Examining the benefits of singing in a choir designed for adults with breathing difficulties

1. Examining the benefits of singing in a choir designed for adults with breathing difficulties C. Jane Gosine1, Kalen Thomson2, Michael O’Keefe1, Jamie Farrell2and Susan Avery2 Memorial University School of Music1 and Faculty of Medicine2 Institute for Life Course and Aging University of Toronto, 28 September 2017

2. Choir objective • to create an environment in which the limitations imposed by participants’ medical conditions need not impact on their ability to participate fully in the choir sessions. • to teach breathing and vocal exercises based on practices used by singers, respiratory therapists, physiotherapists and speech pathologists to use in everyday life. • to provide a support group for participants with accurate information from health-care professionals. • to offer an opportunity for experiential learning for music students.

3. Research overview • using quantitative and qualitative methodologies, focus of study was to examine whether participation in a choir could benefit people with breathing difficulties. • collaborative project between Faculty of Medicine and School of Music. • Ethics clearance was granted through the Health Research Ethics Authority – provincial ethics review body.

4. Context • 65 million people live with COPD globally (WHO, 2015) • Over 800,000 diagnosed cases of COPD in Canada (Statistics Canada, 2014) • Over 1.6 million Canadians may have undiagnosed COPD (Canadian Lung Association) • Almost 13,000 people in Newfoundland and Labrador living with COPD (Statistics Canada, 2014)

5. Select bibliography McNaughton, A. et al. (2016) Sing Your Lungs Out: a qualitative study of a community singing group for people with chronic obstructive pulmonary disease (COPD) British Medical Journal Bonilha, A., G. et al (2009). Effects of singing classes on pulmonary function and quality of life of COPD patients. International Journal of COPD Goodridge, D. et al (2013). Therapeutic singing as an adjunct for pulmonary rehabilitation participants with COPD: outcomes of a feasibility study. Music and Medicine Lord, V. M. et al. (2010) Singing teaching as a therapy for chronic respiratory disease — a randomised controlled trial and qualitative evaluation. BMC Pulmonary Medicine Lord, V.M,. et al. (2012) Singing classes for chronic obstructive pulmonary disease: a randomized controlled trial, BMC Pulmonary Medicine, 12, 69. Morrison et al. (2013) A UK feasibility study on the value of singing for people with Chronic Obstructive Pulmonary Disease (COPD). UNESCO Observatory Multi-Disciplinary Research in the Arts

6. Skingley, A. et al. (2014) Singing for Breathing”: Participants' perceptions of a group singing programme for people with COPD. Arts & Health 6:1, pages 59-74.  Clift, S. et al. (2013). An evaluation of community singing for people with COPD (Chronic Obstructive Pulmonary Disease) Meadows et al.  (2017) Singing for Better Breathing: Findings from the Lambeth & Southwark Singing and COPD Project. Project report. Sidney De Haan Research Centre for Arts & Health: Canterbury Christ Church University, Kent, UK  Lewis, A. et al. Singing for Lung Health – a systematic review of the literature and consensus statement npj Primary Care Respiratory Medicine, 26. Lewis  et al. (2017) Singing for Lung Health: a qualitative assessment of a British Lung Foundation programme for group leaders. BMJ Open Respiratory Research 2017;4:e000216.  McNamara, R. (2016). Singing for adults with chronic obstructive pulmonary disease (COPD). Cochrane Database of Systematic Reviews.

7. Gale, N. et al. (2012). A pilot investigation of quality of life and lung function following choral singing in cancer survivors and their carers. ecancer 6 261 Fancourt, D. et al. (2016). Singing modulates mood, stress, cortisol, cytokine and neuropeptide activity in cancer patients and carers. Ecancermedicalscience, 10, 631. Vickhoff, B. et al. (2013). Music structure determines heart rate variability of singers. Frontiers in Psychology 9 July 2013 Teater, B. et al. (2012). Singing for successful aging: The perceived benefits of participating in the golden oldies community-arts program. The British Journal of Social Work volume 44, Issue 1, 1 January 2014, Pages 81–99 Skingley A. et al. (2010) Therapeutic effects of music and singing for older people. Nursing Standard, 24 (19). Pearce, E. (2016) Is Group Singing Special? Health, Well-Being and Social Bonds in Community-Based Adult Education Classes. Journal of Community & Applied Social Psychology 26:6, pages 518-533. 

