Singing in chronic obstructive pulmonary disease patients: A pilot study in Portugal

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.

Effect of Singing on Symptoms in Stable COPD: A Systematic Review and Meta-Analysis

Background

Chronic obstructive pulmonary disease (COPD) is a chronic lung disease which feature is progressive airflow obstruction. Singing is a popular and convenient activity that requires people to manage their lung volumes and airflow actively. Despite the well-known benefits of singing to healthy people, the specific effect still remains unclear.

Objective

To investigate the mental and psychological benefits of singing in patients with stable COPD.

Search Methods

We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA) on randomized controlled trials (RCTs) including singing exercise as the main intervention in stable COPD. We searched 8 electronic databases, including Web of Science, PubMed, Embase, Cochrane Library, Clinical Trials.gov, and the Physical Therapy Evidence Database (PEDro), CNKI, and Wanfang Database from inception until May 2022. The searching languages was English or Chinese. Data extraction using standardized templates was performed by two independent reviewers. The quality of the studies was assessed using the PEDro scale. Data synthesis was performed with Revman 5.4. The pooled effect sizes are reported by MD and 95% CI.

Results

Five RCTs involving 333 patients with stable COPD were included in this meta-analysis. Singing was regarded as the main intervention in the experimental group. Meta-analysis revealed that singing improves quality of life on Short Form 36 physical component summary (SF-36 PCS) (MD = 12.63, 95% CI: 5.52 to 19.73, P < 0.01) and respiratory muscle in maximal expiratory pressure (PE_max) (MD = 14.30, 95% CI: 0.87 to 27.73, P = 0.04) in patients with COPD. However, it has limited effects on Short Form 36 mental component summary (SF-36 MCS), lung function, exercise capability, and adverse mental state.

Conclusion

Based on results of the meta-analysis, singing could be used to improve quality of life (SF-36 PCS) and respiratory muscles (PE_max) in patients with COPD.

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.

Group singing improves depression and life quality in patients with stable COPD: a randomized community-based trial in China

PURPOSE

To explore the effects of group singing therapy on depression symptoms and quality of life of patients with stable chronic obstructive pulmonary disease (COPD).

METHODS

Patients with COPD were randomly allocated to intervention (n = 30) and control groups (n = 30). The intervention group received group singing therapy once a week for 24 sessions along with routine health education, whereas the control group only received the routine health education. All patients were administered the Hospital Anxiety and Depression Scale depression subscale (HADS-D) and the Clinical COPD Questionnaire (CCQ). Data were collected at baseline and at 1, 3, and 6 months.

RESULTS

Fifty-six participants completed this trial. Significant between-group differences were observed with respect to the main effect of group and time as well as the effect of group × time interaction on HADS-D score. The HADS-D score was significantly improved 1, 3, 6 months after group singing therapy. The CCQ total scores were significantly different between the two groups with respect to the main effect of group and time and the group × time interaction effect. Significantly better CCQ was detected in the intervention group at 3 months and 6 months after intervention.

CONCLUSIONS

Group singing therapy reduces depressive symptoms and improves the quality of life of patients with stable COPD.

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.

Singing Lessons for Respiratory Health: A Literature Review

OBJECTIVE

Several studies have explored the role of music and singing as a treatment for respiratory symptoms. The objective of this paper was to review the current body of literature in regard to the use of singing as both a physiological and a psychological therapy for respiratory disease and assess the role the singing teacher might play in this treatment.

STUDY DESIGN

This is a literature review, discussion of results and directions for further research.

METHOD

Multiple databases were searched using keywords such as "respiratory," "physiotherapy," and "pulmonary" in conjunction with "singing." Studies that met selection criteria were summarized and analyzed.

RESULTS

Seventeen studies pertaining to multiple conditions including chronic obstructive pulmonary disease, asthma, cystic fibrosis, cancer, Parkinson disease, quadriplegia, and multiple sclerosis were analyzed. All studies reported trends of positive physical and/or quality of life outcomes after a series of singing lessons, regardless of statistical significance. Several noted improvements in maximum expiratory pressure and overall breathing technique. Many studies included open-ended interviews revealing participants' perception of singing as an effective therapy that was fun, improved mood, taught breathing and breath control, was a good exercise for the lungs, and had improved physical functioning.

CONCLUSIONS

Singing can be used as an adjunctive treatment for respiratory disease, with the best results occurring after long-term study. Group lessons and a strong teacher relationship feed the need for social interaction and support, which can facilitate treatment compliance. Further research is warranted.

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.

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

OBJECTIVE

To explore the ways in which participation in a community singing group contributed to the health and well-being of patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Qualitative description, based on transcripts from individual interviews and a focus group meeting with people with COPD participating in the singing group, regarding their experience.

SETTING

Urban community, Wellington, New Zealand.

PARTICIPANTS

23 people (13 women and 10 men), 51-91 years with COPD (21) or interstitial lung disease (2).

RESULTS

The weekly singing group was a well-attended activity, with self-reported benefits to health and well-being. 4 key themes were identified: being in the 'right space', connection, purpose and growth, and participation in a meaningful physical activity.

CONCLUSIONS

This study helps us to better understand how participation in a community singing group can benefit the health and well-being of patients with COPD.

TRIAL REGISTRATION NUMBER

ACTRN12615000736549; Results.