Chronic respiratory disease in Ireland is a leading cause of morbidity and mortality, and places an enormous burden on limited healthcare resources. Chronic conditions such as COPD, pulmonary fibrosis and asthma can have a devastating impact on the patient and their families, affecting the holistic wellness of the person – physically, emotionally, socially and economically. Best practice advocates empowering people to self-manage their health and wellness over the long-term, with group settings particularly useful for compliance and support. The “SingStrong” project delivers interventions crafted to address these bio-psychosocial problems through community-based singing and breathing classes, education and social interaction. This intervention has proven to be exceptionally effective in terms of objective measures of health improvement, qualitative reports of participant satisfaction, and value for money.
SingStrong is the brainchild of Dr Roisin Cahalan, physiotherapy lecturer and researcher at the University of Limerick; and Limerick vocal coach and choir leader Ms Ciara Meade. In co-operation with COPD Support Ireland and with funding from the Irish Research Council, this programme of breathing and vocal exercises was first delivered to community COPD support groups in Limerick, Clare and Tipperary in 2019. An evaluation of the 8-week pilot trial was conducted with the assistance of HSE-West clinicians. The 75 participants who attended at least half of the classes were included in the analysis which showed significant improvements in physical endurance as well as non-significant improvements in spirometry and quality of life measures. Focus groups were additionally conducted to inform subsequent iterations of the programme. The feedback was universally positive with participants commonly alluding to improvements in breathing, quality of life and intervention enjoyment.
There are multiple physiological underpinnings for the efficacy of singing as an intervention in lung disease. These include utilisation of cardiorespiratory system during persistent singing training, resulting in enhanced respiratory muscles and an optimized breathing mode. In addition, singing can also cause changes in neurotransmitters and hormones, including the upregulation of oxytocin, immunoglobulin A, and endorphins, which improves immune function and increases feelings of happiness. Many patients with chronic disease display inefficient apical breathing patterns, using the smaller muscles of the neck and shoulder in preference to the primary respiratory muscles of the diaphragm and intercostals. This can lead to disordered breathing, inefficient oxygenation of skeletal muscles, and over time reduced exercise endurance, anxiety and a curtailed ability to participate in life.
SingStrong addresses these multi-pronged problems through hour-long classes which support respiratory muscle training, anxiety management and mindfulness. With the advent of COVID-19, the programme has moved online and now delivers classes to people from all over the island of Ireland. The online programme also facilitates optional breakout rooms for people to chat to others facing similar challenges. This has been a lifeline for many people living alone and cocooning due to the current pandemic. The online format has also allowed the delivery of seminars from relevant experts (physiotherapy, GP, dietician, psychologist), as requested by the members. All classes and talks are free of charge and recorded to be made available to people who cannot attend live.
At present, the majority of members are people with COPD and/or asthma, as well as a lesser number with pulmonary fibrosis or post lung cancer. We also facilitate specific classes catering for people with pulmonary fibrosis and residual lung issues post COVID-19. This cohort poses a challenge to clinicians due to the unknown and evolving nature of the disease. However initial data indicates a high incidence of disordered breathing and suboptimal oxygen saturation in a marked proportion of people post Covid-19, including both ventilated and non-ventilated patients. The trial will evaluate the impact of a targeted breathing retraining and singing programme over a ten-week series of bi-weekly classes.
The founders of SingStrong aim to train a network of vocal coaches skilled in singing for lung health, to support/partner a national network of community based lung-health groups once COVID-19 is under control. The intention is also to continue with online classes to overcome logistical difficulties for people unable/unwilling to attend in person. The joy of this programme is that it is an exercise programme underpinned by clinical rationale, and delivered with specific health aims in mind. But because it is great fun, it doesn’t feel like exercise, and as such compliance is excellent and people are exercising without realising it.
For more information on SingStrong, please contact Katie McIntyre: SingStrong@copd.ie
Dr Roisin Cahalan is a senior lecturer in respiratory and cardiovascular physiotherapy at the University of Limerick. Ms Ciara Meade is a professional singer, trained vocal coach and choir leader with an MA in community music.