8. Participants for the choir were recruited through: • Pulmonary Rehabilitation • Memorial University • Remote Patient Monitoring at Eastern Health • Better Breathing Choir webpage • Religious organizations • Lantern webpage (rehearsal venue) • Choirs • through the media, such as local radio interview

9. Eligibility for choir membership • self identify with having lung disease or breathing difficulties • family member • no need to have any previous musical experience • no need to read music • no registration

10. “We are among people who understand our limitations and don’t look down upon us because we had to cough or breathe as and when we need. … I jokingly refer to it as the only choir where you can breathe and cough as you like.” “One could stop and cough without upsetting anyone.”

11. STUDY ONE • Prospective observational pilot study – participants with COPD • Self-administered Chronic Respiratory Questionnaire (CRQ-SAS) administered before and after the 10-week sessions. • Spirometry testing – administered by respiratory therapist – before and after the 10-week sessions • Questionnaires with Open Ended Questions administered at the end of the 10-week session

12. STUDY TWO • Ethnographic study • Questionnaires with open ended questions administered at the end of the second session to all participants • Participant observation

13. Diagnosis: • chronic obstructive pulmonary disease (COPD) • cancer • asthma • pulmonary fibrosis • emphysema • bronchiectasis • Parkinson’s disease

14. Requirements for rehearsal venue • accessibility • parking close to building • scent-free environment • good air quality – no mold • warm environment • seating appropriate for singing • kitchen close to rehearsal space

16. Choir session structure Welcome period; breathing exercises; posture exercises; relaxation; physical and vocal warm-ups Repertoire chosen for breath awareness/control and the musical preferences of group members Social time and presentations to develop support networks and sense of community

17. Part One: Posture, breathing and vocal exercises • welcome • reminders of good posture • relaxation/breathing exercises • facial massage, yawns • pursed lip and diaphragmatic breathing • physical warm-ups: dynamic stretches – neck and shoulder shrugs and circles, head turns and side stretches, gentle back bends, lower back twists, and coordination exercises • “I like the social milieu. I also feel good exercising with other people. There is a very friendly atmosphere.”

18. “we learned new exercises which encouraged me to do more at home.”

19. Repertoire Bella Mama Swing Low medley Have you seen the ghost of John Heigh Ho! Make new friends One bottle of pop Agnus Dei (Harwood) Amazing Grace Annie’s Song Ash grove Aura Lea Black Velvet Band Blowing in the wind By the glow of the kerosene light Cliffs of Baccalieu Cod liver oil Danny Boy Drink to me Four Strong Winds Hallelujah Hey Jude In Dublin’s Fair City Lady Madonna Let it be Let me fish off Cape St Mary’s Saltwater joys St John’s waltz Song of Newfoundland Take me home country roads Try to remember West country lady Christmas music – various

20. “No pressure on those who were not musically talented” “No tunes in me but sang along”

21. Guest presenters during social time • Susan Haskell, Respiratory Therapist, Eastern Health, Puffer technique and inhaled medication devices • Raymond Down, MScPT, BPAS, Clinical physiotherapist, Eastern Health Exercise as medicine • Susan Haskell, Respiratory Therapist, Eastern Health, Using the Air Quality Health Index • Susan Haskell, Respiratory Therapist, Eastern Health Dangers of radon • Kim Ghaney, Registered Nurse, Eastern Health, Supporting Health. At Home. Remote Patient Monitoring Program • Carolyn Jerrett, Nutritionist, The Secret to Healthy Eating • Gladys Schofield, Registered Nurse, Eastern Health and Centre for Nursing Studies, Memorial University, Understanding Influenza and Pneumococci disease

22. “I appreciate the lectures … and I still keep learning about chest conditions and new methods that are coming out.”

23. Perceived benefits of choir participation • social wellbeing • physical health • mental health • personal development or continued education

24. Belonging – Friendship

25. Belonging and Friendship “The social aspect is very important to me. It gave me something to look forward to each week as it is the only outside activity that I do.” “A very nice and friendly group of participants, almost like a musical family.” “Loved camaraderie – Fellowship – New acquaintances” “Making new friends and having a cup of tea. To relax for night out.”

26. Shared life experiences – understanding

27. Shared life experiences “It is interesting to meet other people with pulmonary problems.” “Meeting new people who have the same problems I do.” “It makes me think that my condition is not as serious as I thought it was.”

