Technology and Health Care 22 (2014) 53–61 DOI 10.3233/THC-130773 IOS Press

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Role of music in the management of chronic obstructive pulmonary disease (COPD): A literature review Atman Panigrahia , Shardul Sohanib , Chioma Amadib and Ashish Joshib,∗ a Asian

Institute of Public Health, Bhubaneswar, India for Global Health and Development, College of Public Health, University of Nebraska Medical Center, OH, USA

b Center

Received 22 July 2013 Accepted 23 December 2013 Abstract. INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a pulmonary disease characterized by airflow limitation that is not fully reversible. It is projected to be the third leading cause of death worldwide by 2020. The objective of the study was to examine the impact of music on psychological and physiological outcomes among individuals with COPD. METHODS: The scientific databases PubMed, google scholar and EBSCO were used to search for relevant articles published during a period of 01/01/2005 to 12/31/2012. The search terms “Music and COPD”, “Music and Emphysema”, “Singing and COPD”, “Singing and Emphysema” , “music improves COPD” and ”singing therapy on COPD”, were used either in single or in combination. The inclusion criteria included studies having an experimental study design, were written in English and were conducted among individuals age 18 years and above. Studies that focused on the healthy population or had a disease other than COPD were excluded. Studies where music therapy was not the primary intervention and were systematic reviews were also excluded from the final analysis. Variables analyzed included year of publication, study location, study setting, target audience, study design, sample size, study duration, intervention and its components and the outcomes including physiological and psychological were assessed. RESULTS: A total of 7 papers that met the inclusion criteria were included in the final analysis. Studies included various music interventions such as singing, listening and playing music. Forty percent of the studies were performed in US. More than half of the studies (70%, n = 5) had a randomized control study design and were performed in a hospital setting. The duration of the studies varied from 6 weeks to 21 months. The sample size in these studies varied from 7 to 72. Music showed improvement in the psychological outcomes such as quality of life, dyspnea and anxiety and mixed results in the improvement of physiological outcomes such as FEV, FVC, and breathing control among individuals living with COPD. DISCUSSION: More research of a longer duration and with a larger sample size is needed to examine the impact of music interventions on clinical, functional, psychological and physiological outcomes among COPD individuals.

1. Background Chronic obstructive pulmonary disease (COPD) is a pulmonary disease in which the airways narrow over time resulting in limited supply of air to the lungs thereby causing a shortness of breath or dyspnea [1]. The condition is difficult to reverse and gets worse if not treated swiftly. Smoking, various ∗ Corresponding author: Ashish Joshi, Center for Global Health and Development, Department of Health Services Research Administration, College of Public Health, OH, USA. Tel.: +1 402 559 2327; E-mail: [email protected]

c 2014 – IOS Press and the authors. All rights reserved 0928-7329/14/$27.50 

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A. Panigrahi et al. / Role of music in the management of chronic obstructive pulmonary disease

