Mary Hart, Research Project Manager, Registered Respiratory Therapist, Certified Asthma Educator and a COPD Educator at Baylor Scott & White Research Institute, Baylor University Medical Center talks about Harmonica’s for Health, and how it is helping COPD patients in more ways than one.
Interview conducted by Ivanhoe Broadcast News in March 2018.
What group within Baylor do you work with?
Mary Hart: I work with Dr. Mark Millard, he’s a pulmonologist and Medical Director of the Martha Foster Lung Care Center here at Baylor.
And we’re located at Baylor University Medical Center in the Sammon’s Cancer Center Building.
Mary Hart: Yes.
What is this program, Harmonicas?
Mary Hart: People that have COPD have trouble breathing. They have trouble getting air in and out of their lungs. This is an idea that we came up with in terms of research to find out if playing a harmonica can improve their breathing.
Would you tell me what COPD does to people and how the harmonica playing might help?
Mary Hart: COPD is a progressive severe disease that makes it very difficult for people to get air in and out of their lungs. Playing a harmonica mimics breathing, moving air in and out of the lungs. With the harmonica there are the little holes that they must breathe through; it creates a resistance and helps exercise the muscles while they’re playing. Exercising lung muscles like exercising these muscles strengthen and can help decrease shortness of breath and help them breathe easier.
Is this something new?
Mary Hart: The COPD Foundation came up with Harmonicas for Health program. Patients who have COPD can purchase a harmonica and a booklet that teaches them how to play and gives them information about breathing techniques and COPD. But they haven’t studied it in terms of research, so this is a research project that we’re doing to study the effects of playing the harmonica in people with COPD
There must be antidotal information that shows that it works.
Mary Hart: Well if you ask a patient they’re happy, it makes them feel better, they are around other people that have COPD and we have that information. But we didn’t have the data to support whether or not it actually improves respiratory muscle strength and ability to breathe easier with activities or measured quality of life.
I think we’ve only started hearing about COPD on TV in the last couple of years. COPD if you ask me is an unknown.
Mary Hart: People are more comfortable talking about it because COPD or chronic obstructive pulmonary disease which is made up of chronic bronchitis and emphysema is typically due to smoking. It has a stigma around it. It wasn’t until the nineties that they started coming out with medications that were simpler to use and more effective for patients that have COPD.
One of the things that just didn’t make any sense to me is how is COPD different than asthma?
Mary Hart: There’s no cure for asthma but it can be controlled. Asthma includes inflammation and constriction of the airways making it very difficult to breathe, but it can be reversed with medications and by avoiding things that make it worse. COPD is a progressive disease characterized by decreased airflow over time, as well as inflammation. COPD is generally caused by smoking. COPD causes deterioration of the lungs which causes you to lose lung function over time.
And how does it affect your daily life?
Mary Hart: I’ll let you talk to patients later, but it limits what you can do. People with COPD get short of breath with activity so it limits what they can do. They may need oxygen and that is a big life style change they have to deal with as well as the limitations of activity due to the shortness of breath. You don’t regain lung tissue, even with medication. Some people who are just diagnosed aren’t given enough information. Some patients tell me when they were just diagnosed with COPD, the doctor may say, ‘there’s nothing I can do, you may need to use oxygen, you can take some medications but there’s nothing I can do to help your lungs get better.’ That’s what a lot of patients hear for the first time. But there is treatment, such as the medications, oxygen and pulmonary rehabilitation that can offer them a better quality of life and they can continue to do the things that they enjoy doing. I should say “most things” and maybe with some modifications.
You made a good analysis; how bad can it be to just take a shower?
Mary Hart: COPD makes taking a shower for some people as difficult as running a marathon. Activities of daily living, those are things such as cooking, bathing, doing laundry, grocery shopping, driving. Going out to the mailbox to pick up your mail, going to visit friends, to a movie. All of those things are affected when you have COPD. When it gets to the point that you are limited physically, and you can’t breathe, just think about it it. It really takes a toll on someone’s life that’s been active.
I mean they’ve been smoking all their lives.
Mary Hart: Some people have smoked all their lives. The number one cause of COPD is smoking. But there are other things that cause COPD, such as environmental pollution, wood burning stoves for cooking not so much in our country but in other countries they cook and they use open fires in their homes and the smoke from that can cause COPD. . There’s also one other thing, it’s genetic, alpha one antitrypsin also causes COPD in some patients. There is a test that your doctor can order to see if someone has alpha one antitrypsin.
