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Integrating Singing into Pulmonary Rehabilitation in People with Chronic Obstructive Pulmonary Disease


Original Editor - Shreya Trivedi Top Contributors - Nicole Pinto, Alexandra Stead, Shreya Trivedi, Vidya Acharya and Rucha Gadgil

Introduction

Although Chronic Obstructive Pulmonary Disease (COPD) has existed for centuries, it remains highly prevalent today. COPD is now one of the top three causes of death worldwide and nearly 90% of these deaths occur in low and middle income countries.[1] More than 3 million people died of COPD in 2021 accounting for 5% of all deaths globally.[1] The commonly seen symptoms in patients with COPD are dyspnoea, sputum, fatigue, reduced lung function (as measured by spirometry) and reduced exercise tolerance. These symptoms are directly associated with disease burden and quality of life (QoL).[1][2]

Role of Pulmonary Rehabilitation (PR) in COPD

Pulmonary rehabilitation (PR) is one of the most evidence-based non-pharmacological interventions available for the management of COPD. PR is a comprehensive, individually tailored, multidisciplinary intervention comprising aerobic exercises, resistance training and breathing exercises, alongside non-exercise components including self-management education, behaviour change support, psychological support, nutritional counselling and smoking cessation advice. [2] [3] [4] Despite the well-established benefits of PR, uptake and long-term adherence remain poor. Key barriers include psychological factors such as anxiety and low health literacy, as well as physical factors including breathlessness, fatigue and functional limitation, all of which reduce motivation to engage and persist with structured programmes. [5] [6] Innovative, feasible and engaging adjuncts or alternative training modalities particularly those that can be delivered in community settings while targeting breathing control and respiratory muscle function may offer a practical solution to improving uptake and long-term adherence to pulmonary rehabilitation. [3] [4]

Three-Phase Singing Approach for People with COPD

Singing is a widely enjoyed recreational activity that, when delivered in a structured and systematic way, has potential therapeutic benefits for people with COPD. To gain therapeutic benefit, singing should be practised regularly and in an organised format. A recent pilot randomised controlled trial [7] suggests that singing sessions for people with COPD can be structured into three simple phases:

1) Warm-up Phase: which includes gentle stretching of the breathing muscles, diaphragmatic and chest breathing exercises and light vocal activities such as lip trills, humming and sustained sounds like “sssss”. These help to activate the breathing and vocal systems.

2) Main Singing Phase: where participants practice breathing control, become familiar with the music and gradually work on singing songs. The songs are chosen to be easy to follow, with soothing melodies, steady rhythms and short phrases.

3) Cool-down Phase: involving slow, deep breathing and relaxation to help the body return to a resting state.

This three-phase structure consisting of warm-up, main exercise and cool-down directly mirrors the standard session format recommended for PR exercise programmes in people with COPD, in which a preparation phase is used to prime the respiratory and musculoskeletal systems before training load is applied, and a recovery phase allows a gradual return to resting cardiorespiratory state [4] Singing sessions are best delivered in a group format and can be incorporated into or scheduled alongside PR programmes.[8] [9] [10] [11]

Mechanisms and Benefits of Singing in COPD

Evidence from both a 2026 pilot RCT [7] and a 2022 systematic review and meta-analysis [12] suggests that structured singing training produces meaningful improvements in exercise capacity and QoL in people with COPD, with psychological benefits consistently demonstrated even where spirometric gains remain limited. Singing is believed to improve symptoms in COPD and QoL as it requires a specific amount of voice production. Controlled respiration is essential for voice production.[13][14][15] It is understandable that singing cannot be solely given to people suffering from COPD as a replacement of PR but it can be helpful as singing incorporates controlled active expiration. In COPD, the loss of lung elastic recoil leads to dynamic hyperinflation and air trapping, placing the diaphragm at a mechanical disadvantage and increasing the work of breathing.[1][7] Hyperinflation in COPD is one of the common symptoms which can be improved with better functioning of elastic recoil. Controlled expiration techniques, work by prolonging expiratory time, reducing respiratory rate and opposing dynamic airway collapse, which collectively reduce hyperinflation and improve tidal volume. [7] [16] This can help patients become more aware of their own breathing pattern and amount of dyspnoea which can further help people with COPD to understand and cope better with the disease.

