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

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.

Pilot study of physiotherapist-led versus music therapist-led breathing control exercises for young adults living with breathing pattern disorder: a randomised controlled trial protocol

INTRODUCTION

Breathing pattern disorder (BPD) is an abnormal breathing pattern associated with biochemical, biomechanical and psychophysiological changes. While physiotherapy is often offered, limited evidence-based therapies for BPD are available. Music therapy-based singing exercises have been shown to improve quality of life for individuals with respiratory conditions and may also be beneficial for individuals living with BPD. No study has previously compared these participatory interventions in the treatment of people living with BPD.

METHODS AND ANALYSIS

This is a study protocol for an assessor blinded 1:1 randomised controlled trial and qualitative interview study. Forty participants aged 18-40 years who score at least 19 on the Nijmegen Questionnaire (NQ) and do not have any underlying respiratory conditions will be recruited. Participants will be randomised to receive either physiotherapy-led or music therapy-led breathing exercises for 6 weeks. The primary outcome will be between-group difference in NQ post-intervention. Semistructured interviews with a purposive sample of participants will be performed. Qualitative data will be analysed using thematic analysis to better understand participants' intervention and trial experiences.

ETHICS AND DISSEMINATION

This study has received ethical approval by Brunel University London College of Health, Medicine and Life Science's Research Ethics Committee (32483-MHR-Mar/2022-38624-3). The anonymised completed dataset will be made available as an open-access file via Brunel University London Figshare and the manuscript containing anonymised patient data will be published in an open-access journal.

TRIAL REGISTRATION NUMBER

This trial is registered on the Open Science Framework Registry (https://osf.io/u3ncw).

Physiological changes related to 10 weeks of singing for lung health in patients with COPD

BACKGROUND

Singing for Lung Health (SLH) was non-inferior to physical exercise training in improving 6-minute walking test distance (6MWD) and quality of life (St. George's Respiratory Questionnaire (SGRQ)) within a 10-week pulmonary rehabilitation (PR) programme for COPD in our recent randomised controlled trial (RCT) (NCT03280355). Previous studies suggest that singing improves lung function, respiratory control and dyspnoea, however this has not yet been convincingly confirmed. Therefore, this study aimed to explore the impact of SLH on physiological parameters and the associations with achieving the minimal important difference (MID) in 6MWD and/or SGRQ.

METHODS

We conducted post hoc, per-protocol analyses mainly of the SLH group of the RCT, exploring associations with 6MWD and SGRQ results by stratifying into achieving versus not-achieving 6MWD-MID (≥30 m) and SGRQ-MID (≤-4 points): changes in lung function, inspiratory muscle strength/control, dyspnoea, and heart rate response using logistic regression models. Further, we explored correlation and association in achieving both 6MWD-MID and SGRQ-MID (or in neither/nor) using Cohen's κ and Cochran-Mantel-Haenszel Test.

RESULTS

In the SLH study group (n=108), 6MWD-MID was achieved by 31/108 (29%) and in SGRQ by 53/108 (49%). Baseline factors associated with achieving MID in either outcome included short baseline 6MWD and high body mass index. Achieving 6MWD-MID was correlated with improved heart rate response (OR: 3.14; p=0.03) and achieving SGRQ-MID was correlated with improved maximal inspiratory pressure (OR: 4.35; p=0.04). Neither outcome was correlated with significant spirometric changes. Agreement in achieving both 6MWD-MID and SGRQ-MID was surprisingly insignificant.

CONCLUSIONS

This explorative post hoc study suggests that SLH is associated with physiological changes after short-term PR for COPD. Future physiological studies will help us to understand the mechanisms of singing in COPD. Our study furthermore raises concern about poor agreement between subjective and objective benefits of PR despite state-of-the-art tools.

Use of Singing for Lung Health as an alternative training modality within pulmonary rehabilitation for COPD: a randomised controlled trial

BACKGROUND

Pulmonary rehabilitation (PR) is a cornerstone in chronic obstructive pulmonary disease (COPD) management. However, PR adherence is generally low, and barriers include availability, economic issues, motivation and an inability to attend or perform physical training. Therefore, alternative, evidence-based PR activities are required. Singing may have benefits for quality of life (QoL), respiratory control and well-being in COPD, but the impact on the PR key outcome, physical exercise capacity, is uncertain.