What is the theory about the harmonicas?
Mary Hart: The theory of playing the harmonica is that it mimics pursed lip breathing which is a breathing technique used with COPD. When you play the harmonica you have to pucker your lips. . When you have COPD one of the ways that you relieve your shortness of breath or calm down when you get panicked, when you can’t breathe, is to take in a deep breath through your nose and blow out through pursed or puckered lips. This technique slows down the exhaled breath reducing airway collapse allowing better breathing. Sometimes with COPD you’re able to take in a breath but it’s difficult to get all the air out because the airways collapse. With activity sometimes, it is even more difficulty to get all the air out. This is called dynamic hyperinflation, but not everybody has it. To see what it feels like to have COPD,I want you to take a deep breath in, now take another deep breath in, and now take another deep breath while not letting the air out of your lungs try to walk or talk. That how it feels. Very scary. Very limiting.
Why is it hard to get air out if you can get it in?
Mary Hart: It has to do with the damage of the lung tissue caused by COPD. The airways tend to collapse and trap air inside the airways when they exhale.
What is advice for someone who may be experiencing CPOD or wondering if they’ve got it? Give me a few things that they can do besides play harmonicas to improve their lung function.
Mary Hart: The first thing they should do is go to a physician and get diagnosed From lung function tests, Without having that lung function test there’s no way for the doctor to really say that you have COPD. The second thing would be if you smoke, stop smoking. Because even at different ages in our life if we stop smoking say at forty five, fifty, even seventy five there’s a decrease in the decline in lung function. Even smoking for all those years you’re still going to get some benefit from stopping. Then the other thing is get in to a good pulmonary rehab program.
Everyone may not be able to attend a formal pulmonary rehab program due to location or cost but you can exercise, you can walk in the mall, you can walk around your neighborhood. One of the things I taught patients when I first started working in rehab is chair exercises. Use things around the house to lift as weights like cans of peas or beans.
Stay active. Everyone who is independent wants to stay that way as long as they can. Modify some of the ways that you do things around the house. For example in the kitchen, we have these big tall cabinets that go up six feet. Well how hard is it to raise your arm up tippy toe and get that plate out? It’s hard for me but if I couldn’t breathe that would take a lot more energy to do that. Modify that, put your plates closer to you, keep things closer to you to where you are not having to exert so much energy. That’s called modifying your home and using energy conservation.
What about breathing exercises? For example, I went to India a couple years ago and I did meditation and yoga and they incorporate all kinds of breathing exercises. Do you recommend that kind of stuff?
Mary Hart: Years ago there was no research at all. Now there’s research that says that yoga does help breathing in terms with patients with chronic lung disease.
What about singing?
Mary Hart: Singing too because you’re having to use your diaphragm which is your largest breathing muscle to sing. One of the things that we’ve incorporated here at Baylor is shibashi which is a form of Tai Chi. It’s movement and breathing and visualization. It clears their mind, it’s a form of meditation, it slows everything down, relaxation, and that’s something that you can do in your home, you can do that anywhere.
If you have COPD you should try to exercise and push yourself?
Mary Hart: Yes. Start out slow and pace yourself. Why? Because we want to build muscle strength and endurance, we want to stay active. If you don’t exercise, then you’re going to continue to deteriorate in terms of being able to do the things that you need to do to remain independent such as bathing yourself or to do the fun things you enjoy
You mentioned to slow yourself down, why is that important? I’m just guessing that when you have trouble breathing you may get agitated or that may cause the release of other chemicals in your brain or your body to become stressed. And that may contribute to restriction or something like that. Like an asthma attack.
Mary Hart: I say to slow down to conserve energy and pacing so that you are able to complete an activity and still be able to breathe without too much trouble. If not you may become very short of breath and it may feel like a panic attack. Having to wear oxygen and carry things often times makes people hurry and they end up anxious and very short of breath. It may take them a long time to recover. Asthma attacks are usually brought on by a trigger, such as an infection, pollen, cigarette smoking or something that makes it difficult to breathe. The airways constrict and become inflamed and it reduces the amount of air movement. This is scary and is usually relieved by using a quick relief medication.
Another thing where mindfulness, yoga, meditation and things like that help to slow you down. I am just suggesting that those might be good things.
Mary Hart: Yes. We have occupational therapists that work in pulmonary rehab with us who are very well trained in methods on relaxation and coping. They use visualization, meditation and breathing exercises to reduce stress. They have patients perform activities while using good body mechanics, pacing and breathing.