environmental exposures such as asbestos and genetics are some of the known causes of COPD. It is also projected to be the third leading cause of death worldwide by 2020 [1]. COPD caused for more than 3 million deaths in 2005 which accounted for about 5% of the deaths in that year [2]. The cost to treat COPD was projected to be nearly $50 billion which included $29.5 billion in direct health care costs, $8.0 billion in indirect morbidity in the year 2010 [3]. The diagnosis of COPD is done through multiple lung function tests and is confirmed via spirometry [4]. Spiometric tests measure the forced expiratory volume in one second (FEV1), and the forced vital capacity (FVC). The ratio of these two tests provides the diagnosis of COPD [5]. Introduction of complementary and alternative therapies like Acupuncture, Balneotherapy or Music therapy have been employed as solutions to various health problems and has been an integral part of various treatment regimes. Acupuncture, an ancient form of Chinese therapy deals with translation of vital energy and its efficacy has been evident in various medical conditions. Traditional medicine indicates numerous mechanisms of physiologic effects of acupuncture. However, it is unclear if the observed effects in clinical studies are due to the precise effects of acupuncture or just broad effects frequently referred to as ‘placebo’ [6]. Balneotherapy or thermotherapy has three subgroups of therapies including thermal and mineral bath therapy, hydroelectric bath therapy and near infrared hyperthermia treatment. They are defined according to the type of water used and are traditionally used in countries like Turkey and Israel [7]. Music therapy is one of the complementary or alternative therapies that belong to the category of “mind-body medicine” [8]. Music therapy is an active or passive use of music to bring about a clinical change. Active therapy involves patients or subjects playing a musical instrument or singing while passive therapy is more focused on listening of various types of music as suggested by the therapist [9]. Music therapy has been subject to substantial research especially in the treatment of chronic conditions. Previous research indicates that live music provided by a music therapist is more effective than recorded music. The use of music therapy has been implemented in multiple health care settings as a treatment or an adjunct to the treatment to cure various diseases. The evidence of the beneficial effects music therapy in palliative medicine has been documented [16, 17]. Studies have suggested that the mastery techniques of posture and breadth control gained from singing could have an impact on improving respiratory control and reducing hyperinflation, commonly experienced by COPD patients [16,17]. The relaxation effects of singing also showed a positive impact on the quality of life of COPD patients through its influence in reducing anxiety and dyspnea [18]. The objective of this literature review is to examine the role of music therapy in the management of Chronic Obstructive Pulmonary Disease (COPD) patients. 2. Methods The scientific database PubMed was used to search for relevant articles published during a period of 01/01/2005 to 12/31/2012. The search terms “‘Music and COPD”, “Music and Emphysema”, “Singing and COPD”, “music improves COPD”, “singing therapy on COPD” and “Singing and Emphysema” were used either in single or in combination. The inclusion criteria included studies having an experimental study design, were written in English and were conducted among individuals age 18 years and above. We excluded studies where the population studied was healthy or had a disease other than COPD. A total of 41 research papers were obtained using the above defined inclusion criteria. Studies where music therapy was not the primary intervention and were systematic reviews were also excluded from the final analysis (Fig. 1).

A. Panigrahi et al. / Role of music in the management of chronic obstructive pulmonary disease

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Scientific Database: PubMed Search limits: 2005-2012 Search terms “Music and COPD”, “Music and Emphysema” “Singing and COPD”, “Singing and Emphysema” ‘music improves COPD’, ‘singing therapy on COPD’

Exclusion Criteria

N=41

Inclusion Criteria

Not related to Music

Study subjects with COPD

Studies performed on healthy individuals

Experimental Study design

Not related to COPD

Published in English Final analysis N= 7

Age 18 years and above

Fig. 1. Inclusion and exclusion criteria.

2.1. Variables extraction Following variables were extracted from the studies included in the final analysis; – Publication Year: Information was gathered about the number of articles during for every year included in the final analysis. – Study location: Information was also gathered to determine the number of studies done in US compared to those outside US. – Study setting: Information gathered included whether studies were done in a hospital, home or an outpatient clinical setting. – Socio-demographic information: included variables such as age and gender of the study population was also recorded. – Study design: Studies were randomized clinical trials or had a pre-post study design was determined. – Sample Size: The average number of subjects that were enrolled in each study was determined. – Study duration: The duration of every study was extracted from the various articles that were included in the final analysis. – Intervention and its components: Information was gathered about the various intervention approaches such as singing, listening to music or a combination of both was extracted. Further information was gathered to specifically assess the type of intervention, sessions duration, and mode of delivery were also extracted from the articles included in the final analysis. – Outcome variables assessed: These included both physiological and psychological outcomes. Limitations of each study were also assessed so that areas of further research can be identified. 2.2. Statistical analysis Descriptive analysis was performed to report the frequency distribution of the various variables extracted for the analysis. Means, standard deviations and range were reported for the continuous variables while frequency distribution was done for the categorical variables. All analysis was performed using SAS V9.1.