METHODS

In this randomised controlled trial (NCT03280355), we investigated the effectiveness of 10 weeks of PR, including either "Singing for Lung Health" (SLH) training or standard physical exercise training (PExT). The primary outcome was a change in exercise capacity (6-min walk distance (6MWD)) from baseline to post-PR. Secondary outcomes were changes in QoL (St George's Respiratory Questionnaire (SGRQ)), Hospital Anxiety and Depression Score (HADS), lung function, dyspnoea and adherence.

RESULTS

We included 270 COPD patients, and 195 completed the study. Demographics across groups were comparable, and both groups improved significantly in 6MWD and SGRQ score. SLH was non-inferior to PExT in improving 6MWD (mean±sd 13.1±36.3 m versus 14.1±32.3 m, p=0.81; difference 1.0 m, 95% CI -7.3-9.3 m) with 21.8% and 25.0%, respectively (p=0.57), reaching the 6MWD minimal important difference of 30 m. We found no significant between-group differences concerning SGRQ, HADS, lung function, dyspnoea or adherence.

CONCLUSION

Our study suggests that SLH is non-inferior to PExT in improving 6MWD during a 10-week PR programme. Future studies addressing reproducibility, long-term effects and health economics are needed.

The physiology of singing and implications for 'Singing for Lung Health' as a therapy for individuals with chronic obstructive pulmonary disease

Singing is an increasingly popular activity for people with chronic obstructive pulmonary disease (COPD). Research to date suggests that ‘Singing for Lung Health’ may improve various health measures, including health-related quality-of-life. Singing and breathing are closely linked processes affecting one another. In this narrative review, we explore the physiological rationale for ‘Singing for Lung Health’ as an intervention, focusing on the abnormalities of pulmonary mechanics seen in COPD and how these might be impacted by singing. The potential beneficial physiological mechanisms outlined here require further in-depth evaluation.

Music and dance in respiratory disease management in Uganda: a qualitative study of patient and healthcare professional perspectives

INTRODUCTION

Music and dance are increasingly used as adjunctive arts-in-health interventions in high-income settings, with a growing body of research suggesting biopsychosocial benefits. Such low-cost, low-resource interventions may have application in low-resource settings such as Uganda. However, research on perceptions of patients and healthcare professionals regarding such approaches is lacking.

METHODS

We delivered sample sessions of music and dance for chronic respiratory disease (CRD) to patients and healthcare professionals. Seven participants took part in one singing and dance sample session. One patient completed only the dance session. We then conducted an exploratory qualitative study using thematic analysis of semistructured interviews with healthcare professionals and patients regarding (1) the role of music and dance in Ugandan life and (2) the perceived acceptability and feasibility of using music and dance in CRD management in Uganda.

RESULTS

We interviewed 19 participants, made up of 11 patients with long-term respiratory conditions and 8 healthcare professionals, who were selected by purposeful convenience sampling. Four key themes were identified from interview analysis: music and dance (1) were central components of daily life; (2) had an established role supporting health and well-being; and (3) had strong therapeutic potential in respiratory disease management. The fourth theme was (4) the importance of modulating demographic considerations of culture, religion and age.

CONCLUSION

Music and dance are central to life in Uganda, with established roles supporting health and well-being. These roles could be built on in the development of music and dance interventions as adjuncts to established components of CRD disease management like pulmonary rehabilitation. Through consideration of key contextual factors and codevelopment and adaptation of interventions, such approaches are likely to be well received.

Exercise as a multi-modal disease-modifying medicine in systemic sclerosis: An introduction by The Global Fellowship on Rehabilitation and Exercise in Systemic Sclerosis (G-FoRSS)