For example, our harmonica patients come in and they park downstairs in the parking garage. They have to get out of their car, get to the elevator, take the elevator up to the second floor and then it’s a long walk all the way around here to the center. If they try to do that all in one piece, by the time they get here, they would be so short of breath it would probably take about thirty minutes for them to recover.
Breaking that activity up in to pieces or pacing yourself might work like this: If getting out of the car is difficult and you’re short of breath, stop and lean against the car and relax for a few minutes. Use your pursed lip breathing techniques that you’ve learned and visualize something that calms you and then walk to the elevator. Once you get off the elevator, there are little couches or chairs that you can sit in and finally make it to the center without being completely out of breath.
You’re doing a research study so what are you actually doing to turn this in to basically a science experiment?
Mary Hart: We started by finding people who did smoke who had been through pulmonary rehab at one time or another. It had to be at least six months ago so that we weren’t looking at the training effect that they received in pulmonary rehab. They had to be over the age of forty five and we did baseline testing on them. We evaluated their lung function, we looked at how far they could walk in six minutes. We have a test that measures their muscle strength both inspiratory muscle and expiratory muscle. A quality of life evaluation and then their perception of what their breathing is like and how severe they think it is. We will repeat the measurements at the end of the 6 months to see if there are any changes.
Then they get in to the harmonica program.
Mary Hart: It was a twelve week program where we met every Wednesday for a couple of hours. First, they had to become comfortable being here and thinking ‘how am I going to play this harmonica? I can’t breathe as it is.’ Teaching them more about the techniques on how to breathe properly and use the pursed lip breathing and how to exercise their diaphragm and then to take those tools home and use them at least five days a week. They also had to learn to play as a group.
What kind of results are you getting?
Mary Hart: I can give you preliminary results but we haven’t finished the study yet. We are seeing significant improvement in muscle strength and in the six minute walk test. That’s how far they can walk in six minutes. We didn’t expect that. In May of this year we will complete the research and we’ll retest them again to see if those who continue to practice still continue to have good results and what changes might occur.
How do you feel about it when you talk to them and you see it’s working, what kind of feelings do you have?
Mary Hart: I will just tell you that Wednesday is my favorite day of the week. Because that’s when I get to come in and see these patients, I call them patients, but they are more like friends now. Because we have been working together since August. It gives me hope that there are other things for people that have COPD that are fun and entertaining. We may take this show on the road one of these days.
Mickey Raphael plays for Willie Nelson and he’s getting old, maybe a COPD person might take over or something.
Mary Hart: Well we’ve had a couple of concerts already. That was one of the goals for our research was that we play here at the Cancer Center at Café Charles. They usually have musicians play out front each day. We were the musicians for the day. We’ve also played at the Christmas Party for the Better Breathing Club We played at the Anatole Hotel here in Dallas and we have a spring fling coming up that they’re all going to be playing in again.
Are they getting better?
Mary Hart: Yes, and they know so many songs. I can’t believe the number of songs we can play. Now granted it’s very basic but they’re playing songs that are longer and more difficult to play. The harmonica is in the key of C and there’s ten holes to blow and draw through. The lowest and the highest notes are more difficult because there’s more resistance. They’re playing more songs that have sevens, eights, nines in them than they were in the beginning.
Okay let’s see what you’ve got.
Mary Hart: I can’t play without music. And you don’t have to read music.
Show me the breathing in and out and the functional part of playing the harmonica and how that helps them.
Mary Hart: You have the holes here and to get a clear note you have to pucker up just like you do with pursed lip breathing t. I’m going to try to do this. This is without using my diaphragm. And here’s using my diaphragm. I don’t know if you could tell or not but whenever you use your diaphragm you’re going to see the abdominal muscle move and you can make more sound longer.
And the diaphragm is important for breathing.
Mary Hart: Yes.
That’s the big muscle that lifts?
Mary Hart: It helps push the air out.
It’s the number one thing in voice lessons, right?
Mary Hart: Yes.
To speak from the diaphragm.
Mary Hart: Yes.
Which means you have to go down deeper in to your thorax in order to get the muscles working. That’s what they teach when they give you singing lessons or voice lessons.
Mary Hart: Right, right. It’s the same thing as singing, using you diaphragm to increase the volume of air to use with the harmonica. It is use to make for “blowing and drawing ” on the harmonica to make sound.
Show me.
