An online breathing and wellness program can help improve quality of life and shortness of breath for people recovering from COVID-19.
These are the results of one of the first clinical trials to report an effective intervention for people with post-COVID syndrome, also known as long COVID. The study is published in Respiratory Medicine The Lancet.
The ENO Breathe program was developed by English National Opera (ENO) and respiratory clinicians from Imperial College Healthcare NHS Trust. He uses singing techniques to improve the well-being of patients with persistent shortness of breath due to COVID-19.
The Social Prescribing Program has been providing support to people in London and across England since September 2020 and is run by ENO Engage, ENO’s learning and engagement department.
Patients are referred to ENO Breathe through specialist NHS post-COVID assessment services after a review of their condition and medical treatments. 70 services now refer to ENO Breathe in London and England.
This includes areas that Arts Council England and the Department for Culture, Media and Sport have identified as upgrade locations for culture such as Blackpool, Peterborough, North Somerset and Stoke on Trent. The six-week program is delivered online, starting with an individual session, group sessions once a week, and a range of online resources throughout the program. To date, more than 1,000 participants have accessed the free program.
A clinical trial of 150 participants, with continued shortness of breath for an average of 320 days since the onset of COVID-19 symptoms, was conducted by researchers at Imperial College London alongside the program team from Imperial College Healthcare.
The study found that participants in ENO Breathe experienced a 10.48 point (out of 100) reduction in shortness of breath while running, compared to people who just continued with usual care alone. They also experienced a 2.42-point improvement in the mental component of quality of life, measured by a validated online questionnaire.
We urgently need evidence-based treatments and interventions for people who have had long-term COVID-19, which currently affects around 1 in 50 people in the UK. Our study suggests that health arts interventions can be effective tools for carefully selected participants, especially when successfully integrated with clinical services. Dr. Keir Phillip Clinical researcher at the National Heart and Lung Institute
These health improvements were further explained using focus groups and questionnaires, which showed that ENO Breathe participants reported seeing an improvement in their symptoms, felt the program complemented other care they were receiving and that the use of singing and musical techniques met their needs. Additional analyzes focused on participants who attended all sessions, found improvements in a wider range of respiratory symptoms, anxiety, and had greater improvements in quality of life.
For example, 40% of ENO Breathe participants experienced a five-point improvement in the mental component of quality of life, compared to 17% in the usual care group. This suggests that participants who engaged the most in the program achieved the greatest benefit. Although the physical component of quality of life did not improve further in either group.
ENO Breathe uses weekly online group sessions and digital resources, developed with the support of healthcare professionals, to give participants tools and techniques to improve the way they breathe and how they interact with their breathing. The program is led by professional ENO singers and focuses on respiratory rehabilitation through singing techniques, using lullabies as a musical starting point. No experience or interest in singing is required.
Shortness of breath is one of the most common symptoms in people with long COVID. Many factors can contribute to this, including damage to the lungs and supporting tissues, impact on the nervous system, and other persistent symptoms such as fatigue and cough.
Breathing anxiety can exacerbate shortness of breath, and all of these factors can influence how people breathe after COVID-19 infection, potentially worsening their quality of life. In January 2022, an estimated 1.5 million people in the UK could have long symptoms of COVID.
The study’s lead author, Dr Keir Phillip, a clinical researcher at the National Heart and Lung Institute at Imperial College London, said: “We urgently need evidence-based treatments and interventions to people with long COVID, which currently affects around 1 in 50 people in the UK. Our study suggests that health arts interventions can be effective tools for carefully selected participants, especially when successfully integrated with clinical services.
“Our study suggests that the improvements in symptoms experienced by participants result both from the practical breathing techniques learned, but also from the creative, humane and positive way in which the program is delivered.”
Lead author Dr Sarah Elkin, Chief Program Consultant and Respiratory Consultant at Imperial College Healthcare NHS Trust, said: “As we continue to recover from the impact of the pandemic, it is essential that we were finding ways to support people with long COVID who experience debilitating symptoms long after they have recovered from their initial COVID-19 infection. It is extremely important to build an evidence base for programs like ENO Breathe, so that we can continue to understand how to best support people with long-term COVID and make improvements that can lead to better outcomes.
Professor Nicholas Hopkinson, co-lead author and Professor of Respiratory Medicine at Imperial College London, said: “Breathlessness is one of the most common symptoms that people with long experience of COVID. The ENO Breathe program is designed to help people with the disease learn to better control their breathing. Our research shows it is effective, and the program has already benefited over 1000 people recruited from post-COVID clinics across the UK”
Dr Harry Brunjes, Chairman of English National Opera, said: “We are extremely proud that ENO Breathe has been proven to aid the recovery of those with long term covid for whom it was designed. Research like this demonstrates the enormous benefit the arts can have when applied in a medical context. We are extremely grateful to our partners at Imperial College Healthcare NHS Trust for their dedicated work in developing this program with us, and to the phenomenal team at Imperial College for their painstaking research.
James Sanderson, CEO of the National Academy for Social Prescribing (NASP), said, “At NASP, we believe social prescribing can transform people’s health, so it’s exciting to see published clinical evidence that demonstrates the effectiveness of a social prescription program. We are delighted to be able to support ENO’s “Breathe” classes which are improving the lives of hundreds of people living with long COVID.
As we continue to recover from the impact of the pandemic, it is essential that we find ways to support people with long-term COVID who experience debilitating symptoms long after they have recovered from their initial COVID infection. -19. It is extremely important to build an evidence base for programs like ENO Breathe, so that we can continue to understand how to best support people with long-term COVID and make improvements that can lead to better outcomes. Dr Sarah Elkins Respiratory Consultant at Imperial College Healthcare NHS Trust
The trial participants were all recovering from COVID-19 with ongoing shortness of breath, with or without associated anxiety, and were referred from post-COVID assessment clinics after appropriate investigations and treatment. The majority of participants (81%) were women, which is broadly representative of the broader population of patients with long-term COVID.
The participants were divided into two groups. One group (74 people) participated in the six-week ENO Breathe program and a control group (76 people) continued their usual care as directed by their post-COVID assessment clinic. Both groups were assessed after six weeks, and then the control group also had the opportunity to participate in the program.
Researchers gathered information about participants’ health and well-being via online questionnaires, and used focus groups and feedback questions to assess participants’ experience. They measured the mental and physical components of a validated ‘health-related quality of life’ tool that assesses key indicators of quality of life, including difficulties resulting from health problems, social impacts, pain and the impact on daily activities. The researchers also assessed other impacts of the disease, including shortness of breath, anxiety and a range of other symptoms.
There were also three common qualitative themes regarding the participants’ experience – an improvement in symptoms, feeling that the program complemented the care they were receiving, and that the singing and breathing met their needs.
“An online breathing and wellness program (ENO Breathe) for people with persistent symptoms following COVID-19: a randomized, single-blind, parallel-group controlled trial” by Keir Philips et al. is published in Respiratory Medicine The Lancet.