CLINICAL TRIAL article
Front. Physiol.
Sec. Exercise Physiology
Singing as training modality within pulmonary rehabilitation for COPD patients may enhance diaphragmatic function: A pilot RCT exploring impact on diaphragmatic mobility and thickness
Provisionally accepted
- 1School of Rehabilitation Medicine, Binzhou Medical University,, Yantai, China
- 2Henan Luoyang Orthopedic Hospital, Luoyang, China
- 3Qingdao Central Hospital of University of Health and Rehabilitation Sciences, Qingdao, China
- 4Dalian Medical University, Dalian, China
- 5Qingdao Municipal Hospital Group, Qingdao, China
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Introduction:Previous studies have suggested that singing training (ST) has been proposed as an engaging adjunct to pulmonary rehabilitation (PR) patients with COPD and may improve diaphragmatic function and alleviate symptoms. We aimed to explore whether ST (a structured, facilitator-led group singing-based intervention for COPD) was associated with improvements in diaphragmatic function and related clinical outcomes—including pulmonary function, exercise capacity, health-related quality of life, and psychological symptoms. We hypothesized that ST would improve diaphragmatic function and yield better patient-reported outcomes than health education (HE). Methods: In randomized controlled trial (No. ChiCTR2100052874), we conducted with 40 stable COPD patients randomly assigned to either the ST group or the HE group. Primary outcomes were ultrasound-derived diaphragmatic function (dynamic and static diaphragmatic excursion and diaphragmatic thickening fraction). Secondary outcomes included respiratory muscle strength (MIP/MEP), pulmonary function (FEV1/FVC, FEV1predict), exercise capacity (6-minute walk distance, 6MWD), health-related quality of life (St George's Respiratory Questionnaire, SGRQ), and psychological symptoms (Hospital Anxiety and Depression Scale, HADS). We report between-group differences in change (95% CI) and MCID attainment for 6MWD (≥30 m increase),CAT (≥2-point decrease), SGRQ (≥4-point decrease), and HADS (≥1.5-point decrease); for other outcomes, a pragmatic ≥10% improvement threshold was applied Results: Thirty-three patients completed follow-up (ST n=18; HE n=15). Compared with HE, ST produced greater improvement in dynamic diaphragmatic mobility (mean SD change 0.7±0.6 vs 0.1±0.5 cm; difference 0.6 cm, 95% CI 0.1–1.3; P=0.03) and diaphragmatic thickening fraction (DTF; 23.4±39.8 vs 1.4±35.7%; difference 22.0%, 95% CI −3.4–47.3; P=0.06). For key secondary This is a provisional file, not the final typeset article outcomes, ST showed greater improvements in 6MWD (52±49 vs 5±46 m; difference 47 m, 95% CI 18–76; P<0.01), SGRQ (−12.6±11.0 vs −1.8±9.2; difference −10.8, 95% CI −16.8 to −4.8; P<0.01), and HADS-D (−1.6±1.7 vs +0.7±2.1; difference −2.3, 95% CI −3.5 to −1.0; P<0.01), whereas no between-group differences were observed for FEV1/FVC or FEV1%pred (both P>0.30).Conclusion: In this pilot trial, ST was associated with improved diaphragmatic mobility and several clinically relevant outcomes compared with HE. These findings suggest that ST may serve as a relevant adjunct to pulmonary rehabilitation, however larger trials are needed to confirm efficacy.
Keywords: chronic obstructive pulmonary disease, Diaphragmatic function, Diaphragmatic ultrasound, Pulmonary Rehabilitation, Respiratory muscle training, Singing training
Received: 20 Oct 2025; Accepted: 23 Jan 2026.
Copyright: © 2026 Lv, Qiao, 张, Xin and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Kai Liu
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