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Journal of Integrative Medicine | Volume 08 | Issue 02 | December 2020
Distributed under creative commons license 4.0 DOI: https://doi.org/10.30564/jim.v8i2.2137
Journal of Integrative Medicine
https://ojs.bilpublishing.com/index.php/jim
ARTICLE
Dance Movement Therapy: A Promising Lifestyle Intervention in the
Management of Chronic Obstructive Pulmonary Disease
Iqbal Akhtar Khan*
Independent Scholar, Lahore, Pakistan
ARTICLE INFO ABSTRACT
Article history
Received: 13 July 2020
Accepted: 21 July 2020
Published Online: 30 July 2020
Chronic Obstructive Pulmonary Disease (COPD), a progressive multi-
component malady with high morbidity and mortality, is an important
public health challenge, throughout the world. Despite remarkable progress
in its diagnostic and therapeutic modalities, signicant number of patients,
especially the elderly, continue to suffer from distressing dyspnoea and
harrowing extra-pulmonary manifestations limiting their daily activities,
with resultant exercise intolerance. Dance Movement Therapy (DMT), a
pleasurable and feasible exercise, has been found to be equally efcacious
when compared to routinely prescribed physical exercises. Moreover, it has
aesthetic expression, attractive to both genders irrespective of age, tempting
to those with disabilities, and a fruitful tool in developing self-condence.
During the current stressful situation, caused by COVID-19 pandemic, the
COPD patients, notably those over 70 years, are particularly vulnerable
to intensication of symptoms and some of them may experience serious
disorders of mental illness. Home isolation, social distancing,limiting
outdoor activities and prohibiting participation in group exercises, though
being appropriate prophylactic measures, are likely to add to already
existing physical inactivity and heighten stress and depression, with
deleterious effects on overall well-being. Solo dancing, while restricted
to home, is a highly accessible, doable, sustainable and well rewarding
alternative.
Keywords:
Chronic obstructive pulmonary disease
Dance movement therapy
Lifestyle intervention
COVID-19 Pandemic
Integrative medicine
1. Introduction
“C OPD outstrips all the other compara-
tors-heart failure, ischemic heart disease,
diabetes and renal failure-as the cause of
hospital admissions,” Prof. Darcy Marciniuk Chair of the
Canadian Thoracic Societyʼs COPD Committee [1].
Chronic Obstructive Pulmonary Disease (COPD), a
progressive degenerating lung condition “slowly robbing
its sufferers of the ability to draw life-sustaining breath”,
is a multi- component malady with pulmonary and ex-
tra-pulmonary manifestations. It is an important public
health challenge, throughout the world.
The Canadian Thoracic Society denes it as “a respira-
tory disorder largely caused by smoking, and is character-
ized by progressive, partially reversible airway obstruc-
tion and lung hyper- inflation, systemic manifestations,
and increasing frequency and severity of exacerbations”
[2]. The Global Burden of Disease Study reports a preva-
lence of 251 million cases of COPD globally in 2016. The
*Corresponding Author:
Iqbal Akhtar Khan,
Independent Scholar, Lahore, Pakistan;
Email: proakhan@gmail.com
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Journal of Integrative Medicine | Volume 08 | Issue 02 | December 2020
Distributed under creative commons license 4.0
gure is continually rising, particularly in those aged 65
years and above. It has been estimated that 3.17 million
deaths were caused by the disease in 2015, more than
90% of which were in low and middle-income countries [3].
Currently, it is the 4th leading cause of death globally and
is projected to be the 3rd, by 2030.
With the recognition of poor lifestyle as the major
determinant of chronic diseases (notably COPD) and the
“Physical activity: generic prescription for health” [4] as
one of the important component of lifestyle intervention,
there is dire need to search for innovatives in the manage-
ment of COPD.
2. Rationale
“There is still a huge gap between scientific knowledge
and population-based interventions, although many ways
to reduce or prevent the burden of COPD are identifi-
able”. Prof.Nicolino Ambrosino Respirologist [5].
Despite remarkable progress in diagnostic and thera-
peutic modalities of COPD, signicant number of patients
continue to suffer from distressing dyspnoea and har-
rowing extra-pulmonary manifestations notably skeletal
muscle weakness and osteoporosis limiting their daily
activities, with resultant exercise intolerance. In a German
prospective cohort study, Waschki et al demonstrated that
physical activity of patients with COPD decreases across
all severity stages and this decline is parallel by a wors-
ening of lung function and health status [6]. Conversely,
Garcia-Aymerich et al, on the basis of a population based
study in Copenhagen, have shown that COPD patients
performing some level of regular physical activity had a
lower risk of both hospitalization and mortality [7].
