achievable. It is not known how effective the SLH groups supported by the British Lung Foundation (BLF) in the UK are. The objective was to understand the clinical impact SLH has on individuals with respiratory disease.

METHODS

The BLF conducted a questionnaire survey of singers with respiratory disease from new SLH groups set up in 2016-2017. Questionnaires were administered prior to participants' first session and after 12 weeks of singing. Health-related quality of life, patient activation, anxiety and breathlessness outcomes were included. Healthcare resource utilisation including general practitioner (GP) visits, hospitalisations and frequency of inhaler use were recorded.

RESULTS

A total of 228 singers participated from 26 SLH groups in the UK. Participants were 70.7 (10.1) years old, 156 (68.4%) were female and 114 (47.5%) had chronic obstructive pulmonary disease (COPD). In all, 113 (49.5%) participants provided 12-week data. There were significant improvements in COPD Assessment Test (CAT) score (Mean = -1.4, CI: (-0.25 to -2.48) (  p = .017)). Furthermore, 45% of singers reported reduced GP visits (  p ≤ .001) and 18% reported reduced hospital admissions (  p = .01). However, there were no significant improvements in general quality of life, anxiety, patient activation, breathlessness or inhaler use. Baseline characteristics were not significantly different between people who completed the 12-week evaluation and those who did not.

CONCLUSIONS

This service evaluation found that participants in SLH groups report improvement in respiratory health-related quality of life and a reduction in healthcare utilisation. SLH has potential economic and health benefits. Therefore, to confirm these findings, these endpoints should be evaluated further in large-scale randomised controlled trials (RCTs).

Singing for adults with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Singing is a complex physical activity dependent on the use of the lungs for air supply to regulate airflow and create large lung volumes. In singing, exhalation is active and requires active diaphragm contraction and good posture. Chronic obstructive pulmonary disease (COPD) is a progressive, chronic lung disease characterised by airflow obstruction. Singing is an activity with potential to improve health outcomes in people with COPD.

OBJECTIVES

To determine the effect of singing on health-related quality of life and dyspnoea in people with COPD.

SEARCH METHODS

We identified trials from the Cochrane Airways Specialised Register, ClinicalTrials.gov, the World Health Organization trials portal and PEDro, from their inception to August 2017. We also reviewed reference lists of all primary studies and review articles for additional references.

SELECTION CRITERIA

We included randomised controlled trials in people with stable COPD, in which structured supervised singing training of at least four sessions over four weeks' total duration was performed. The singing could be performed individually or as part of a group (choir) facilitated by a singing leader. Studies were included if they compared: 1) singing versus no intervention (usual care) or another control intervention; or 2) singing plus pulmonary rehabilitation versus pulmonary rehabilitation alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and selected trials for inclusion, extracted outcome data and assessed risk of bias. We contacted authors of trials for missing data. We calculated mean differences (MDs) using a random-effects model. We were only able to analyse data for the comparison of singing versus no intervention or a control group.

MAIN RESULTS

Three studies (a total of 112 participants) were included. All studies randomised participants to a singing group or a control group. The comparison groups included a film workshop, handcraft work, and no intervention. The frequency of the singing intervention in the studies ranged from 1 to 2 times a week over a 6 to 24 week period. The duration of each singing session was 60 minutes.All studies included participants diagnosed with COPD with a mean age ranging from 67 to 72 years and a mean forced expiratory volume in one second (FEV₁) ranging from 37% to 64% of predicted values. The sample size of included studies was small (33 to 43 participants) and overall study quality was low to very low. Blinding of personnel and participants was not possible due to the physical nature of the intervention, and selection and reporting bias was present in two studies.For the primary outcome of health-related quality of life, there was no statistically significant improvement in the St George's Respiratory Questionnaire total score (mean difference (MD) -0.82, 95% confidence interval (CI) -4.67 to 3.02, 2 studies, n = 58, low-quality evidence). However, there was a statistically significant improvement in the SF-36 Physical Component Summary (PCS) score favouring the singing group (MD 12.64, 95% CI 5.50 to 19.77, 2 studies, n = 52, low-quality evidence). Only one study reported results for the other primary outcome of dyspnoea, in which the mean improvement in Baseline Dyspnoea Index (BDI) score favouring the singing group was not statistically significant (MD 0.40, 95% CI -0.65 to 1.45, 1 study, n = 30, very low-quality evidence).No studies examined any long-term outcomes and no adverse events or side effects were reported.

AUTHORS' CONCLUSIONS

There is low to very low-quality evidence that singing is safe for people with COPD and improves physical health (as measured by the SF-36 physical component score), but not dyspnoea or respiratory-specific quality of life. The evidence is limited due to the low number of studies and the small sample size of each study. No evidence exists examining the long-term effect of singing for people with COPD. The absence of studies examining singing performed in conjunction with pulmonary rehabilitation precludes the formulation of conclusions about the effects of singing in this context. More randomised controlled trials with larger sample sizes and long-term follow-up, and trials examining the effect of singing in addition to pulmonary rehabilitation, are required to determine the effect of singing on health-related quality of life and dyspnoea in people with COPD.

