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Harmonica Therapy
for Pulmonary Disease
Ventilatory Muscle Training
(Respiratory Muscle Training)
CSPR Annual Conference
May 16
th2014
Pulmonary Rehabilitation Harmonica Team
Vivian Low MPH, RN-BC, FPCNA
Clinical Manager
Missy Von Luehrte RN, BSN
Pulmonary Rehabilitation Nurse
Leslie Rusinak RCP, CRT, AE-C
Pulmonary Rehab Therapist
Dennis Low MD
General Internal Medicine
Volunteer Harmonica Instructor
DISCLOSURE STATEMENT:
There are no conflicts of interest and no disclosures to report.
2
Not-for-profit community hospital in Mountain View & Los Gatos,
California
2 campuses (Enterprise)
-
399 beds in Mountain View
-
143 beds in Los Gatos
•
AACVPR Certification
Cardiac Rehab 2002 to present
Pulmonary Rehab 2003 to present
CPWC celebrated
our 20
thAnniversary in 2014
San Francisco and South Bay Area
Home of Harmonica Greats
David Barrett
http://www.schooloftheblues.com/harmonica-lessons
Mark Hummel –
Blues Harmonica Blowout®
http://www.markhummel.com/
Charlie
Musselwhite
At the White House All-Star
Celebration Of Memphis Soul
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Why consider harmonica play ?
Evidence:
We lose up to half of our lung function between age 30 and 70.
It appears that those who use lungs in extraordinary ways
have less loss of lung function with age. (i.e. horn players,
opera singers, breath holding divers)
Questions:
Does their activity mimic inspiratory muscle training (IMT)?
Does the pursed-lip and increased volume of breathing during
harmonica play result in improved strength of the diaphragm and
less loss of lung function?
Is improving respiratory muscle strength
EFFECTIVE?
There are published Meta-analysis and systematic reviews looking
at the effect of Inspiratory Muscle Training(IMT) in Chronic
Obstructive Pulmonary Disease (COPD).
ACCP/AACVPR does not support
routine
use of IMT.
"This therapy may be considered for respiratory patients with
documented respiratory muscle weakness
or persons who
remain symptomatic, with dyspnea and exercise limitation despite
peripheral muscle endurance and strength training."
ACSM does support IMT also referred to as Ventilatory Muscle
Training. (Clinical trials – benefits to sports performance)
4
Outcome challenges for IMT in pulmonary rehab
•
It is hard to separate the global effect of pulmonary rehab
and physical exercise from the local effect on respiratory
muscles.
•
Will the benefits of IMT be maintained after pulmonary
rehab if patients stop training? It is well documented that
muscular strength declines when strength training stops in
any muscle training.
•
Choice of IMT devices, including harmonica are very
personal and individual. Not everyone enjoys this type of
training.
IMT using harmonica therapy
What’s the evidence?
No consensus on published scientific studies to date that can
quantify improved outcomes.
Anecdotal reports and observations conclude that harmonica
playing improves RPE, 02 saturation, and exercise capacity.
Alexander, J. L. & Wagner, C. L. (2012). Is harmonica playing an
effective adjunct therapy to pulmonary rehabilitation?
Rehabilitation Nursing, 37
(4), 207-212.
No significant
improvements between groups in pulmonary rehab.
Dr. J. P. Schaman, Medical Director - cardiac rehabilitation and
sports medicine, Breslau clinic, Ontario Aerobics Centre. Canada
Formation of the Harmonica Exercise for Lung Program (H.E.L.P.)
in 2007.
5
Research challenges :
Patients who are too compromised presented with too
many variables and a high drop out rate for research.
Older patients had trouble achieving melodic single notes
and this type of playing did not provide adequate
pulmonary challenge.
To achieve a
“
dose-specific
”
study to evaluate a therapeutic
response, it is necessary to determine a therapeutic
“
dose
”
.
How much drawing/blowing do you need for positive
outcomes?
Exclusions:
Patients at risk for pneumo-thorax or rib fractures.
Relative cardiac risk and instability.
Dr. Schaman
Early Observations:
•
2007 – Used standard harmonica teaching and melody playing in a
relatively stable pulmonary population. Participants self reported a
rather low RPE with this methodology. Early pulmonary function
measurements did not show significant changes.
•
Single note playing for melodies was found to be difficult for older
patients and showed no real pulmonary challenge.
New techniques and methodology developed:
•
Training technique: Chordal (3+ holes) rhythmic playing.
