Dr. Mette Kaasgaard, PhD, M.Sc., Classical Singer and Singing Pedagogue.

Affiliation

Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark & Pulmonary Research Unit Zealand (PLUZ), Department of Medicine, Zealand University Hospital Roskilde and Naestved Hospital, Denmark & PROgrez Research and Implementation Unit, Department of Physiotherapy and Occupational Therapy, Naestved-Slagelse-Ringsted Hospitals, Slagelse, Denmark

Singing groups for people with respiratory diseases have become increasingly popular all across the world, primarily as a community-based leisure-time activity. Singing is associated with experiences of joy, meaning, and social cohesion, but might singing also confer measurable health benefits? Might singing even be relevant within pulmonary rehabilitation programs? Our recent large-scale, multicenter randomized controlled trial demonstrated promising results and has provided important future perspectives and implications for practice, health care, and research.^1–3

Challenges in Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is a cornerstone in care for people with lung diseases, including chronic obstructive pulmonary disease (COPD). PR enhances physical capacity, improves quality of life (QoL), and supports life-style changes, and includes Physical Exercise Training (PExT) as a key component. Although evidence-based and effective, PR with PExT faces challenges and barriers, both regarding adherence and long-term maintain of activity, effects, and life-style changes.^4–6 Thus, there is a continuing need for alternative or supplementary evidence-based activities to support both PR adherence and maintain of activity following PR. A number of adjunctive activities have been suggested, including group singing. However, the evidence is still scarce regarding effects and underlying mechanisms of singing and regarding the most appropriate methodology, content, and delivery of singing programs.^7–9 Moreover, little is known about the longer-term impact of time-limited programs of group singing for people with lung conditions.

Singing for people with respiratory diseases?

Currently, singing groups for people with lung diseases are mostly delivered heterogeneously and without a disease-specific approach, but with focus on musical performance and on building a positive social support.^8,10,11 Singing is, however, a highly physiologically-oriented activity with focus on building control, coordination, and flexibility in the respiratory muscles to support vocalization and musical expression.^8,9 Therefore, the link between singing and respiratory diseases seems obvious and intuitive, and a number of initial studies have been conducted to investigate potential health-related effects of singing. ^7,9,12–14 Some studies have suggested that singing improves quality of life (QoL), wellbeing, depression, and anxiety, and some studies have suggested that singing improves respiratory aspects and physical stamina and fitness. Underlying hypotheses regarding physiological effects and mechanisms of singing specifically comprise operating lung volumes, hyperinflation, air-trapping, dyspnea, and respiratory muscle strength and control.^8,9,13 It has also been suggested that singing is a motivating activity that supports maintain of an active lifestyle, and that singing might build confidence and mobilize people to become able to participate in physical exercise training.¹⁵ However, current evidence is based on heterogenous small-scale trials and qualitative research, and findings are inconsistent.^7,8,16 Importantly, there is an overall lack of studies that investigate impact of singing specifically on key PR outcomes and that address the underlying physiological mechanisms of singing. Moreover, optimal methodology and delivery of singing groups for people with lung diseases, including COPD, has not yet been established.

Our recent RCT – singing in COPD

We included 270 people with COPD, all referred for PR with PExT. 195 completed both baseline and short-term follow-up assessments. Both study arms improved significantly within-group in 6MWD and SGRQ. Between-group, SLH was non-inferior to PExT in 6MWD and in all secondary outcomes, including adherence. Main results were published in the European Respiratory Journal (Impact Factor 24.3).¹ In post-hoc studies, we found a strong dose-response between adherence and both objective effect (6MWD) and subjective effect (SGRQ). No single factor was related to adherence ¹⁷. Moreover, a larger proportion in SLH improved in SGRQ (49%) than in 6MWD (29%),² Notably, we found no impact on spirometry parameters, however, SLH seemed to be associated with improved respiratory strength and control and with dyspnea control.² Moreover, singing was considered a safe activity with no reportings of severe adverse events.

In 2023, we have conducted a long-term follow-up study within the RCT cohort and manuscript is currently under preparation for submission. Subsequently, we are planning for an RCT investigating effects and impact of SLH after surgical resection for non-small cell lung cancer. This research project will also include a supplementary qualitative study and a further exploration of physiological mechanisms in singing.

