Effect of Singing on Symptoms in Stable COPD: A Systematic Review and Meta-Analysis

Figures & data

Figure 1 PRISMA flowchart of study selection.

Notes: Adapted from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. Creative Commons Attribution (CC BY 4.0) license.¹Abbreviations: PEDro, Physiotherapy Evidence Database; RCT, randomized controlled trial.

Table 1 Summary of Studies Characteristics

Author Year Country	Setting	Participant Characteristics					Intervention Program	Training			Main Outcomes	Adverse Events
		Sample Size	Mean Age	Sex (M:F)	Disease Course (Year)	COPD Stage		Frequency (Weekly)	Time (Min)	Duration (Week)
Liu 2019, China^Citation11	Hospital	T:56 EG:28 CG:28	63.51 ± 4.72	EG: 24:4 CG: 26:2	–	Mild to severe	EG: routine health education + group singing therapy Relaxation exercises (5min), respiratory exercise (10min), vocalization exercises (15min), singing exercises (30min) CG: routine health education	1	60	24	HADS-D, CCQ	–
Lord 2012, UK^Citation18	Clinic	T:24 EG:13 CG:11	68.30	–	–	–	EG: singing class (vocal exercises, posture and relaxation) CG: film workshops (once weekly)	2	–	8	HADS, SF-36, CAT, ISWT,	–
Lord 2010, UK^Citation19	Clinic	T:28 EG:15 CG:13	67.30	–	–	–	EG: standard session on breathing control and techniques + singing (posture, relaxation and vocal exercises) CG: standard session on breathing control and techniques	2	60	6	SF-36, HADS, SGRQ, ISWT,	–
Kaasgaard 2022, Denmark^Citation20	Community	T:195 EG:108 CG:87	69.50 ± 8.40	–	–	Mild to very severe	EG: singing physical warm-ups (20min), vocal warm-up with rhythm and pitch games (20min), singing (40min), cooling down (10min) CG: standard physical exercise training (PExT), physical warm-up (20min), PExT including handling of dyspnoea (60min), cooling down(10min)	2	90	10	6MWD, SGRQ, HADS, FEV1 (Data unavailable), FEV1%, mMRC,	–
Bonilha 2009, Brazil^Citation5	Hospital	T:30 EG:15 CG:15	71.70±7.50	EG: 12:3 CG: 12:3	–	–	EG: singing relaxation exercises (5min), respiratory exercises (10min), vocalization exercises (15min), singing training (30min) CG: handcraft artwork	1	60	24	FVC, FEV1, FEV1/FVC, BDI, SGRQ, IC, PEmax.	–

Abbreviations: T, total; M, male; F, female; EG, experimental group; CG, control group; CCQ, The Clinical COPD Questionnaire; HADS, the Hospital Anxiety and Depression Scale; HADS-D, The hospital anxiety and depression scale-depression; HADS-A, The hospital anxiety and depression scale-anxiety; mMRC, modified Medical Research Council Dyspnoea Scale; CAT, COPD assessment test score; SF-36, the Short Form 36 questionnaire; ISWT, the incremental shuttle walk test; 6MWD, 6-Minute Walking Test Distance; SGRQ, St. George’s Respiratory Questionnaire; FEV₁, Forced Expiratory Volume in One Second; FVC, forced vital capacity; IC, inspiratory capacity; FEV₁%, FEV₁ predicted; BDI, basal dyspnea index; PEmax, maximal expiratory pressure.

Table 2 Study Quality Assessment of Eligible Trials

PEDro Criteria	1	2	3	4	5	6	7	8	9	10	11	Total
Liu 2019^Citation11	–	1	0	1	1	0	0	1	1	1	1	7
Lord 2012^Citation19	–	1	1	1	0	0	1	0	1	1	1	7
Lord 2010^Citation20	–	1	1	1	0	0	1	1	1	1	1	8
Kaasgaard 2022^Citation21	–	1	1	0	1	1	1	0	1	1	1	8
Bonilha 2009^Citation5	–	1	0	1	0	0	0	0	1	1	1	5

Note: 9~10 are very high quality; 6~8 are high quality; 4~5 are medium quality; ≤ 3 is considered low quality.

Abbreviation: PEDro, Physiotherapy Evidence Database.

Figure 2 Meta-analysis of experimental and control groups in SF-36 PCS.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; SF-36 PCS, Short Form 36 physical component summary.

Figure 3 Meta-analysis of experimental and control groups in SF-36 MCS.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; SF-36 MCS, Short Form 36 mental component summary.

Figure 4 Meta-analysis of experimental and control groups in ISWT.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; ISWT, the incremental shuttle walk test.

Figure 5 Meta-analysis of experimental and control groups in Hads-A.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; HADS-A, the hospital anxiety and depression scale-anxiety.

Figure 6 Meta-analysis of experimental and control groups in Hads-D.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; HADS-D, the hospital anxiety and depression scale-depression.

Table 3 Acceptance, Completion and Drop-Out Rates

Study	Acceptance Rate	Completion Rate	Drop-Out Rate	Sample Size
Liu 2019^Citation11	0.30	0.93	0.07	56
Lord 2012^Citation19	0.14	0.73	0.25	24
Lord 2010^Citation20	0.39	0.78	0.22	28
Kaasgarrd 2022^Citation21	0.86	0.72	0.23	195
Bonilha 2009^Citation5	0.55	0.70	0.30	30
Total(unweight)	0.50	0.75	0.22	333
Total(weight)	0.65	0.76	0.21	333

Figure 7 Flowchart showing the numbers of participants from all included studies.

Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71

 PubMed Web of Science ®Google Scholar

Liu H, Song M, Zhai ZH, Shi RJ, Zhou XL. Group singing improves depression and life quality in patients with stable COPD: a randomized community-based trial in China. Qual Life Res. 2019;28(3):725–735. doi:10.1007/s11136-018-2063-5

 PubMed Web of Science ®Google Scholar

Lord VM, Hume VJ, Kelly JL, et al. Singing classes for chronic obstructive pulmonary disease: a randomized controlled trial. BMC Pulm Med. 2012;12:69. doi:10.1186/1471-2466-12-69

 PubMed Web of Science ®Google Scholar

Lord VM, Cave P, Hume VJ, et al. Singing teaching as a therapy for chronic respiratory disease--a randomised controlled trial and qualitative evaluation. BMC Pulm Med. 2010;10:41. doi:10.1186/1471-2466-10-41

 PubMed Web of Science ®Google Scholar

Kaasgaard M, Rasmussen DB, Andreasson KH, et al. Use of singing for lung health as an alternative training modality within pulmonary rehabilitation for COPD: a randomised controlled trial. Eur Respir J. 2022;59(5):2101142. doi:10.1183/13993003.01142-2021

 PubMed Web of Science ®Google Scholar

Bonilha AG, Onofre F, Vieira ML, Prado MY, Martinez JA. Effects of singing classes on pulmonary function and quality of life of COPD patients. Int J Chron Obstruct Pulmon Dis. 2009;4:1–8.

 PubMedGoogle Scholar

Cox NS, Oliveira CC, Lahham A, Holland AE. Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the theoretical domains framework. J Physiother. 2017;63(2):84–93. doi:10.1016/j.jphys.2017.02.002

 PubMed Web of Science ®Google Scholar