Allows patients to:
- achieve a better pulmonary physiological challenge
- is easier to play blow and draw chords rather than single
notes to accompany soundtracks – rhythmic accompaniment.
•
Designed the
“
Diatonic Chord Harmonica®”, a medical
harmonica for this purpose. Plays 8 chords – 4 blow/4 draw but
still allows single note chords. (Dishwasher safe)
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Dr. Schaman’s Goal: To validate and provide
proven methods for harmonica therapy.
•
Beginning in the Fall of 2013, participants have been keeping diary charts
to record pattern of harmonica play including RPE, time and quantity.
Respiratory inductance plethysmography will be used as a pre/post
measurement comparing the intensity/duration/frequency of harmonica
playing that occurred to determine a “dosing” correlation.
•
Also plans to quantitate inspiratory and expiratory muscle strength with
new equipment. As lung tissue is not trainable, like skeletal and heart
muscle, would like to document any changes in the strength of the
muscles of breathing.
•
Will explore incorporating quality of life scores.
(harmonicaMD [email protected] http://harmonicamd.com/)
We know it has motivated people to
exercise their lungs!
History of Harmonica Programs
started to improve lung function.
University of Michigan Health Center Ann Arbor, Michigan Seton Medical Center Austin, Texas
Sinai Hospital in Baltimore Maryland – pediatric patients Bloomington Hospital Bloomington, Indiana Deborah Heart & Lung Center Brown Mills, New Jersey Luther Hospital/Sacred Heart Hospital
Eau Claire, Wisconsin
Florida Hospital Celebration Health Kissimmee, Florida A.T. Still University, Mesa, Arizona
El Camino Hospital Mountain View, California Jacksonville Mayo Clinic, Naples, Florida Advocate Christ Medical Center
Oaklawn, Illinois Breslau clinic Ontario, Canada
John C. Lincoln North Mountain Hospital, Phoenix Arizona Senior Friendship Center Sarasota, Florida Northside Hospital & Tampa Bay Heart Institute
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Harmonica Therapy at El Camino Hospital
Patient initiated idea, personal testimony.
Curriculum developed by School of the Blues/David Barrett in
2004 and presented at the Better Breather’s Club.
Exercising the muscles of ventilation
-
The diaphragm (primary muscle of breathing)
- Intercostal muscles
Introductory beginners sessions now 1:1 and then onto group
classes.
Beginner and advanced groups join for performances.
Program development
Considerations
Challenges
Instruction
Space for the program to meet
Primary focus/goal
Cost
Patient participation
Managing different skill levels
Reliable, cost effective committed instructor
Area large enough that will accommodate
music play
Clinical based, music based or support
group atmosphere
Instructor fees, material costs, staff support
to facilitate program
Intimidation of learning to play,
a commitment to continue, drop out rate
Keeping all skill levels challenged as new
players join.
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Respiratory Muscle Training in
Acute Pulmonary Rehab
One hour introduction session starting the 8 week program
Breathing re-training
PFLEX®
Harmonica therapy
Enhance individualized
treatment plans
Breathing retraining
Pursed lip breathing and diaphragmatic breathing:
•
Inhale 1-2 through the nose, allow the diaphragm to relax,
abdomen to expand.
•
Exhale 1-2-3-4 slowly through pursed lips while
contracting the diaphragm muscle.
Flow resistive training (breathing through a progressively smaller orifice)
IMT PFLEX®
Harmonica therapy
Mimics pursed lip breathing
Playing requires support from the diaphragm for both
short and long breath patterns.
Inhaling and exhaling through the reeds is a resistive
exercise
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Clinical application of IMT
Training Program
Use a threshold IMT device.
4-5 days/week,
30 minutes/day or
two 15 minute sessions/day
Initial Loads > 30% of a
person
’
s maximum
inspiratory pressure if data is
available.
Supervision. Monitor initial
02 saturation-respiratory
rate.
Progression
Shortness of Breath (SOB)
scale of 3-4. (Modified Borg
Dyspnea Scale 0-10 scale).
Rate of Perceived Exertion
(RPE) scale between 12 – 14
somewhat hard (The Borg
Rating of Perceived Exertion
Scale 6-20)
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Current trends in IMT
Renewed interest
Inspiratory muscle training protocol study for patients with
COPD using the POWERbreathe KH1®
Devices readily available to the public:
Lung Boost Respiratory Trainer®
Diatonic Chord Harmonica
®
Development of the Pulmonica®
Question: Are these respiratory specific training devices more
effective than harmonica play or similar?