Perspectives for future practice

Current evidence is still too limited to support agreement on technical standards for the delivery of singing for people with respiratory disease, neither as community-based singing groups or as training modality within PR. Nevertheless, community-based singing groups to support people experiencing lung problems have been established across the world, and they are generally welcomed by participants as beneficial. Moreover, singing is a low-tech and low-cost activity that is easily implementable. However, it is of importance to establish high-quality and homogeneous training and supervision for the singing leaders, as outcomes of participating remain uncertain and impossible to document or evaluate. Singing leaders also report to greatly benefit from having attended a training program¹⁴ and often experience feelings of isolation, insecurity, and inadequacy when having no formal training, guideline, or network.¹⁰

Advice for practice of singing groups has previously been suggested regarding content, delivery, and approach.^{1,8–10,18–20} Thus, a current outline of generic points - based on current knowledge - to ensure sensible, operational, and ethical delivery would comprise e.g.:

Overall advice:

• Attend updated and qualified courses within best-practice methodology, delivery, and approach, and seek peer-network for knowledge-sharing.
• Gain knowledge about the current, best-practice approach and the current body-of-research to singing for respiratory disease.
• Seek basic knowledge about pathophysiological traits in lung diseases and how these impacts breathing etcetera.
• Avoid repeating misleading and/or exaggerated myths about potential effects and benefits, g. “singing trains the lungs”, “singing improves lung function” or “singing can treat depression”.
• If not wanting to focus on potential health-related benefits, focus on the musical and social aspects of the choir – and be transparent about it.
• Consult a health-professional if in doubt regarding health-aspects, and encourage participants to seek medical advice in case of considerations about their symptoms or g., about their pharmacological treatment or oxygen-therapy. 

Content and delivery:

• Use exercises and songs as “tools for purpose”, targeted the specific pathophysiological characteristics and challenges related to the specific lung diseases in the choir.
• Focus on improving body posture, body awareness, and interoception.
• Avoid high-costal-oriented breathing and tension in the accessory muscles, but focus on building a diaphragmatic-oriented breathing pattern.
• In COPD, focus on long phrases to support the expiratory movement and to help “emptying the lungs”.
• Include simple exercises and songs that can be sung without paper sheets and make sure to include repertoire preferred by the participants in the specific local and cultural context.
• The repertoire should be appropriately challenging as too complicated and demanding repertoire may influence participants’ confidence, motivation, and engagement negatively.
• Apply playful activities including vocal games, artifacts, movement, and dancing along with singing throughout the sessions – and focus on having fun.
• Let the singing group form a circle (with chairs, allowing to sit down when needed) to facilitate equality and interaction between the singing leader and the participants and to ensure an optimal setting for listening, sensing, and adjusting. 

Approach:

• Meet the participants with a positive, empathic, and encouraging attitude.
• Create a warm and safe space and focus on creating feelings of cohesion and success.
• Be humble, observe, and listen carefully to the signals and responses of the participants (both verbally and non-verbally). 

Perspectives for future research

Our studies have demonstrated that singing – when delivered as a structured, disease-specific intervention - can be more than a leisure-time activity but may confer measurable physiological and psychosocial improvements that are relevant and central in PR. Hence, our studies have transcended the overall field of arts and health-research and have emphasized the importance of conducting rigorous research with use of disease-specific and acknowledged core outcomes and with respect to the evidence hierarchy for developing and evaluating health care interventions. Thus, our studies represent a valid and significant contribution for future high-quality research to build on. 

Overall, future research is needed to build a robust body-of-evidence based on high-quality studies. These should focus on all aspects of a new intervention: 1) Developing of common terminology and preferred endpoints for future studies of singing in lung diseases, based on current standards within PR with PExT; 2) Developing a generic methodological framework and standards for singing as training modality in lung diseases; 3) Exploring mechanisms and impact of singing as training modality in mechanistic, physiological studies and, moreover, in qualitative studies, including factors related to benefits, motivation, and barriers; 4) Building further evidence (reflecting GRADE framework) within singing as training modality in lung diseases, e.g., repetition of our RCT in similar and other settings; exploring long-term impact of singing on maintain of activity and sustain of short-term effects; exploring impact on COPD exacerbation rate and health-economic aspects; investigating effect targeted specific phenotypes in COPD; investigating effect on other lung diseases; Ideally, future research should be based on international, multi-disciplinary collaborations and should include frameworks for both singing pedagogy, PR standards,^21,22 and complex interventions.²³

Conclusion

In conclusion, findings from our recent trial in Denmark point to the potential value of singing as training modality within a more personalized PR offer for COPD, e.g., for those who are not able to – or do not want to – participate in physical exercise training. Moreover, a course of singing may enable participants to attend physical exercise training subsequently and may contribute to motivation for maintain of activity after PR. However, further high-quality research is needed to clarify relevance, feasibility, and role of singing as training modality as a part of future PR. 

Notably, current community-based singing groups for people with lung conditions are conducted heterogeneously regarding methodological approach and without documented effects and relevance, and, thus, do not necessarily confer the same effects as we have found in our studies. However, group singing seems to be a safe and joyful activity, and the current advice for health professionals considering recommending their patients for joining a local singing group would still be: “Do go ahead, but don’t skip your physical training!”