Systemic sclerosis (SSc) is a heterogeneous multisystem autoimmune disease whereby its main pathological drivers of disability and damage are vascular injury, inflammatory cell infiltration, and fibrosis. These mechanisms result in diffuse and diverse impairments arising from ischemic circulatory dysfunction leading to painful skin ulceration and calcinosis, neurovascular aberrations hindering gastrointestinal (GI) motility, progressive painful, incapacitating or immobilizing effects of inflammatory and fibrotic effects on the lungs, skin, articular and periarticular structures, and muscle. SSc-related impairments impede routine activities of daily living (ADLs) and disrupt three critical life areas: work, family, social/leisure, and also impact on psychological well-being. Physical activity and exercise are globally recommended; however, for connective tissue diseases, this guidance carries greater impact on inflammatory disease manifestations, recovery, and cardiovascular health. Exercise, through myogenic and vascular phenomena, naturally targets key pathogenic drivers by downregulating multiple inflammatory and fibrotic pathways in serum and tissue, while increasing circulation and vascular repair. G-FoRSS, The Global Fellowship on Rehabilitation and Exercise in Systemic Sclerosis recognizes the scientific basis of and advocates for education and research of exercise as a systemic and targeted SSc disease-modifying treatment. An overview of biophysiological mechanisms of physical activity and exercise are herein imparted for patients, clinicians, and researchers, and applied to SSc disease mechanisms, manifestations, and impairment. A preliminary guidance on exercise in SSc, a research agenda, and the current state of research and outcome measures are set forth.

Physiological demands of singing for lung health compared with treadmill walking

Introduction

Participating in singing is considered to have a range of social and psychological benefits. However, the physiological demands of singing and its intensity as a physical activity are not well understood.

Methods

We compared cardiorespiratory parameters while completing components of Singing for Lung Health sessions, with treadmill walking at differing speeds (2, 4 and 6 km/hour).

Results

Eight healthy adults were included, none of whom reported regular participation in formal singing activities. Singing induced acute physiological responses that were consistent with moderate intensity activity (metabolic equivalents: median 4.12, IQR 2.72–4.78), with oxygen consumption, heart rate and volume per breath above those seen walking at 4 km/hour. Minute ventilation was higher during singing (median 22.42 L/min, IQR 16.83–30.54) than at rest (11 L/min, 9–13), lower than 6 km/hour walking (30.35 L/min, 26.94–41.11), but not statistically different from 2 km/hour (18.77 L/min, 16.89–21.35) or 4 km/hour (23.27 L/min, 20.09–26.37) walking.

Conclusions

Our findings suggest the acute metabolic demands of singing are comparable with walking at a moderately brisk pace, hence, physical effects may contribute to the health and well-being benefits attributed to singing participation. However, if physical training benefits result remains uncertain. Further research including different singing styles, singers and physical performance impacts when used as a training modality is encouraged.

Trial registration number

ClinicalTrials.gov registry (NCT04121351).

"SingStrong": Singing for better lung health in COPD - A pilot study

Background: Chronic Obstructive Pulmonary Disease (COPD) affects up to 440,000 people in Ireland. Multiple domains of biopsychosocial health are affected. Community-based interventions supporting behavioral change and self-management are advocated. The aim of this pilot study was to evaluate the efficacy of an 8-week singing intervention, "SingStrong", to improve biopsychosocial wellness in persons with COPD. Methods: Seventy-eight adults with COPD were recruited from three COPD Support groups in the Irish Mid-west. Pre and post-intervention testing performed by physiotherapy and nursing staff comprised Six-Minute Walk Test (6MWT), COPD Assessment test (CAT), Hospital Anxiety and Depression Scale (HADS), and Spirometry: FEV1, FVC, FEV1/FVC. The intervention was a weekly one-hour group class for eight weeks led by a trained choir leader at each site. This included physical and vocal warm-up, breathing exercises and singing. Participants were given a songbook based on their song preferences and a CD with vocal, breathing exercises and songs, and encouraged to practice daily. Semi-structured focus groups were conducted post intervention. Parametric or non-parametric t-tests were conducted to establish significance. Results: Fifty-eight (74%) participants who attended at least 4/8 session were re-tested. There was a statistically significant improvement in 6MWT (p = .02), non-significant improvements in CAT (p = .24) and HADS Depression (p = .238), and non-significant worsening in HADS Anxiety (p = .34). All qualitative feedback was positive, including improvements in breathing, quality of life and intervention enjoyment. Principal Conclusions: Singing for lung health has positive implications for persons with COPD. Future longer studies should examine outcomes of exacerbation level, hospitalization and medication use.

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.

