How singing could help people with long COVID breathe easier

Singing was the only time I felt in control of my lungs and, paradoxically, able to forget about them.

It was October and my shortness of breath had worsened after weeks of teasing improvement. I felt breathless walking or resting, lying down or sitting, working or watching Netflix, talking or silently meditating. But not while singing.

Since my likely COVID-19 infection last June, I've grown familiar with the discomfort and frustration of feeling as if my body is not getting all the air it needs. I've also come to deeply appreciate the moments when my breathing returns to its autonomous function and takes up no portion of my consciousness.

My early symptoms a year ago were fairly typical for COVID-19: sore throat, headache, fatigue and shortness of breath. Although I never tested positive for SARS-CoV-2, some of my doctors believe I was infected. I also suspect it, given I'm still dealing with symptoms a year later.

Music has always been part of my life, including through the pandemic. I began classical violin lessons at age 5, leaving them behind for folk music six years later. I longed to be part of the various folk music traditions my older sister was playing on the piano and hammered dulcimer. I joined my first choir at age 12, which spoiled me with a repertoire of songs ranging the world over. As an adult, I've done my best to satisfy ethnomusicological proclivities with workshops, song-sharing events and jam sessions, but I haven't regularly sung with a choir since college. The pandemic provided a new opportunity: a "cross-countries" virtual choir.

From September 2020 through April 2021, we met one weekend a month to learn a Yoruba play song from Nigeria, a song from the Sevdalinka tradition in Bosnia and Herzegovina, an Appalachian standard, a folk song from the Gilan province of Iran and many more.

Quebec was one of our "destinations" in October, and all stress melted from my body the first time I heard "Mes chers amis, je vous invite." The dissonant harmonies of the mournful French Canadian drinking song may not relax everybody, but they resonated with me so strongly that I started spending much of my free time learning its tricky middle harmony.

I was surprised by how much relief it gave — both physical and emotional. Even after I'd mastered the notes and memorized the words of that Québécois song, I'd sing through it anytime I needed a break from the shortness of breath. (Click here to listen to Zuraw on SoundCloud.)

Longer breaths, lower stress

Long before COVID-19, music therapists used singing and wind instruments to help patients with respiratory issues like chronic obstructive pulmonary disease (COPD) and asthma.

Longer breaths can help promote relaxation and reduce the body's stress response, said Seneca Block, who oversees most of the music and art therapy programs at University Hospitals health system in northeastern Ohio. This is why practices like yoga and meditation focus so much on breathwork.

And the controlled breathing required for singing or playing the harmonica can help a person fully grasp what it means to lengthen exhalation.

"When you breathe into a harmonica … you're hearing a pitch," said Block, whose team has led harmonica groups for COPD patients. "That's teaching them that that's the marker, so they're doing it right."

People with respiratory issues are sometimes given an "incentive spirometer" — a medical device to help them exercise their lungs. Singing therapy works in a similar but less technical way, with notes that replace a rising and falling ball as the incentive, Block said.

Breathing incentives with singing and wind instruments have been linked to better sleep, less shortness of breath and brighter mood, said Joanne Loewy, director of the Louis Armstrong Center for Music and Medicine at Mount Sinai Health System in New York.

Loewy leads a choir of patients recovering from stroke. It can look like any other choir at certain moments, "but in between the songs, we might focus on the memory," she said. "We're constantly seeking ways to help people stay well with music."

Researchers are beginning to study whether these same therapies can help patients recover from COVID-19 as well.

In early August, about a month into my recovery, I heard about one such program being developed in England called ENO Breathe. In the pilot program, 12 participants learned breathing and singing exercises based on the techniques of professional singers. By the end of the trial, most participants reported improvement in their breathlessness and a drop in anxiety.

Having first experienced breathing exercises in choirs, I thought ENO Breathe made sense. Singing warmups can help prepare the body for sustained exhalations. Breathing from the diaphragm — a muscle separating the chest and abdomen — is how singers get more air into their lungs to support the power and length of their notes.

Loewy's team and Mount Sinai's Center for Post-COVID Care plan to launch a yearlong study of how weekly virtual group music therapy might improve respiratory symptoms, depression, anxiety, quality of life, fatigue, sleep and resilience in long-COVID-19 patients with continuing respiratory issues.

The University of Limerick in Ireland is running a similar study with the aim of retraining the muscles used in breathing.

'Peace in the chaos'

I turned to music for help in a less clinical capacity, but I'm not the only person with persistent COVID-19 symptoms to do so.

When Danielle Rees, 34, of Tucson, Arizona, learned about a breathwork program used by many other "long haulers," it reminded her of singing, so she dug out CDs of her high school choir and started singing along, "because it's way more fun than just trying to breathe in and out for 10 minutes."

Singing through an entire song again makes her feel accomplished, as does playing piano, something she hadn't done since grade school.

"When I felt like I wanted to practice piano, I was able to sit down and make that happen," Rees said. "That, for me, was a big sign that my brain was functioning again."

I've heard from other long haulers struggling with cognitive challenges, often referred to as "brain fog," who hope that teaching themselves to play a new musical instrument will help them out of it. Others sing, play instruments or just listen to music to bring some normalcy back into their lives and help them find solace from the anger and anguish of long COVID-19.

Music therapists say it's difficult to separate the entwined physical and psychological benefits of their work because of how connected the mind and body are.

I don't know whether singing through my shortness of breath last October simply soothed me or actually improved how my lungs functioned. I suspect it helped on both fronts.

Music helps combat the anxiety and stress caused by a lack of socialization, said Block of University Hospitals in Ohio. "Music, historically, was something that was just always really amazing at bringing people together and kind of creating a social context in and of itself," he said.

Because of internet latencies, syncing voices or musical instruments is practically impossible over Zoom. I spent my virtual choir rehearsals on mute, singing along with an instructor or recording, unable to hear anyone else in the choir doing the same in their own homes.

Over the eight months, we recorded ourselves singing what we learned and sent those recordings to the choir leaders, who edited them together. During our last gathering in April, we listened to all the collaborations in a Zoom concert.

I miss the feeling when first learning a song when my vocal cords finally notch into the right note and hearing it in the context of the harmonies all around me. I miss the energy you give and take with people around you during a performance.

A virtual choir may not have been the same as in-person, but through the isolation, stress and physical limitation, I was deeply grateful to have had it.

"During these times of great stress and great anxiety, things like music and the arts become even more important to people," Block said. "It helps retain a sense of hope and a sense of peace in the chaos."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.