The slogan “Exercise is Medicine” has its roots in an-
tiquity. It is like medicine because it can be prescribed in
a specic formulation, dosage, frequency and duration on
an individualized basis. The concept is old but is gaining
ground rapidly. Its roots can be traced to the teachings of
Maha Rishi Susruta (oruit 1500 BCE). Garry Egger et al,
while developing National Physical Activity Guidelines,
suggested that “Think of movement as an opportunity, not
an inconvenience”[8]. This approach is very realistic and
would be highly rewarding, if adhered to in the manage-
ment of all chronic diseases (notably COPD). Undoubt-
edly, exercise is a valuable component of pulmonary re-
habilitation programs for those with COPD. However, the
traditional exercise sessions yield sub-optimal response
with resultant inadequate outcomes. Moreover, with an
increase in exercise intensity, the resultant dyanamic hy-
perination is the major contributor to dyspnea, limiting
physical activity.
3. Dance Movement Therapy (DMT)
“The dance of medicine men,priest or shaman belongs to
the oldest form of medicine and psychotherapy in which
the common exaltation and release of tensions was able
to change man’s physical and mental suffering into a new
option on health.We may say that at the dawn of civiliza-
tion dancing,religion, music and medicine were insepara-
ble”. Joost AM Meerlo (1903-1976 CE)-Dutch Psychoan-
alyst Author [9].
Medical Dance ( dance for healing) has its roots in
antiquity.The ancient Greeks were well aware of the link
between physical and psychological states [10].The use of
dance for healing and curative purposes has a long and
venerable history.The modern concept of Dance Move-
ment Theapy (DMT) dates back to the work of Carl
Gustav Jung. (1875-1961), Swiss Psychoanalyist, who
pioneered the abstraction of dance as psychotherapy, in
1916. Mary Starks Whitehouse (1911-1979), a profession-
al dancer and then a teacher, worked further on the appli-
cation of Jungian theory for healing various ailments. In
1942, Marian Chace (1896-1976), a dancer and teacher at
the Denishawn School of Dancing and Related Arts in Los
Angeles, was invited to work at St. Elizabeths Hospital in
Washington, D.C. She was licensed the “First Full-time
Dance Therapist” in 1947. In 1966, she rose to the posi-
tion of Founding President of American Dance Therapy
Association (ADTA). The concept gradually gained pop-
ularity at international level. At present,remarkable and
well-rewarding work on its efcacy is in progress.
Dr. Lynn Berman Physical Therapist is quite right that
the dance:an ideal exercise: a total body work is “a great
way to access all movement planes and access some mus-
cles that get ignored in typical day-to-day activities,”.
But dancing has additional merits which have been enu-
merated by Dr. Shilagh Mirgain Psychologist University
of Wisconsin- “It involves both a mental effort and social
interaction. Regular dancing can help prevent cognitive
decline as we age and is associated with a reduced risk of
dementia”.
DMT has been dened, by ADTA, as the “psychothera-
peutic use of movements to promote emotional,social,cog-
nitive,and physical integration of the individual,for the
purpose of improving health and well-being”.
Fong Yan et al, in a systematic review and meta-anal-
ysis,concluded that DMT is more efficacious than other
forms of usually prescribed physical exercises [11]. The
“Let’s Boogie” Pilot Study, on the feasibility of dance
intervention, revealed that DMT was an enjoyable, safe,
and feasible way to exercise, for COPD patients [12]. DMT
could be an effective intervention for COPD associated
DOI: https://doi.org/10.30564/jim.v8i2.2137
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psychological stress. In a population based cross-sectional
Singaporean study, there was signicantly stronger associ-
ation of life event stress with depressive symptoms among
individuals with COPD than among those without [13]. It is
known that around 40% of COPD patients are affected by
severe depressive symptoms or clinical depression [14]. An
interventional study was conducted in Finland to ratify the
effects of adding DMT to usual treatment (TAU ) for pa-
tients suffering from depression. One group received TAU
alone while the other was on TAU plus DMT. The prog-
nosis was found to be much better in the second group [15].