Moving singing for lung health online in response to COVID-19: experience from a randomised controlled trial

INTRODUCTION

Singing for lung health (SLH) is a popular arts-in-health activity for people with long-term respiratory conditions. Participants report biopsychosocial benefits, however, research on impact is limited. The 'SLH: Improving Experiences of Lung Disease trial', a randomised controlled, single (assessor) blind, trial of 12 weeks SLH versus usual care for people with chronic obstructive pulmonary disease (COPD) (n=120) was setup to help to address this. The first group (n=18, nine singing and nine controls) started face-to-face (five sessions) before changing to online delivery (seven sessions) due to COVID-19-related physical distancing measures. As such, the experience of this group is here reported as a pilot study to inform further research in this area.

METHODS

We conducted semistructured interviews and thematic analysis regarding barriers, facilitators and key considerations for transitioning from face-to-face to online delivery. Pilot quantitative outcomes include attendance, premeasures and postmeasures of quality of life and disease impact (Short Form 36 Health Survey, COPD Assessment Test score), breathlessness (Medical Research Council breathlessness scale, Dyspnoea-12), depression (Patient Health Questionnaire-9, PHQ-9), anxiety (Generalised Anxiety Disorder-7), balance confidence (Activity specific Balance Confidence, ABC scale) and physical activity (clinical visit PROactive physical activity in COPD tool, combining subjective rating and actigraphy).

RESULTS

Attendance was 69% overall, (90% of the face-to-face sessions, 53% online sessions). Analysis of semistructured interviews identified three themes regarding participation in SLH delivered face to face and online, these where (1) perceived benefits; (2) digital barriers (online) and (3) digital facilitators (online). Findings were summarised into key considerations for optimising transitioning singing groups from face-to-face to online delivery. Pilot quantitative data suggested possible improvements in depression (treatment effect -4.78 PHQ-9 points, p<0.05, MCID 5) and balance confidence (treatment effect +17.21 ABC scale points, p=0.04, MCID 14.2).

DISCUSSION

This study identifies key considerations regarding the adaptation of SLH from face-to-face to online delivery. Pilot data suggest online group singing for people with COPD may deliver benefits related to reducing depression and improved balance confidence.

Dance for people with chronic respiratory disease: a qualitative study

OBJECTIVES

To explore the experiences and perceived impact on health and well-being related to participation in a dance group for people with chronic respiratory disease (CRD).

DESIGN

An exploratory qualitative study using thematic analysis of semistructured interviews.

SETTING

A community dance group in a UK health centre.

PARTICIPANTS

Convenience sample of long-term dance group participants.

INTERVENTION

Weekly community dance sessions designed for people with breathlessness, lasting 75 min, led by a trained community dance leader.

RESULTS

Convenience sample of eight participants, six females, aged 57-87 years (mean 75), with a median 2-year attendance at weekly dance sessions. Long-term attendance was driven by strongly held beliefs regarding the health and well-being benefits of participation. Four key themes were identified: dance as (1) a holistically beneficial activity, with physical and psychosocial health benefits including improved or maintained physical fitness and psychological well-being, and reduced need for healthcare; (2) an integral part of their life; (3) an enjoyable activity; and (4) a source of deep social cohesion.

CONCLUSIONS

Dance group participants perceived a broad range of health benefits of relevance to the biopsychosocial impacts of their respiratory disease. The themes identified are useful in the ongoing planning and evaluation of dance as a holistic complex intervention for people with CRD. Further research is required to assess the extent of health impacts identified, and how dance might be most effectively placed as an option in the management of CRD.

TRIAL REGISTRATION NUMBER

NCT04006015.

Music and dance in chronic lung disease

Arts in Health interventions show potential to improve the quality of life of people with chronic lung disease. Listening to music, making music, and dance have accepted and established roles in the lives of people without chronic disease. However, their potential utility in chronic disease management is infrequently considered by medical professionals. The aim of this review is to examine the use of music and dance in the treatment and self-management of chronic lung disease. Although the evidence base is currently limited, existing research suggests a range of biopsychosocial benefits. As personalised medicine and social prescribing become more prominent, further research is required to establish the role of arts interventions in chronic lung disease.

Interest in the arts in health is growing, and initial research suggests that music and dance have a range of health benefits and show promise as tools to promote living well and self-management in people with chronic lung diseasehttp://ow.ly/bFxd30o8t0X

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).