Current Goals
Increase long term patient participation
Evaluate structure and instruction – flexibility to change
program based on volume and resources
Stabilize funding
Determine which patients will benefit most from
respiratory muscle training
,
the best training regime
Develop a trial to determine the functional and health
benefits of respiratory muscle training and which
method is most effective
Three groups practicing IMT
Measure MIP pre/post rehab
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What patients are saying
Linda Mankin (7 years)
“
At the visit to my
pulmonologist last week, I
was told I didn't
’
t need to
return for 6 months!
I attribute this success
entirely to the fact that
I practice deep breathing
constantly while having a
wonderful experience playing
the harmonica.
”
What patients are saying
Jack Goldberg (7 years)
“
I believe that as a result
of these exercises
(harmonica play), my
breathing has gotten more
controlled and more
powerful. Recently during
my standard spirometry
test the technician
remarked that my air
volume tested much higher
than 4 years ago!
”
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Enjoying harmonica play at home –
Learning to make music in a unique way
is uplifting for all!
Faye Knight with her
Practice partner
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C Diatonic Harmonica: Breathing & Chugging
(Stand – Up!)
•
Diaphragmatic Breathing: hands on abdomen, in and out
•
Articulation: Draw (in) Ta – Ta; Blow (out) te –te
•
Shuffle rhythm, used in blues, swing, jazz
•
Hold the harp like a corncob, lower notes on the left
•
Embouchure: relaxed lips, mouth slightly open
•
Bring harp tilted down into mouth, cover left three holes
•
4 beat shuffle, left – right – left – right
•
Ta – Ta, te – te, Ta – Ta, te – te
•
Let’s play some 12 bar blues!
12 Bar Blues Structure
•
I
I
I
I
•
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
•
TaTa tete TaTa tete TaTa tete TaTa tete
•
TaTa tete TaTa tete TaTa tete TaTa tete
•
IV
IV
I
I
•
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
•
tete tete tete tete TaTa tete TaTa tete
•
tete tete tete tete TaTa tete TaTa tete
•
V
IV
I
I
•
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
•
TaTa TaTa tete tete TaTa tete TaTa tete
•
TaTa TaTa tete tete TaTa tete TaTa tete
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Oh! Susanna by Stephen Foster
Train Whistle
bonus
•
4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4+, 4
•
4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4, 4+
•
4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4+, 4
•
4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4, 4+
•
5, 5, 6, 6, 6, 6+,6+, 5+, 4+, 4,
•
4+, 4, 5+, 6+, 6+, 6, 6+, 5+, 4+, 4, 5+, 5+, 4, 4, 4+
•
Finish flourish, blow sliding-up harmonica holes 4+thru10+
•
Train Whistle: cover holes 3-4-5, draw while articulating:
Keeee – youuuu - eeeee
Thank you for participating in
this musical journey with us!
Vivian Low MPH, RN-BC, FPCNA Leslie Rusinak RCP, CRT, AE-C
Clinical Manager
Pulmonary Rehab Therapist
[email protected] [email protected]
650 988-7630
650 988-8236
Missy Von Luehrte RN, BSN
Dennis Low MD
Pulmonary Rehab Nurse
General Internal Medicine
[email protected] Volunteer Harmonica Instructor
650 988-8225
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Acknowledgments
•
Pulmonary Rehab Medical Directors: Dr. Bruce Beck, Dr. Judith Pickersgill
•
David Barrett – School of the Blues
•
Dennis Carelli – Harmonica Instructor
•
Dr. J. P. Schaman – Breslau clinic, Ontario Canada Aerobics Centre
•
El Camino Hospital Foundation
•
El Camino Hospital Marketing & Communications
•
Monica Frankel – Graphic Communications Specialist
•
Karen Halverson, Jack Black – Health Library Resource Center
•
Mike Ichikawa – Multimedia Coordinator
•
Special thanks to harmonica patients and participants for their support:
Jack Goldberg, Fay Knight, Linda Mankin, Renee Martinson, Barbara
Perkins
References
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American Association of Cardiovascular and Pulmonary Rehabilitation. (2011). Guidelines for Pulmonary
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Barrett, D. & Bucko, D. (2005). Harmonica for Fun & Health. Pacific, MO: Mel Bay Publications, Inc. Beckerman, M., Magadle, R., Weiner, M. & Weiner, P. (2005). The effects of 1 year of specific inspiratory muscle training in patients with COPD. Chest, 128, 3177-3182
Begley, S. (2006). One more reason to play harmonica: it's good for the pipes. Wall Street Journal. Retrieved from
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References
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References
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