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A. Panigrahi et al. / Role of music in the management of chronic obstructive pulmonary disease Table 1 Description of the studies included in the final analysis

Study ID 1

Year of publication 2010

Study location UK

Sample size 36

2

2009

Brazil

43

3 4 5 6 7

2009 2005 2012 2012 2013

India US US UK Canada

72 11 28 24 21

Study population Patients with chronic respiratory disease Patients with respiratory disorders Patients with COPD Patients with COPD Patients with COPD Patients with COPD Patients with COPD

Study duration 6 Weeks

Study setting Hospital

24 weeks

Hospital

21 months 9 weeks 10 weeks 8 weeks 8 weeks

Hospital Clinic Hospital Hospital Hospital

Table 2 Intervention and its components Study ID 1

Setting Hospital

Intervention type Singing

Intervention duration 6 weeks

Session duration One hour weekly

2

Hospital

Singing

24 weeks

One hour

3

Hospital

Listening to music

NP

Two sessions daily of 30 minutes

4

Clinic

Singing

6 weeks

45 minutes

5

Hospital

Playing music

10 weeks

6

Hospital

singing

8 weeks

5 min not exceed 20 min twice a day One hour biweekly

7

Hospital

singing

8 weeks

One hour weekly

Intervention activities Teaching of posture, relaxation and vocal exercises Singing training, including Brazilian folk music/songs Non-lyrical Instrumental music including following instruments flute, sitar, mandolin, and mixed instrumentals. Posture and breath management exercises along with choral speaking and singing. Harmonica Vocal exercises, posture, relaxation and breadth management Relaxation and stretching exercise, singing and vocalizations exercises

3. Results The search resulted in a total of 7 articles for final analysis after they met the inclusion and the exclusion criteria. 2 each of the 7 studies were published in 2009 and 2012 and one each study was published in 2005, 2010 respectively. Forty percent (n = 2) of the studies were performed inside the US compared to the remaining 60% that were performed outside the US and included India (n = 1), Canada (n = 1), United Kingdom (n = 2) and Brazil (n = 1). More than half of the studies (70%, n = 5) had randomized control study design and were conducted within a hospital setting (Table 1). Only 1 study had a pre post study design. The duration of the studies varied from 6 weeks to 21 months. The sample size in these studies varied from 7 to 72. Hundred percent of the studies (n = 7) reported age and gender of the subjects (Table 2). 3.1. Intervention and its components Majority of the studies were hospital based and the various interventions included singing (n = 5), listening to music (n = 1) and playing harmonica (n = 1) (Table 2). The various interventions lasted

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Table 3 Physiological and psychological measurements Study ID

1 2 3 4 5 6 7

Forced vital capacity (FVC) X X

Physiological measures Force expiratory Pulse/Respiratory volume (FEV) rate

X X

Breathing control

Psychological measures Dyspnea Quality of life

X X X X X X

X X X X

X X

X X X X X

X X X X X X

from 6 weeks to 24 weeks. The duration of each session of singing was about 45 minutes to 1 hour (Table 2). In the study conducted by Lord et al., of the 36 patients, 20 were allocated to the singing group and 16 to the control group. Two subjects from the singing group and one participant from the control group withdrew from the study; three did not attend the final assessment once completing the workshops. The teacher who taught singing to the intervention group was blinded to the outcome measures used hence could not “teach to the test”. Physiological and Psychological outcomes: All the studies examined the impact of music on physiological (100%; n = 7) and psychological variables (100%; n = 7) (Table 3). The physiological measurements included Forced Vital capacity (FVC), Force Expiratory Volume (FEV), respiratory rate and breathing control. Psychological measurements included variables that would influence or were intended to influence the mind or emotions. These variables included dyspnea, quality of life and anxiety. Most of this data was collected through various validated surveys or questionnaires. Physiological and psychological variables assessed for each study have been outlined in Table 3. Functional Exercise capacity (n = 1), FEV1/FVC ratio (n = 1), Expiratory Reserve volume, (n = 1) Inspiratory capacity (n = 3), Progressive Muscle relaxation (n = 1) and total lung capacity (n = 1) were the other physiological measures that were performed to examine the lung functions. Anxiety (n = 2) was other psychological measure assessed in these studies. Further information was also gathered to determine the various instruments that were used to assess the outcomes assessed in this literature review (Table 4).