Community singing groups for people with chronic obstructive pulmonary disease: participant perspectives

AIM

Chronic obstructive pulmonary disease (COPD) is a major public health issue which is irreversible and progressive, but previous research suggests that singing may have beneficial effects. The aim of this study was to establish the views of participants with COPD taking part in a singing for better breathing programme.

METHODS

This was a descriptive qualitative study nested within a single-cohort feasibility study which included measures of lung function and wellbeing. Participants ( n = 37) were interviewed following a community singing programme that ran over 10 months in South East England.

RESULTS

Findings support those from previous studies regarding the impact of singing on respiratory wellbeing. These included the teaching on breath control, relaxation and the breathing exercises, singing as a means to deflect attention away from breathing problems, leading to increased activity levels and the mutual support for respiratory problems. Beyond the impact on breathing, the singing was also seen as fun, and provided friendship and a 'feel-good' factor which led to motivation to participate in further activities. For some, it was the highlight of the week, and singing together in a group was felt to be central to the benefits experienced. Findings are compared with the quantitative measures within the same study.

CONCLUSION

The majority of participants reported improvements in respiratory symptoms as well as mental and social wellbeing following the programme. The study contributes to the evidence base in supporting and highlighting the consistently positive experiences of a large sample of participants, despite variable outcomes in clinical measures.

Singing for Lung Health: a qualitative assessment of a British Lung Foundation programme for group leaders

Introduction

Singing for Lung Health (SLH) groups are an increasingly popular intervention for people with respiratory disease. There are limited data as to how these groups should be developed and run. We aimed to evaluate the experience of singing leaders both to assess the training provided by the British Lung Foundation (BLF) and to provide information to guide future development of programmes.

Methods

A convenience sample of 15 leaders who had received BLF SLH training participated in the BLF service evaluation. Fifteen singing groups were observed, and singing leader interviews and questionnaires were collected. Inductive themes from the qualitative data were the primary outcome. The content of observed singing groups was also rated against the training leaders had received.

Results

Singing leaders valued the BLF training but felt that a significant level of expertise is required before joining. Singing leaders often found setting up groups challenging and some found clinician support beneficial. There were important technical aspects of running a lung health group including issues around content, for example, choice of repertoire to suit breathing pattern, and delivery, for example, pace, rhythm and management of group dynamics. Leaders said that group participants reported physical health improvements such as reduced breathlessness on activity. The content and delivery of singing classes observed displayed a good level of fidelity, suggesting that SLH training is effective.

Conclusion

The experience of the leaders highlights the requirements, support and technical skills needed to run SLH groups, which have features distinct from generic community singing groups.

Sing Your Lungs Out-a community singing group for chronic obstructive pulmonary disease: a 1-year pilot study

OBJECTIVE

Singing group participation may benefit patients with chronic obstructive pulmonary disease (COPD). Previous studies are limited by small numbers of participants and short duration of generally hospital-based singing group intervention. This study examines the feasibility of long-term participation in a community singing group for patients with COPD who had completed pulmonary rehabilitation (PR).

METHODS

This was a feasibility cohort study. Patients with COPD who had completed PR and were enrolled in a weekly community exercise group were recruited to a new community-based singing group which met weekly for over 1 year. Measurements at baseline, 4 months and 1 year comprised comprehensive pulmonary function tests including lung volumes, 6 min walk test (6MWT), Clinical COPD Questionnaire (CCQ), Hospital Anxiety and Depression Scale (HADS) and hospital admission days for acute exacerbation of COPD (AECOPD) for 1 year before and after the first singing group session.

FINDINGS

There were 28 participants with chronic lung disease recruited from 140 people approached. Five withdrew in the first month. 21 participants meeting Global Initiative for Chronic Obstructive Lung Disease criteria for COPD completed 4-month and 18 completed 1-year assessments. The mean attendance was 85%. For the prespecified primary outcome measure, total HADS score, difference between baseline and 12 months was -0.9, 95% CI -3.0 to 1.2, p=0.37. Of the secondary measures, a significant reduction was observed for HADS anxiety score after 1 year of -0.9 (95% CI -1.8 to -0.1) points, p=0.038 and an increase in the 6MWT at 1 year, of 65 (95% CI 35 to 99) m compared with baseline p<0.001.

CONCLUSIONS

Our findings support the feasibility of long-term participation in a community singing group for adults with COPD who have completed PR and are enrolled in a weekly community exercise group and provide evidence of improved exercise capacity and a reduction in anxiety.

TRIAL REGISTRATION NUMBER

ACTRN12615000736549; Results.