Whereas anxiety and depression are well recognized
comorbidities in COPD patients [16], their rates may be
much more in comparison to those suffering from other
chronic diseases [17]. In a systematic review and meta-anal-
ysis, by Torres-Sanchez et al, cognitive impairment was
found associated with the prole of COPD severity and its
comorbidities [18]. The results of meta-analysis, by Koch et
al,suggest that DMT, in addition to decreasing depression
and anxiety, improves quality of life and cognitive skills
[19].
Projects of dance therapy are gaining popularity at var-
ious forums.The benecial effects of DMT, when tested in
group form, have been very promsing. In a multi-centered
Randomised Controlled Trial (RCT), aimed at testing the
efcacy of 10 week DMT group intervention in patients
suffering from stress, signicant improvement in QoL, in
short term and long term follow up, was demonstrated [20].
In an interventional study for pulmonary rehabilitation,
it was found that the group dance classes provide suitable
training to physical tness in COPD patients. The partici-
pants found themselves of not only in good mood,but also
there was distraction from dyspnea [21].
Wellcome Trust-funded interdisciplinary “Life of
Breath Project” (2015-2020) is carrying out an integrative
research program to explore the possibility of DMT as an
ad-on therapy in pulmonary rehabilitation program.When
designed for COPD, it is being used in a collaboration
between King’s College London and choreographer Evan-
gelia Kolyra.
All the participants rated it “extremely enjoyable and
benecial”. Dr. Victoria MacBean,the Academic Lead, re-
marked “ I certainly believe that dance-based exercise has
the potential to enhance clinical care in this population”.
“Dancing Your Way to Better Breathing”, an interesting
combination of therapy and fun, organized by Respiratory
Therapist Joe Wynes, at the Sebastian Community Center
Sebastian Florida, demonstrared the therapeutic effects of
enjoyable dancing for COPD patients.
Undoubtedly, RCT is “Golden Standard” for ascertain-
ing the efcacy of a newly introduced technique or claim.
However, in an under-scored and insufciently sponsored
sub-speciality such as DMT, multi-centered RCTs requir-
ing huge funding are not easy.
The Bezmialem Vakif University Istanbul Turkey has
championed to initiate “The First Interventional (Clini-
cal Trial) Study to Apply Dance-based Exercise Training
in COPD” - with the goal to “to investigate the effect of
creative dance based exercise training on respiratory,
balance and cognitive functions, respiratory and periph-
eral muscle strength and functional capacity in COPD
patients”. It started on September 1, 2019 and the esti-
mate completion date is May 17, 2021. This would bridge
a gap in international literature and the ndings will,most
hopefully, “provide important methodological and proto-
col data required for the fully powered RCT to evaluate
efcacy and mechanisms of action of DMT”.
3.1 DMT for Elderly Patients
“With the diminishing of cognitive skills in elderly, it
is important to enhance the level of embodiment. It is
through body movement that the older adult can express
feelings, and experience a sense of belonging, increased
self- esteem, and personal growth”. Donna New-
man-Bluestein - Panel Presenter ADTA 2017 [22].
COPD is strongly associated with aging. At least 10%
of persons aged 65 years and above, in the United States,
are diagnosed with COPD. Internationally, the gure may
reach up to 16% depending on the country. However, the
gure is still an underestimate because of underdiagnosis
and underutilization of pulmonary function tests [23]. The
over-age 65 population, according to WHO estimates, was
703 million in 2019 and, with consistent growth, is likely
to double to 1.5 billion (22% of total world population) in
2050. Moreover, the number of those 80 years or above is
expected to rise from 125 million to 434 million, by 2050.
The feasibility of DMT in elderly is well recognized.
The two groups which Marian Chace opted to work with,
in 1942, were psychiatric and elderly. It would be highly
advisable to schedule most of the sessions with elderly
in settings of special care type like hospital, community
center or a well-equipped residential home. A warm and
well-greeted atmosphere, under supervision of a trained
therapist, needs to be created for the group. To expect
progress the participants must be motivated to attend
DMT sessions on regular basis. The health outcome is
much better in those who are regularly regular.
DMT has been found to exert benecial effects on over-
all well-being in elderly. Moreover, it improves balance
and mobility and reduces risk of falls which is a serious
problem of aging population [24]. A Brazilian [25] and anoth-
er British study [26] revealed that the impact of uniqueness
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of dancing was not limited to age-related physical aspects
but also on self-perception and psychological well-being.
