Singing for better breathing: findings from the Lambeth & Southwark singing and COPD project.

Introduction
Over the last eight years there has been a growth of interest in the potential value of participation in singing groups for people with chronic obstructive pulmonary disease (CODP) and other respiratory illnesses. This is shown by the increasing number of singing for breathing groups established across the UK over this period. The British Lung Foundation have taken a leading role in promoting this activity through their ‘Singing for Lung Health’ programme.

A limited number of small-scale research studies have assessed the benefits of singing for people with COPD and other lung conditions. These include three randomised controlled trials, one in Brazil, and two conducted at the Royal Brompton Hospital in London. Further studies have been carried out in Canada, New Zealand, the UK and the USA. There is limited evidence that singing improves lung function and exercise capacity, but qualitative feedback from participants has been highly positive. Testimonies point to singing having substantial subjective benefits for physical, psychological and social wellbeing, and in enabling people with COPD to better manage their lung condition.

The current study in Lambeth and Southwark, South London, was based on earlier research conducted in East Kent, UK. Morrison et al. (2013) established and evaluated a network of six community singing groups for people with COPD which ran over the course of ten months. Seventy-two people with COPD were followed up
over this time and assessed using validated questionnaires, with St. George’s Respiratory Questionnaire (SGRQ) as the primary outcome measure. Spirometry was also used to assess lung function. Significant improvements were found on the total and impact scores from the SGRQ, and participants also improved in their lung function.

Project and evaluation.
The aim of the current study was to further test the feasibility of setting up a network of community singing groups for people with COPD to run over the course of ten months from end of September 2015 to end of July 2016. Recruitment took place over the period April-September 2015. The study involved two cohorts, assessed
in September 2015 and January 2016. The two groups were comparable on all baseline measures, and were combined for the purpose of the evaluation. A total of 60 participants with breathing difficulties were recruited into the study.

Assessment included a battery of validated questionnaires, with the SGRQ as the primary outcome measure. Questions were also included on use of health and social care services and medication, including the use of inhalers. Participants underwent a comprehensive assessment to measure lung function. The principal measures were the amount of air expelled forcibly from the lungs in one second (FEV1); the total volume of air forcibly expelled from the lungs (FVC), and distance walked in six minutes – the Six-Minute Walk Test (6MWT).

Singing groups met weekly over the course of the project in four venues, led by two experienced and skilled facilitators. Three groups started in late September/early October 2015 and ran for 38-40 sessions and a fourth group, commenced in January 2016, and ran for 25 sessions.

At follow-up, 44 participants completed the questionnaires again and 42 completed the lung and exercise assessments (attrition rate 27-30% due to health issues and family commitments). In addition, 37 participants took part in a structured interview in April/May 2016 to gather feedback on their experiences of the singing groups and their perceptions of any benefits gained. Average level of attendance was 26 sessions, with approximately 82% participants attending at least 20 sessions. Filming and photography was also used throughout to provide a documentary record of the project, and the final film giving an account of the whole project is included with this report.

Sidney De Haan Research Centre for Arts and Health
Findings from the Lambeth and Southwark Singing and COPD Project 3

Among the participants followed-up, 31 were shown to have COPD from the lung function tests at baseline (FEV1/ FVC <0.7) - six mild, 15 moderate, nine severe, and one very severe. Findings for the total sample and for those with COPD are presented, but particular attention is given to the changes seen for participants with COPD.

Findings
The principal quantitative findings for the COPD group were as follows:
• A significant improvement on the SGRQ symptom scale
• Participants with COPD reported ‘fewer bad days’ and ‘more good days’
• No change on FEV1
• A small but statistically significant decline in FVC
• A small but statistically significant increase in FEV1/FVC
• No change in distance walked on the 6MWT
• No change in breathlessness after the 6MWT
• No change in reported health service use

The accounts provided in the interviews were consistently and highly positive. Participants claimed that regular singing helped them in managing their respiratory symptoms, and reported improvements in mental wellbeing, attributing this to the singing group. Social benefits were also described, extending to participants meeting outside of the singing sessions, and group members providing each other with support and advice.

Reflections
Our study shows that COPD patients who took part in singing groups experienced a reduction in symptoms, as measured by the St. George’s Respiratory Questionnaire. Detailed structured interviews also revealed a wide range of physical, psychological and social benefits, which together substantially improved the wellbeing of participants. In addition, lung function and functional exercise capacity was maintained throughout the course of the 6 – 10 month singing intervention.

The findings add to the previous body of research in supporting the value of regular singing for people with COPD, and other respiratory conditions. We agree with the conclusions reached in a recent systematic review (Lewis, et al., 2016) that further, larger-scale controlled trials are needed to establish benefits and address a range of outstanding questions on effective delivery.

Confounding factors of weather and background air pollution may have had some impact on the participants in this study. Such factors can only be controlled for through multi-centre trials in which an intervention is run over a wide geographical area including inner-city and rural locations.

Our experience of difficulties with recruitment indicates the need for greater resources, time and effort to ensure sufficient numbers for any future studies on singing for people with lung disease.