4. Results 4.1. Psychological outcomes In the study conducted by Lord et al, patients were allocated to the singing and the control group. Study participants characteristics did not differ at the baseline. The intervention group showed significant improvement in HAD anxiety score −1.1(2.7) vs. +0.8(1.7) p = 0.03 and SF-36 physical component score +7.5(14.6) vs. −3.8(8.4) p = 0.02. The comparison of mean Saint George’s Respiratory Questionnaire (SGRQ) variations between the groups was not significant; the difference between the final and initial values reached at least 5 points in each group (14). It was found that practicing singing caused small but significant increase on the Borg dyspnea scale 2 minutes after the end of the singing exercise (14). The Spielberger’s trait anxiety inventory (STAI) main effect was statistically significant F = 19.528,

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A. Panigrahi et al. / Role of music in the management of chronic obstructive pulmonary disease Table 4 Instruments used to assess various physiological and psychological outcomes

Study ID 1

Outcomes measured Anxiety, Well-being and daily life Control of breathing Dyspnea Score Heart rate

Measuring tool St George’s Respiratory Questionnaire Short form 36 Breath hold test and Single breath counting Borg’s Dyspnea score Incremental shuttle walk test

2

FVC, FEV1, FEV1/FVC, IC and ERV Inspiratory & expiratory pressures Dyspnea Quality of life

Spirometry Basal Dyspnea Index Saint George’s Respiratory Questionnaire

3

Dyspnea Anxiety Pulse and Respiratory Rate

Visual Dyspnea Scale State trait anxiety inventory Counting movement of chest wall or abdomen rise for a minute

4

FEV and Inspiratory threshold Distance walked in 6 minutes Breath control and Breathlessness Dyspnea Quality of life general well being

Pulmonary function meter Modified Borg symptom rating scale Visual analog scale, Duke health profile

5

Resting heart rate and SpO2. Maximal inspiratory and expiratory pressure Shortness of Breath Health-Related Quality of Life Functional Exercise Capacity

Shortness of Breath Questionnaire Short Form 36 Human Activity Profile (HAP), The 6-minute walk

6

Breathing control Functional exercise capacity Daily physical activity Dyspnea Health related quality of life Anxiety and depression

Breadth hold test and single breadth counting Incremental shuttle walk test Sense wear pro activity monitor Borg dyspnea score Short form 36 (SF-36) Hospital anxiety and depression scale

7

Functional exercise capacity Heart rate and blood oxygen saturation Health related quality of life Illness perception Feasibility measures

Six minute walk test Pulse oximetry SGRQ questionnaire Brief illness perception questionnaire Number of therapeutic singing sessions attended

p = 0.000, but interaction effect F = 8.222, p = 0.000 was not of clinical significance. Mean difference in dyspnea reductions in music group was 23.1. Measures like Shortness of Breath Questionnaire (SOBQ), role of physical vitality, social functioning and 6-minute walk test (6MWD) were found to be significantly different [15].

4.2. Physiological outcomes Respiratory rate showed significant main effect across two sessions and interaction effect across two groups [11]. In another study, effect of singing and respiratory exercise on COPD was examined. The study investigated numerous dependent variables measuring breathing mode, pulmonary function, diaphragmatic endurance, breath management, and perception of symptoms in a one-group pretest-posttest design with repeated measures. FEV, inspiratory threshold, or distance walked, were analyzed and were not found to be significantly different across time [12]. Functional outcomes of breath management and

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Table 5 Physiological and Psychological measurements Study ID

1 2 3 4 5 6 7

Forced vital capacity (FVC)

Physiological measures Force expiratory Pulse/Respiratory volume (FEV) rate

Yes

Yes

No change

No change No change No change No change

No change No change

No change

Breathing control No Yes No

Psychological measures Dyspnea Quality of Anxiety life Yes Yes Yes Yes Yes Yes Yes Yes No change No change Yes Yes No