3.2 DMT for Patients with Diabilities
“Being disabled should not mean being disqualied from
having access to every aspect of life.” Emma Thompson
(1959-) - British Writer.
There is significant association between COPD and
major physical limitations and comorbidities in elderly
population. In an American telephone survey of health-re-
lated behaviors, it was found that the mobility disability,
had the highest prevalence of 45.9 % in 2016 and 48.4 %
in 2017.Interestingly, the highest prevalence was noted
among those 45-64 years old, contrary to those of 65 years
or above [27]. Clinical depression and anxiety were noted in
40 % and 36% respectively in 60-89 aged outpatients with
COPD, in a university teaching hospital of United King-
dom [28].
Certain Disability Arts Organisations, National Insti-
tutes of Dancing, Disability-related Dance Companies and
National and International Disability Organisations, with
good resources, offer advice and support to persons with
disabilities.They provide more opportunities for disabled
and would be of special interest to COPD patients with
disabilities planning to avail the benets of DMT. Adding
physical activity,in the form of DMT, to such patients is
an effective tool of improving their functional tness.
Wheelchair Dancers Organization (WDO), by provid-
ing well structured supervised dance sessions, to all those
in need of special assistance, has succeeded in bringing
remarkable change in their lives. An inspiring, instructive
and invigorating message from Beverly Weurding, the
Founder, is “We have no limitations except those we place
upon ourselves.”
3.3 DMT for COPD Patients during COVID-19
Pandemic
“The debilitating symptom of breathlessness often limited
COPD patients’ participation in social activities. Conse-
quently, many became socially isolated and prone to de-
veloping depression”. Suk Fong Wai et al [29]
Philip et al have argued that COVID-19 pandemic will
affect all people with chronic respiratory diseases (notably
COPD )having potentially detrimental affects on physical,
psychological and social wellbeing [30]. The present situa-
tion reveals that the individuals with COPD, notably those
over 70 years, are particularly vulnerable to intensication
of respiratory symptoms and some of them may experience
serious psychological disorders [31]. Alarmingly, over one
third of COVID-19 afflicted hospitalized patients were
found to have respiratory pre-existing conditions such as
COPD, as reported by the Centers for Disease Control and
Prevention [32]. It may be due to the infection itself, man-
datory isolation/ quarantine at designated centers ; and
impending hospitalization.
The appropriate prophylactic measures (home isolation,
social distancing, limiting outdoor activities, prohibiting
participation in group exercises) are likely to add to al-
ready existing physical inactivity and heighten stress and
depression, with deleterious effects on overall well-being.
There is tangible need to identify activities which could
have positive impact on their physical and mental health.
Solo dancing, while restricted to home, is a highly acces-
sible, doable, feasible, sustainable and beneficial alter-
native. As suggested by Shilagh Mirgain “Dance just for
yourself, allowing any movements to flow that feel good
- or pretend that someone is watching to enhance your
personal dancing experience.” Online group-sessions for
dance are available for those, willing to get benet.
4. Conclusion
“…..The care of the chronically ill is moving toward meth-
ods that aim to preserve and enhance quality of life of our
patients and activities of daily living through identication
of their culture, motivation, caregiver/home trends and
perceptions of daily wellness routines”. Joanne Loewy -
Director Louis Armstrong Center at MSBI.
DMT, a pleasurable and feasible exercise, has been
found to be equally efficacious when compared to rou-
tinely prescribed physical exercises. It has aesthetic ex-
pression, attractive to both genders irrespective of age,
tempting to those with disabilities, and a fruitful tool in
developing self-confidence. Under the present stressful
situation of COVID-19 Pandemic, when COPD patients
are particularly vulnerable to intensication of symptoms,
DMT should be confidently prescribed to them. Even
when delivered remotely,it is more relevant to promote
their physical activity and wellbeing at a time when they
have been subjected to more strict home isolation.
Source of Funding
This research was totally un-funded.
Disclosure Statement
The author has no conicts of interest to disclose.
DOI: https://doi.org/10.30564/jim.v8i2.2137
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Journal of Integrative Medicine | Volume 08 | Issue 02 | December 2020
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Acknowledgement
The author is highly grateful to Prof. Nicolino Ambrosino
(Respirologist Italy ) for pre-submission review of the
manuscript and scholarly advice for its improvement.