References

1. Kaasgaard M, Rasmussen DB, Andreasson KH, et al. Use of Singing for Lung Health as an alternative training modality within pulmonary rehabilitation for COPD: a randomised controlled trial. Eur Respir J. 2022;59(5):2101142. doi:10.1183/13993003.01142-2021
2. Kaasgaard M, Rasmussen DB, Løkke A, Vuust P, Hilberg O, Bodtger U. Physiological changes related to 10 weeks of singing for lung health in patients with COPD. BMJ Open Resp Res. 2022;9(1):e001206. doi:10.1136/bmjresp-2022-001206
3. Kaasgaard, Mette. Singing in Pulmonary Rehabilitation of People with Chronic Obstructive Pulmonary Disease (COPD). PhD thesis. Aarhus University; 2022. https://drive.google.com/file/d/1vuXJuFaHZLnDQMNYZEj4RXWLowqoj6En/view?usp=sharing
4. Vogelmeier, C., et al. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD Report. 2022.; 2022. https://goldcopd.org/2022-gold-reports-2/
5. Heerema-Poelman A, Stuive I, Wempe JB. Adherence to a Maintenance Exercise Program 1 Year After Pulmonary Rehabilitation: WHAT ARE THE PREDICTORS OF DROPOUT? Journal of Cardiopulmonary Rehabilitation and Prevention. 2013;33(6):419-426. doi:10.1097/HCR.0b013e3182a5274a
6. Gibson GJ, Loddenkemper R, Sibille Y, Society ER, Lundbäck B. The European Lung White Book: Respiratory Health and Disease in Europe. European Respiratory Society; 2013. https://books.google.dk/books?id=-C_fnQEACAAJ
7. McNamara RJ, Epsley C, Coren E, McKeough ZJ. Singing for adults with chronic obstructive pulmonary disease. Cochrane Airways Group, ed. Cochrane Database of Systematic Reviews. Published online December 18, 2017. doi:10.1002/14651858.CD012296.pub2
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10. Kaasgaard M, Andersen IC, Rasmussen DB, et al. Heterogeneity in Danish lung choirs and their singing leaders: delivery, approach, and experiences: a survey-based study. BMJ Open. 2020;10(11):e041700. doi:10.1136/bmjopen-2020-041700
11. Goldenberg RB. Singing Lessons for Respiratory Health: A Literature Review. 2018 Jan;32(1). Journal of Voice. 2017;32(1):85-94. doi:10.1016/j.jvoice.2017.03.021
12. Liu H, Song M, Zhai ZH, Shi RJ, Zhou XL. Group singing improves depression and life quality in patients with stable COPD: a randomized community-based trial in China. Qual Life Res. 2019;28(3):725-735. doi:10.1007/s11136-018-2063-5
13. Bonilha, A. G J, Onofre, F., L., V M, Prado, M. Y., Martinez, J. A. Effects of singing classes on pulmonary function and quality of life of COPD patients. International Journal of Chronic Obstructive Pulmonary Disease. 2008;4:1. doi:10.2147/COPD.S4077
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15. Soriano JB, Hopkinson NS. Sing out for COPD! Eur Respir J. 2022;59(5):2102961. doi:10.1183/13993003.02961-2021
16. Yoeli H, Macnaughton J. ‘To more than I can be’: A phenomenological meta-ethnography of singing groups for people with chronic obstructive pulmonary disease. Health (London). Published online December 15, 2020:136345932097852. doi:10.1177/1363459320978520
17. Kaasgaard M, Bech Rasmussen D, Andreasson K, et al. Adherence to singing training vs. Physical training in COPD rehabilitation. In: Rehabilitation and Chronic Care. European Respiratory Society; 2021:PA320. doi:10.1183/13993003.congress-2021.PA320
18. Clift S. An Evaluation of Community Singing for People with COPD Chronic Obstructive Pulmonary Disease: Final Report. Canterbury Christ Church University; 2013.
19. Heydon R, Fancourt D, Cohen AJ. Heydon, R., Fancourt, D., & J. Cohen, A. The Routledge Companion to Interdisciplinary Studies in Singing (1st Ed.). 2020. Volume III: Wellbeing. PART I Singing and Health. Chapter 7, Pp. 86-97. Routledge." Https://Doi.Org/10.4324/9781315162546. Routledge; 2020.
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21. Holland AE, Cox NS, Houchen-Wolloff L, et al. Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report. Annals ATS. 2021;18(5):e12-e29. doi:10.1513/AnnalsATS.202102-146ST
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