28. “I had been involved with choirs since I was about seven years old but had to stop because of my lung condition... I have a form of leukemia which has compromised my immune system and as a result I have had numerous lung infections ... All of this has left me with a chronic cough which can be triggered by anything. No choir will accept a person who cannot either hold and control a deep breath and certainly not one who cannot control a sustained coughing spurt.”

29. Intergenerational learning

30. Intergenerational environment “Students – a real treat. Nice to have young people around.” “[I] like that there are young music students in the mix.”

31. Perceived benefits of physical warm-ups, breathing exercises, vocal exercises and singing

32. “Better breathing at a time when I need it.” “The choir is the best lesson for people with COPD to help open up their lungs to have better breathing and have more confidence in themselves. It’s very beneficial to people like myself.” “The biggest challenge is opening up my airways and my vocal cords. Great exercise for lung condition.” “[I feel] like my lungs have a workout.” “a lot like aerobics because you are encouraged to take deeper breaths thus more oxygen and maybe the release of “happy’ hormones.”

33. Breath awareness and control “I enjoyed the breathing exercises because they gave me a greater awareness of how I can get better and controlled breaths.” “I find myself conscious of developing better breathing by diaphragmatic breathing more after and by following exercises with conscious breathing effects.” “I’m more conscious of making an effort to breathe deeply both in and out.” “The breath control while singing is great exercise for the lungs.”

34. Deeper breathing “It made me realize the need for deep breathing to strengthen my lungs.” “I feel I have learned to take deeper breaths and hold for a while.” “I now know when I am required to take in a deep breath or shallow breath and when to hold a note.”

35. Relaxation and release “It makes me forget tensions and I get happy.” “The relaxation exercises are so important. It helps me, and I expect others, to focus on ourselves and forget the trials and tribulations of the day behind us.” “I feel relaxed and glad that I have been participating. Music makes me feel happy.” “At the end of the session I leave relaxed, happy and recharged.” “Uplifted, relaxed and energized.”

36. Positive feelings “Upbeat and positive.” “Invigorated.” “Good for having participated in something positive.” “Very positive highlight of the week.”

37. Increased overall confidence “I feel content, happy and good about myself” “Increased [my] self confidence and self esteem.” “Best program for COPD patients is to have social activity with others and shows them that anyone with this sickness can sing and feel better about themselves when it’s over.” “it makes a COPD person feel like a person and that they can participate in singing.” “it made me feel I can be part of a group and not need to worry that I have to cough a lot. Gave me back some self confidence.”

38. Increased musical confidence “The singing gave me the confidence that I could sing again, having not done so for about 15 years.” “I feel that I can sing in the choir no matter how bad I sound.” “The singing itself was fun and I definitely feel more confident in singing with the group now.” “Gave me the confidence to try and sing again despite all my mistakes.”

39. Lifelong learning

40. Continuing musical education: challenges and success “For me it has been a great learning experience.” “I feel that I have gained new skills, knowledge and understanding of the notes.” “it is a great learning experience for one who has absolutely no musical training. Learning when to breathe and hold a note. Even the pattern of the squiggles on the music sheets are beginning to make some sense.”

41. Practice at home “Didn’t do any singing at home until I got the disc of music, which I have sung with since.” “I learnt new pieces by sight reading. I sang through all the songs at least twice a week and any I knew, I sang as I performed some daily tasks around the house.” “My biggest disappointment is the fact that I cannot read music, so when I get home I usually cannot remember the tune of the music, so it makes it difficult to practice, but my experience attending the choir is 100% more than I expected.”

42. Music student involvement

43. “I have lived my whole life with my facilities to create, perform and listen to music without any issues. However, it was not until I started working with the Better Breathing Choir that I realized this ability is not one to be taken lightly… I have been able to witness the positive impacts of music on a group of people who otherwise may not have been able to participate…”

44. “Empowerment does not occur to the individual alone, but has to do with experiencing a sense of shared experience and connectedness with other people” (WHO, User empowerment in mental health, 2010 )

45. “I think music groups for other people going through medical problems, would promote their sense of well being, help them feel that they are not alone, and would give them the opportunity to focus, not on their illness, but on their enjoyment.”

46. https://betterbreathingnl.wixsite.com/bbnfld https://betterbreathingchoir.wordpress.com jgosine@mun.ca