References
[1] Benady S. The Human and Econimic Burden of
COPD:A Leading Cause of Hospital Admission in
Canada-Canadian Thorasic Society, 2010: 1-8.
[2] O’Donnell DE, Hernandez P, Kaplan A, Aaron S,
Bourbeau J, Marciniuk D, Balter M, Ford G, Gervais
A, Lacasse Y, Maltais F, Road J, Rocker G, Sin D,
Sinuff T, Voduc N. Canadian Thoracic Society Rec-
ommendations for management of chronic obstruc-
tive pulmonary disease - 2008 update - highlights for
primary care-Can Respir J. 2008, 15 Suppl A: 1A-
8A.
[3] WHO-WHO Updates Fact Sheet on Chronic Ob-
structive Pulmonary Disease (COPD)-Geneva -1 De-
cember 2017.
[4] Climstein M, Egger G. Physical activity: generic pre-
scription for health. In G Egger, A Binns, S Rossner,
M Sagner (eds.). Lifestyle medicine: lifestyle, the
environment and preventive medicine in health and
disease, 2017 3rd edition, Elsevier, Cambridge, USA.
[5] Ambrosino N, Bertella E. Lifestyle interventions
in prevention and comprehensive management of
COPD. Breathe, 2018, 14: 186-94.
[6] Waschki B, Kirsten AM, Holz O, Mueller KC,
Schaper M, Sack AL, Meyer T, Rabe KF, Magnus-
sen H, Watz H. Disease Progression and Changes in
Physical Activity in Patients with Chronic Obstruc-
tive Pulmonary Disease. Am J Respir Crit Care Med.
2015 Aug 1, 192(3): 295-306.
[7] Garcia-Aymerich J, Lange P, Benet M, Schnohr P.
Anto JM-Regular physical activity reduces hospital
admission and mortality in chronic obstructive pul-
monary disease: a population based cohort study.
Thorax, 2006
DOI: 10.1136/thx.2006.060145
[8] Egger G, Donovan RJ, Giles-Corti B, Bull F, Swin-
burn B. Developing National Physical Activity
Guidelines for Australians-Austral New Zeal J
Publlic Health, 2001, 25(6): 561-63.
[9] Moore C, Yamamoto K. Beyond Words: Movement
Observation and Analysis. New York: Gordon and
Breach, 1988.
[10] Ackerknecht EH, The history of psychosomatic med-
icine. Psychol Med 1982, 12: 17-24.
[11] Fong Yan A, Cobley S, Chan C, Pappas E, Nicholson
LL, Ward RE, Murdoch RE, Gu Y, Trevor BL, Vas-
sallo AJ, Wewege MA, Hiller CE. The Effectiveness
of Dance Interventions on Physical Health Outcomes
Compared to Other Forms of Physical Activity: A
Systematic Review and Meta-Analysis-Sports Med.
2018, 48(4): 933-51.
[12] Wshah A, Butler S, Patterson K, Goldstein R, Brooks
D, Let’s Boogie. Feasibility of a Dance Intervention
in patients with Chronic Obstructive Pulmonary
Diseae- J Cardiopulmon Rehab Prevention: Septem-
ber 2019, 39(5): E14-E19.
[13] Lu Y, Nyunt MSZ, Gwee X, et al. Life event stress
and chronic obstructive pulmonary disease (COPD):
associations with mental well-being and quality of
life in a population- based study. BMJ Open 2012, 2:
e001674.
[14] Stage KB, Middelobe T, Stage TB, Sorensen CH.
Depression in COPD - Management and Quality of
Life Considerations - Int J COPD, 2006, 1(3): 315-
320.
[15] Pylvänäinen PM, Muotka JS, Lappalaine R. A dance
movement therapy group for depressed adult patients
in a psychiatric outpatient clinic: effects of the treat-
ment- Front. Psychol., 10 July 2015.
DOI: https://doi.org/10.3389/fpsyg.2015.00980
[16] Pumar MI, Gray CR, Walsh JR, Yang IA, Rolls TA,
Ward DL-Anxiety and depression-Important psycho-
logical comorbidities of COPD. J Thorac Dis., 2014,
6(11): 1615-1631.
