Authors: Keir EJ Philip¹, Adam Lewis², Samantha L Harrison³

1. National Heart and Lung Institute, Imperial College London, London, UK.
2. Brunel University London, Uxbridge, UK
3. School of Health and Life Sciences, Teesside University, Middlesbrough, UK

Individuals living with chronic respiratory diseases (CRD) experience physical, psychological and social health impacts. Physical impacts include symptoms of breathlessness and fatigue limiting activities of daily living, psychological sequalae such as depression and anxiety are also common and are further compounded by social isolation and loneliness (1). The COVID-19 pandemic is likely to exacerbate these broad disease impacts because of necessary social distancing, isolation and quarantine measures. Furthermore, CRDs are socially patterned and associated with inequality contributing to the higher infection rates observed in populations that are socially and-economically deprived, which in many countries will have additional consequences regarding access to affordable healthcare (2).

Individuals with CRD, many of whom are over 70 years old, are particularly vulnerable in the current COVID-19 pandemic and therefore are strongly advised to physically isolate themselves from wider society via social distancing measures, often requiring they stay at home (3). This necessary and appropriate advice is unfortunately likely to limit physical activity. Physical inactivity is a leading cause of mortality worldwide (4). Individuals with CRDs, particularly COPD, have significantly low levels of physical activity(5), which is associated with an increased risk of respiratory disease exacerbations and mortality (6). Despite physical activity and exercise being integral components of disease self-management, maintaining physical activity and avoiding sedentary behaviour is challenging to achieve while advised to stay at home.

Attendance at group exercise programs is currently no-longer possible with Pulmonary Rehabilitation (PR) and PR-maintenance exercise groups having been suspended to limit the risk of contracting or transmitting infection. In many countries, participating in community activity groups or simply walking to local pubs, restaurants or leisure centres has been prohibited. Although these interventions are vital, we should not underestimate the potential impacts of such measures on other aspects of physical and mental health. Stress, anxiety and depression are likely to be heightened, associated with concerns regarding the development of COVID-19 (7), ongoing management of established health conditions, financial issues and loneliness.

Approaches, which can encourage physical activity whilst people are living in social isolation, are urgently required. These need to be delivered in formats that are accessible, affordable, and which connect people socially while they are physically isolated. Interventions such as singing and dance are physically engaging and fun activities that share a natural social bonding ethos across cultures. Such approaches can be contextually adapted and projects in South Africa, Uganda, and the Kyrgyz Republic suggest singing and dance for CRD management are well received and appropriate across a range of cultures, contexts and countries (8, 9). They can be performed independently and have the potential to promote physical activity for people with CRDs.

Prior to the COVID-19 pandemic, singing and dance were gaining in popularity as approaches to promote physical activity in the management of CRD (8). There are approximately 100 Singing for Lung Health (SLH) groups in the UK alone, with many other groups internationally. Research suggests SLH can reduce health impairment (10, 11), improve functional walking capacity (12) anxiety (13), and  the ability of individuals to cope with their condition (14). Preliminary research has shown dance-based interventions to be feasible and fun (15), with suggested benefits on exercise capacity, balance, and symptoms (i.e. breathlessness) (16). Findings conferred by qualitative research (under review/in preparation) emphasise the fun and playful element of dance “I feel like a kid in the playground again”. Narratives portray such approaches to be holistically beneficial for physical and psychological health and there is a sense of learning and developing together, which enhances social bonds (15). Though the formal evidence-base for these interventions is currently limited, that which exists suggests such approaches could be particularly useful at this unprecedented time.

Clearly, given the current requirements to physically isolate and social distance, innovation is required to ensure the delivery of such interventions is appropriate. Online resources and groups are becoming available to address this need, with integrated research activities to assess their impact. The Life of Breathe project, in collaboration with Sian Williams (community dance leader), has produced online dance videos for people with Breathlessness (https://lifeofbreath.org/2020/03/dance-easy-breathe-better-and-feel-good/) which people can access at home and in their own time. Virtual group-sessions for singing and dance are being delivered through online platforms such as Zoom, meaning people can participate together. A cystic fibrosis virtual choir ‘One Voice’ recently performed at the European Cystic Fibrosis Conference in 2019 (https://www.youtube.com/watch?v=B-Qt3Dm2GxU) showing the powerful potential of the Arts engendering social connection when living in isolation.