An infographic created to show the effects of singing in COPD
An infographic to show the effects of singing in COPD

Conclusion

People with COPD frequently believe they must limit their activities due to dyspnoea, leading to restricted social participation in everyday life. This avoidance behaviour perpetuates a cycle of deconditioning, worsening breathlessness perception, low mood and further inactivity. Group singing directly interrupts this cycle by providing a structured, enjoyable and socially engaging activity that simultaneously trains the respiratory muscles and fosters connection, motivation and positive affect, as illustrated in the pathway below. [7] [12]

The combined psychological and psychological effects of singing in COPD
The combined psychological and psychological effects of singing in COPD


The evidence therefore supports a combined physiological and psychosocial rationale for singing as an adjunct to PR in people with COPD. By targeting both respiratory muscle function and the psychological drivers of reduced QoL, singing offers meaningful improvements in exercise capacity, breathlessness, mood and overall QoL within a single, accessible and enjoyable intervention. [8] [16] [17]

References

  1. ↑ 1.0 1.1 1.2 1.3 Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2026 report
  2. ↑ 2.0 2.1 Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13–e64.
  3. ↑ 3.0 3.1 Holland AE, Cox NS, Houchen-Wolloff L, et al. Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc. 2021 May;18(5):e12-e29. doi: 10.1513/AnnalsATS.202102-146ST. PMID: 33929307; PMCID: PMC8086532.
  4. ↑ 4.0 4.1 4.2 Rochester CL, Alison JA, Carlin B, et al. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2023;208(4):e7–e26. doi:10.1164/rccm.202306-1066ST.
  5. ↑ Oates GR, Niranjan SJ, Ott C, Scarinci IC, Schumann C, Parekh T, Dransfield MT. Adherence to pulmonary rehabilitation in COPD: a qualitative exploration of patient perspectives on barriers and facilitators. J Cardiopulm Rehabil Prev. 2019;39(5):344–349. doi:10.1097/HCR.0000000000000436.
  6. ↑ Qin H, Jia P, Yan Q, Li X, Zhang Y, Jiang H, Yang H, Li L. Barriers and facilitators to pulmonary rehabilitation in COPD: a mixed-methods systematic review. BMC Pulm Med. 2025;25(1):314. doi:10.1186/s12890-025-03769-9.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Lv D, Qiao Z, Zhang J, Xin J and Liu K (2026) Singing as training modality within pulmonary rehabilitation for COPD patients may enhance diaphragmatic function: a pilot RCT exploring impact on diaphragmatic mobility and thickness. Front. Physiol. 17:1728597. doi: 10.3389/fphys.2026.1728597
  8. ↑ 8.0 8.1 Olsman E, Duggleby W, Willems D. A singing choir: understanding the dynamics of hope, hopelessness, and despair in palliative care patients: a longitudinal qualitative study. Palliat Support Care. 2015;13(6):1643–1650.
  9. ↑ McNamara RJ, Epsley C, Coren E, McKeough ZJ. Singing for adults with chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2017;12:CD012296. doi:10.1002/14651858.CD012296.pub2.
  10. ↑ Coulton S, Clift S, Skingley A, Rodriguez J. Effectiveness and cost-effectiveness of community singing on mental health-related quality of life of older people: randomised controlled trial. Br J Psychiatry. 2015;207(3):250–255. doi:10.1192/bjp.bp.113.129908.
  11. ↑ Abell RV, Baird AD, Chalmers KA. Group singing and health-related quality of life in Parkinson's disease. Health Psychol. 2017;36(1):55–64. doi:10.1037/hea0000412.
  12. ↑ 12.0 12.1 Fang X, Qiao Z, Yu X, Tian R, Liu K, Han W. Effect of singing on symptoms in stable COPD: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. 2022;17:2893–2904. doi:10.2147/COPD.S382037.
  13. ↑ 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.
  14. ↑ Tamplin J, Baker FA, Grocke D, Brazzale DJ, Pretto JJ, Ruehland WR, Buttifant M, Brown DJ, Berlowitz DJ. Effect of singing on respiratory function, voice, and mood after quadriplegia: a randomized controlled trial. Arch Phys Med Rehabil. 2013;94(3):426–434. doi:10.1016/j.apmr.2012.10.006.
  15. ↑ Effect of Singing along with Pulmonary Rehabilitation on Quality of Life and Dyspnea in Patient with Chronic Obstructive Pulmonary Disease.
  16. ↑ 16.0 16.1 Lewis A, Cave P, Stern M, Welch L, Taylor K, Russell J, Doyle AM, Russell AM, McKee H, Clift S, Bott J, Hopkinson NS. Singing for Lung Health—a systematic review of the literature and consensus statement. NPJ Prim Care Respir Med. 2016;26:16080. doi:10.1038/npjpcrm.2016.80.
  17. ↑ Lord VM, Hume VJ, Kelly JL, Cave P, Silver J, Waldman M, White C, Smith C, Tanner R, Sanchez M, Man WD, Polkey MI, Hopkinson NS. Singing classes for chronic obstructive pulmonary disease: a randomized controlled trial. BMC Pulm Med. 2012;12:69. doi:10.1186/1471-2466-12-69.
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