DOI: 10.3978/j.issn.2072-1439.u201
[17] Solano JP, Gomes B, Higginson IJ. A comparison of
symptom prevalence in far advanced cancer, AIDS,
heart disease, chronic obstructive pulmonary disease
and renal disease. J Pain Symptom Manage, 2006,
31: 58-69.
[18] Torres-Sánchez I, Rodríguez-Alzueta E, Cabre-
ra-Martos I, López-Torres I,Maria Paz More-
no-Ramírez MP, Carmen Valenza MC. Cognitive
impairment in COPD: a systematic review. J. Bras
Pneumol São Paulo, 2015, 41(2).
DOI: 10.1590/S1806-37132015000004424
[19] Koch SC, Riege RFF, Tisborn K, Biondo J, Martin L,
Beelmann A. Effects of Dance Movement Therapy
and Dance on Health-Related Psychological Out-
comes. A Meta-Analysis Update. Front. Psychol.,
2019, 10: 1806.
DOI: 10.3389/fpsyg.2019.01806
[20] Bräuninger I. The efficacy of dance movement
therapy group on improvement of quality of life: A
randomized controlled trial. Arts Psychother, 2012,
39(4): 296-303.
[21] MacBean V, Reilly CC, Rafferty GF, Kolyra E.
Dance as a rehabilitative strategy for patients with
DOI: https://doi.org/10.30564/jim.v8i2.2137
18
Journal of Integrative Medicine | Volume 08 | Issue 02 | December 2020
Distributed under creative commons license 4.0
COPD-Europ Resp J., 2017, 50: PA3715.
DOI: 10.1183/1393003.congress-2017.PA3715
[22] Capello PP. Dance/Movement Therapy and the Older
Adult Client: Healing Pathways to Resilience and
Community. The 2017 ADTA International Panel,
Am J Dance Ther.
DOI: 10.1007/s10465-018-9270-z
[23] Akgn KM, Crothers K, Margaret Pisani M. Epide-
miology and Management of Common Pulmonary
Diseases in Older Persons. J Gerontol A Biol Sci
Med Sci., 2012, 67A(3): 276-291.
DOI: 10.1093/gerona/glr251
[24] Keogh JWL, Kilding A, Pidegeon P,Ashley L,Gillis
D. Physical benefits of dancing for healthy older
adults: a review. J Aging Phys Activ, 2009, 17:
479-500.
[25] da Silva MV,Lima DA, da Conceicao TM, de Car-
valho Melo TMT, da Cunha VP, da Silva MNP.
Dance: a therapeutic re- source in the third age. J.
Nurs., 2016, 10: 232-238.
DOI: 10.5205/reuol.7901-80479-1-SP.
1001sup201606
[26] Cooper L, Thomas H. Growing old gracefully: Social
dance in the third age. Ageing and Society. 2002,
22(6): 689-708.
DOI: 10.1017/S0144686X02008929
[27] Djibo DA, Goldstein J, Ford JG-Prevalence of dis-
ability among adults with chronic obstructive pulmo-
nary Disease. Behavioral Risk Factor Surveillance
System, 2016-2017-PLOS ONE Feb, 2020: 1-15.
[28] Yohannes AM, Baldwin RC, Connolly MJ. Mood
disorders in elderly patients with chronic obstructive
pulmonary disease. Rev Clin Gerontol., 2000, 10(2):
193-202.
[29] Wai SF, Choo KL, Man CS, Vong YP, Leung CH, Ma
HT. Impact of Music Therapy on Chronic Obstruc-
tive Pulmonary Disease Patients. Respirology, 2018,
23(52).
[30] Philip KEJ, Lewis A, Harrison SL. Singing and
Dance for People with Chronic Breathlessness during
the COVID-19 pandemic- American Thoracic Soci-
ety-Quarterly Bite 2020.
[31] Yohannes AM. COPD patients in a COVID-19 soci-
ety: depression and anxiety, Expert Rev Resp Med
2020
DOI: 10.1080/17476348.2020.1787835
[32] Garg S, Kim L, Walker M et al. Hospitalization Rates
and Characteristics of Patients Hospitalized with
Laboratory-Confirmed Coronavirus Disease 2019 -
COVID- NET, 14 States, March 1-30, 2020. MMWR
2020, 69: 1-7.
DOI: https://doi.org/10.30564/jim.v8i2.2137