The Covid-19 pandemic will affect all people with CRDs, having potentially detrimental affects on physical, psychological and social wellbeing. Before the current pandemic singing and dance were emerging as useful approaches to disease management. Perhaps now, when delivered remotely, these could be even more relevant to promote physical activity and wellbeing at a time when people with CRD are more vulnerable than ever.

References

1. Yohannes AM, Alexopoulos GS. Depression and anxiety in patients with COPD. Eur Respir Rev. 2014;23(133):345-9.
2. Resnik A, Galea S, Sivashanker K. BMJ Opinion2020. [cited 2020]. Available from: https://blogs.bmj.com/bmj/2020/03/18/covid-19-the-painful-price-of-ignoring-health-inequities/.
3. Mahase E. Covid-19: UK starts social distancing after new model points to 260 000 potential deaths. Bmj. 2020;368:m1089.
4. Organisation WH. Global Health Risks: Mortality and burden of disease attributable to selected major risks. Geneva: World Health Organisation; 2009.
5. Vaes AW, Garcia-Aymerich J, Marott JL, Benet M, Groenen MT, Schnohr P, et al. Changes in physical activity and all-cause mortality in COPD. The European respiratory journal. 2014;44(5):1199-209.
6. Gimeno-Santos E, Frei A, Steurer-Stey C, de Batlle J, Rabinovich RA, Raste Y, et al. Determinants and outcomes of physical activity in patients with COPD: a systematic review. Thorax. 2014;69(8):731-9.
7. Yang Y, Li W, Zhang Q, Zhang L, Cheung T, Xiang YT. Mental health services for older adults in China during the COVID-19 outbreak. Lancet Psychiatry. 2020.
8. Philip K, Lewis A, Hopkinson NS. Music and dance in chronic lung disease. Breathe. 2019;15(2):116-20.
9. Philip KE, Akylbekov A, Stambaeva B, Sooronbaev T, Jones R. Music, Dance, and Harmonicas for People With COPD. Respiratory care. 2019;64(3):359.
10. Bonilha AG, Onofre F, Vieira ML, Prado MY, Martinez JA. Effects of singing classes on pulmonary function and quality of life of COPD patients. Int J Chron Obstruct Pulmon Dis. 2009;4:1-8.
11. Skingley A, Page, S., Clift, S., Morrison, I., Coulton, S., Treadwell, P., Vella-Burrows, T., Salisbury, I., Shipton, M.,. “Singing for Breathing”: Participants' perceptions of a group singing programme for people with COPD. Arts & Health. 2014;6(1):59-74.
12. McNaughton A, Weatherall M, Williams M, McNaughton H, Aldington S, Williams G, et al. Sing Your Lungs Out-a community singing group for chronic obstructive pulmonary disease: a 1-year pilot study. BMJ Open. 2017;7(1):e014151.
13. Lord VM, Cave P, Hume VJ, Flude EJ, Evans A, Kelly JL, et al. Singing teaching as a therapy for chronic respiratory disease--a randomised controlled trial and qualitative evaluation. BMC pulmonary medicine. 2010;10:41.
14. Lewis A, Cave P, Stern M, Welch L, Taylor K, Russell J, et al. Singing for Lung Health-a systematic review of the literature and consensus statement. NPJ primary care respiratory medicine. 2016;26:16080.
15. Harrison SL BK, Edwards J, McFaull V, McLusky S, Russell A, Williams G, Williams S. DANCE FOR PEOPLE WITH CHRONIC BREATHLESSNESS: A FEASIBILITY STUDY. Thorax2019.
16. Wshah A, Butler S, Patterson K, Goldstein R, Brooks D. "Let's Boogie": FEASIBILITY OF A DANCE INTERVENTION IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE. J Cardiopulm Rehabil Prev. 2019;39(5):E14-E9.