breathing mode were analyzed. A significant improvement was recorded in breathing control which was sustained for about 14 days after the intervention [12]. This was evidenced by a change in breathing mode from a shallow one to a more relaxed abdominal breathing [12]. The study found that even though the treatment groups adhered to harmonica playing (Average Practice Days per Week = 5.5; Average Practice Minutes per Day = 18) there was no statistically significant difference between the intervention and the control groups. Pulmonary overall rehabilitation showed significant differences [12]. There was increase in breath hold time in the control group as compared to the singing group −0.3 (SD = 6.9) sec vs. +5.3 (SD = 5.7) sec (p = 0.03) [13]. One of the studies which compared the effects of randomizing patients to singing classes or film clubs reported no significant differences in breathing control, daily physical activity or functional exercise capacity. The study however, reported significant improvement in the physical component of the quality of life assessment, in the singing group (+12.9(19.0) compared to the film club group (−0.25(11.9) (p = 0.02) [18]. However, a study which examined the effect of singing as an adjunct for pulmonary rehabilitation in COPD patients compared to ‘usual care’ did not find significant improvements in functional exercise capacity or illness perceptions in both groups [19]. However, almost all participants in the intervention group expressed that the singing intervention had a positive impact on their breathing control (86%, n = 12). In another study, a statistically significant difference between two groups regarding the measurement of PEmax was seen. The control Group exhibited a mean decrease in PEmax close to 11 cm H2 O compared to the Singing Group showed an increase of 3 cm H2 O. This was the most important finding of this study [14]. A significantly higher SaO2 was also found during the act of singing [14]. The Singing Group showed an increase of Inspiratory Capacity (IC) and decrease of Expiratory Respiratory Volume (ERV). The mean Inspiratory Capacity of the Singing Group increased 0.14 L, and the mean ERV decreased −0.01 L 2 after the patients stopped singing. The control group showed opposite outcomes [14]. A summary of the change in the physiological and psychological measures have been outlined in Table 5. 5. Discussion Results have shown that music can have impact both on psychological and physiological outcomes. Singing classes can improve quality of life measures and anxiety and are viewed as a very positive experience by patients with respiratory disease. Results showed no improvement in the control of breathing measures, or functional exercise capacity. Both groups showed significant improvements of Quality of life within group comparisons. Results showed that singing classes are a well tolerated activity for selected subjects with COPD. Regular practice of singing may improve Quality of life and preserve the maximal expiratory pressure of these patients. Music is effective in reducing anxiety and dyspnea along

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A. Panigrahi et al. / Role of music in the management of chronic obstructive pulmonary disease

with physiologic measures such as pulse rate and respiratory rate in two sessions in COPD patients hospitalized with exacerbation. Findings of this study suggest that vocal instruction, inclusive of breathing exercises, may help to improve the quality of life for senior citizens. Results also showed that harmonica playing does not significantly affect the clinical, psychosocial, or functional status of COPD patients. Positive reviews about general well-being and social support were also reported [13]. Singing practice could produce an acute increase in inspiratory capacity, indicating a reduction in gas entrapment. The intervention group showed a significantly higher saturation level of oxygen in hemoglobin during the act of singing [14]. In another study, spirometry, inspiratory muscle strength or exercise capacity did not show any change. Results showed that listening to music brought about clinically significant changes in anxiety and dyspnea their findings recommended that music along with progressive muscle relaxation (PMR) are capable of reducing anxiety and dyspnea in two sessions in hospitalized COPD patients after medical stabilization. Except for STAI larger reduction were seen in all the variables after second session, these changes though were not statistically significant [11]. Results of another study showed that harmonica playing was not beneficial when combined with traditional pulmonary rehabilitation program [15]. Although participants did show a marked improvement in some important outcome measures like Shortness of Breath Questionnaire, role of physical vitality, social functioning and 6-minute walk test [15]. However several limitations were associated with the existing literature review. Majority of the studies have been done with a small sample size and have limited study follow up. The studies suggest music therapy can help to improve some of the outcomes of the COPD patients, including reducing the anxiety in the patients, as well as their blood pressure. Considerable heterogeneity was observed among all studies. Analysis of the studies found there was substantial contrast between subjects with objective or subjective methods, and with different follow-up durations, but not between study settings though the studies were conducted in geographically diverse settings.

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Role of music in the management of chronic obstructive pulmonary disease (COPD): a literature review.

Chronic obstructive pulmonary disease (COPD) is a pulmonary disease characterized by airflow limitation that is not fully reversible. It is projected ...
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