The main findings of this study are that (1) the program of singing classes improved quality of life and anxiety but did not improve the control of breathing measures, or functional exercise capacity. (2) In interviews, patients who had participated in the trial reported benefits in their physical performance and general well-being as well as a sense of achievement and self-efficacy. (3) Individuals who chose to participate in the open singing sessions were overwhelmingly positive about the experience.
Significance of findings
The idea that singing was beneficial for health goes back at least to the 19
th century [
24]. Two previous studies have looked specifically at singing in COPD patients. Bonilha
et al randomised patients to either singing lessons, or a handicraft class once a week for 6 months [
10]. Although singing practice produced an acute increase in inspiratory capacity, implying a reduction in gas trapping, it did not alter basal dyspnoea index (BDI). SGRQ improved equally in both groups and the singing group had an improvement in maximum expiratory pressure. Exercise capacity was not assessed. Engen studied 7 patients with emphysema who attended twice weekly vocal instruction classes for 6 weeks [
23]. There was no change in spirometry, inspiratory muscle strength or exercise capacity, but patients had an improvement in single breath counting, which was associated with a change from a 'clavicular' to a 'diaphragmatic' pattern of breathing. In that study there was no control group and the teacher was not blind to the outcome measures.
In the present study, anxiety score and physical component score of the SF36 improved and participants who were interviewed reported that they felt that the singing had been helpful in their everyday lives. HAD scores were not particularly high at baseline and patients were selected on the basis that they had symptomatic COPD and were able to attend, rather than because they were felt specifically to have a dysfunctional breathing pattern or psychological difficulties. It is possible that greater improvements might be found in particularly anxious sub-populations. The benefit in the physical rather than the mental component is consistent with the open workshop participants' reports that they felt physically different after the sessions.
The immediate benefits reported by patients participating in the open workshops and from the interviews with singing patients are consistent with the previous observation that singing has an acute effect of reducing gas trapping [
10]. Most reported sustained physical benefits, specifically identifying the value of learning breathing control. Several participants also mentioned that they felt that it was important to keep up the vocal exercises and singing in order to maintain any gains which may suggest that a longer period is necessary.
The present study is also consistent with previous work that has found that singing training does not change, at least over the time courses explored to date, parameters such as exercise capacity [
10,
23]. We had expected that even if the singing class did not improve exercise tolerance it might hasten recovery, with patients adopting a more efficient breathing strategy. However, recovery time for heart rate, oxygen saturation or symptoms did not improve. Given the subjective benefits in physical sensation described by patients, the lack of change in exercise capacity is interesting. One possibility is that the improvements are entirely mediated in a psychological fashion. Since anxiety and depression are common and important co-morbidities in COPD [
25,
26] a novel approach to dealing with them could in any case be useful, particularly a non-drug treatment. An analogy would be the use of exercise prescriptions to treat depression [
27]. Given the clear effects on wellbeing mentioned by the participants, one could also speculate that there might be benefits to efficacy and control in the absence of great physiological improvement. A patient's experience of their illness will be affected by a range of psychosocial factors in addition to their physical condition. All patients interviewed reported doing more singing and other pleasurable activities in their lives, suggesting that there may be long term benefits to participation in such a group. Consistent with this, singing has been used with some success in small studies to treat chronic pain where it seemed to improve coping [
15] and after knee surgery [
28].
A second possibility is that the 'dose' of singing was insufficient to alter conventional measures of breathing control or exercise capacity and that a longer or more intense period would be required to produce changes apparent in daily life. The singing teacher reported that she felt that after 6 weeks she was "only just starting to make progress" with many of the participants.
It is interesting that in the current study, patients reported that what was identified to them as a 'diaphragmatic' breathing pattern was helpful. This involves facilitating outward movement of the abdomen while reducing upper ribcage movement during inspiration. It has been thought to be helpful in some patients, but although a reduction in oxygen cost of breathing has been noted [
29], the approach has been associated with both an increased sensation of breathlessness and reduced mechanical efficiency in severe COPD [
30,
31] and is not recommended for routine use in the recent British Thoracic Society/Association for Chartered Physiotherapist in Respiratory Care(BTS/ACPRC) guidelines on "Physiotherapy management of the adult, medical, spontaneously breathing patient" [
12].
The improvement in breath hold time observed in the control group was unexpected. A strength of the study was that the singing teacher was blind to the outcome measures used so could not "teach to the test". The teacher speculated that the singing group may have learnt to take a more controlled or comfortable breath and therefore smaller breath in, leading paradoxically to a reduction in breath hold time. Hyperventilation has been shown to increase breath hold time in patients with respiratory disease which might also be relevant [
22].
If the benefits of participating in a singing group are largely psychological, it would suggest that attention would need to be focused on the aspects of the singing that addressed this, or even on the choice of material, rather than focussing on particular nuances of technique. Singing is, of course, likely to be a therapy that suits some people and not others, and the benefits that accrue are likely to be greatest in those who enjoy the experience. This is to some extent different from pulmonary rehabilitation where the health benefits of exercise are generally accepted. As with pulmonary rehabilitation the physiological and psychological effects could be complementary.
A limitation of our study was the absence of an active control group. The previous paper of Bonilha et al. showed similar improvements of quality of life in patients submitted to singing training or handcraft artwork [
10], so the observed improvements in anxiety and quality of life in the trial may have been due to regular contact with a social group rather than the singing specifically. However, in our study patients reported immediate positive effects on well being (probably because of a reduction in dynamic hyperinflation [
10]) and this may therefore have reinforced participation in singing groups (as opposed to other 'social activities' which, although social have no physical effect), making the provision of singing classes a good strategy for reducing social isolation, a significant problem in chronic respiratory disease [
32].