Mary Hart: The way they hold it is like this, they sit up nice and straight so that the airway is open when they play. A lot have oxygen on. This is the harder end of the scale.
With harmonica you blow and suck.
Mary Hart: That’s true.
Mary Hart: The way that we teach, we don’t read music we use arrows. The arrow up is blow out, the arrow done is to inhale or draw in air. The music is usually on a music stand or table when they play. . I’m not very good but I’m good when I sit and I play with them.
We really build each other up, you heard me I don’t usually play that badly. But we laugh a lot. That’s what you’ll see, a lot of laughter. If somebody is out of breathe, the other person plays. And sometimes you’ll hear them playing and they’ll all run out of air at the same time and the music just kind of stops. We try not to do that.
It would seem to me in terms of improving your lung function laughter is another thing that would be good.
Mary Hart: Yes, yes. It’s good for breathing but at the same time it releases endorphins that keep us happy and healthy. And you’ll hear a lot of that. One of the things that I didn’t expect or I didn’t think about when we started with this study is that blowing and inhaling on the harmonica creates airway clearance. It makes them cough and helps get up some of the mucus in their lungs. Sometimes you will hear that in class and so we pass out tissues to everyone.
On the research part you’re not done quite yet but it sounds very promising.
Mary Hart: Yes, it does sound promising. We probably need to do a larger study. One of the things we are doing regardless is we’re opening the harmonica playing to other people that want to come to the Cvetko Center and learn to play together. We wanted to study the benefits in people with COPD, but it doesn’t matter whether you have lung disease or not; being in a group of people playing and laughing is fun. We learn to play together- it’s worthwhile and very beneficial. We believe that it will be an option for breathing exercises that we’ll be able to offer to patients when they are in the Pulmonary Rehab program.
You say this is happening all around the country?
Mary Hart: All around the country people are learning to play the harmonica. The Better Breathing Club groups, which is a group of patients that have lung disease, are playing together. They entertain at some of our professional meetings. I forgot to tell you the name of our group; we’re The Harmaniacs, because they’re maniacs on the harmonica.
I’m sure it’s helping people and that’s got to be pretty satisfying.
Mary Hart: It’s very satisfying, very rewarding for me. My grandmother died with COPD and at the time I didn’t know much of anything that could be done to make her life easier and happier. I was a respiratory therapist but we were so limited then. There wasn’t pulmonary rehab where we lived. There wasn’t anyone that focused on getting those patients active. My grandmother lived her last few years attached to oxygen at home with an inhaler to help her when she got short of breath. It was difficult to watch her life completely change.
It’s not like that anymore.
Mary Hart: No, it is not like that. That’s why I do what I do in terms of being a respiratory therapist and working with these chronic patients as well as I work with our professional organization, doing things in the community to bring about awareness of COPD, offer free spirometry and education at community events.
What’s that?
Mary Hart: Spirometry measures lung function. It is a test that measures volume and flow of gas that you can inhale and exhale. It can help determine if you have obstruction in your lungs. I. It’s used as part of getting the diagnosis for COPD.
Is that the little ball in the tube?
Mary Hart: No that’s an exerciser. This is a machine that has a mouthpiece and a tube that you blow into forcefully. One measurement is called a forced vital capacity where you put the mouth piece in your mouth and you take a deep breath, blow it out as fast as you can for at least 6 seconds.
Without any kind of therapy or any treatment the future is not very good for COPD patients?
Mary Hart: You’re correct, I’ll just put it that way.
A few things have changed over the past couple of decades for patients with COPD. We have better medications and pulmonary rehabilitation and guidelines to follow. There’s more research.
Mary Hart: Yes, yes. That’s true because of physicians and respiratory therapists and patients who believed in doing more. Doing research to see if exercise helped, etc. At one time in my career I was the pulmonary rehab coordinator and my job was to work with the physicians to help get their patients in to the PR Rehab program. I was to teach them how to exercise, take their medications, use their oxygen, and learn self-management tools. The first conversation I had with these patients was: I want you to come in and exercise with me. They would laugh and say, ‘are you kidding? I can’t even breathe to stand up, you expect me to exercise?’ I had to explain to them how we were going to do this very slowly but I guaranteed in six to eight weeks they would see a difference. And they did about half way through. They would come in with a smile on their face and they would say, I think I am going to up my treadmill just a little bit today. I think I can walk a little faster today. I’d say, well how about walking a little bit longer instead of faster.
END OF INTERVIEW
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