Professional Documents
Culture Documents
Melodic Intonation Therapy and Aphasia Another Variation On A Theme PDF
Melodic Intonation Therapy and Aphasia Another Variation On A Theme PDF
Melodic Intonation Therapy and Aphasia Another Variation On A Theme PDF
To cite this article: Monica Strauss Hough (2010) Melodic Intonation Therapy and
aphasia: Another variation on a theme, APHASIOLOGY, 24:6-8, 775-786, DOI:
10.1080/02687030903501941
Address correspondence to: Monica Strauss Hough PhD, Communication Sciences & Disorders,
East Carolina University, Health Sciences Building, Greenville, North Carolina, USA 27858.
E-mail: HoughM @ecu.edu
© 2010 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/aphasiology DOI: 10.1080/02687030903501941
776 HOUGH
METHOD
A modified version of MIT was implemented with BR, a 69-year-old Caucasian male
with chronic Broca’s aphasia of 48 months duration and right hemiparesis, resulting
from a left cerebro-vascular accident (CVA) 4 years previously. BR specifically
presented with a nonfluent aphasia, characterised by one, two, and occasionally
three-word utterances. He could follow one-step commands and basic conversation.
Speech output was slow and segmented, with some distortion of isolated sounds
which he often self-corrected. These latter behaviours are consistent with a moderate-
marked apraxia of speech (AOS). BR passed a modified hearing screening for older
adults (Ventry & Weinstein, 1983, 1992). He had been a university professor with 22
years of education. Additionally, he was right-handed by self-report and a native
English speaker. BR had received traditional speech-language therapy intermittently
since his CVA; however, he did not receive any additional therapy during this
investigation.
Upon further investigation, it was discovered that MIT had been implemented
previously with BR at another facility with little success, although he presented with
an appropriate communicative profile for use of the technique. BR’s spouse reported
that he had difficulty with the tapping element of MIT; attempts at rhythmic behaviour
while using the approach interfered with any production of verbal output. It also was
reported that the packaged phrases previously used lacked functionality, adversely
affecting BR’s motivation relative to using the approach.
In preparation for implementing MIT in treatment, BR, his spouse, and the
examiner generated a series of two- to four-word functional phrases that BR was
unable to produce with consistency. Some of the phrases generated appeared to be
778 HOUGH
TABLE 1
Stimulus examples used with modified
Melodic Intonation Therapy
Automatic Self-generated
I love you Find my glasses
Thank you Time for e-mail
Have a nice day Grandpa is here
Good morning I need my cane
more routine or automatic phrases whereas others were intuitively more proposi-
tional or individualised. It was hypothesised that these latter phrases would be more
difficult for BR to generate, and therefore should be treated separately from the
“automatic” phrases. Subsequently, 60 undergraduate students (two sections of the
introductory communication disorders class) were asked to determine whether each
of 55 phrases was an “automatic” phrase or a “self-generated” phrase, as part of an
extra credit assignment. The examiner explained that an automatic phrase was a rote
statement or question; the meaning of the particular phrase was based on the com-
bined contribution of all the words in the phrase. In another linguistic context the
individual words from the phrase would be independent and have a completely dif-
ferent meaning. A self-generated phrase was identified as a statement/question that
was individualised to a particular person’s needs or wants; each word was independ-
ent relative to contributing to the meaning of the utterance.
Only phrases that were considered automatic or self-generated by at least 95% of
the students were identified as treatment stimuli for implementing MIT with BR.
Analysis of the student ratings resulted in 40 phrases that met this criterion: 15
phrases were identified as automatic (“I love you”); 25 phrases were personal/self-
generated (“find my glasses”). Of the latter set, 15 were randomly chosen as treat-
ment stimuli and 10 as generalisation probes that were not treated, resulting in two
sets of 15 treatment stimuli (30 stimuli, 10 probes). Examples of automatic and self-
generated stimuli are presented in Table 1.
A multiple baseline design across the automatic and self-generated treatment
stimuli was implemented. Three baselines were obtained on all treatment and
probe (untreated) stimulus phrases. A criterion of 75% accuracy over two consec-
utive sessions was established for both sets of treatment stimuli. Treatment was
implemented on the automatic phrases while baseline measurements were
continued on the self-generated phrases. When criterion was met for the automatic
phrases, treatment was initiated for the self-generated stimuli. The generalisation
probe (untreated) stimuli were presented to BR at the last weekly session of each
week of treatment. For both baseline and untreated probe stimuli, each phrase was
read aloud by the examiner with typical melodic contour and intonation. BR was
required to repeat the phrase. If BR, had difficulty, the phrase was repeated using
Sprechgesang and BR was required to repeat the production. Phrases were
considered correct if each word of the phrase was uttered and each word was
produced accurately and intelligibly. Intra- and inter-judge reliability for response
accuracy were analysed and are presented below. Follow-up probing with all
stimuli occurred at 2 and 4 weeks post-treatment. BR attended three weekly treat-
ment sessions, which were approximately 1 hour in length, for 8 weeks using the
modified MIT protocol.
MELODIC INTONATION THERAPY AND APHASIA 779
Using the specified stimuli, MIT programming was begun with BR at the ECU
Speech, Language, and Hearing Clinic, administered by the primary author. MIT
was implemented without the tapping component for stages 1 and 2, using the
traditional approach. Thus, in stage 1, the examiner introduced humming of intoned
phrases, producing each phrase three times. During presentation of each phrase BR
was primarily required to listen to each production. He could tap or nod his head in
a rhythmic manner if chosen. In stage 2 BR was required to repeat the hummed
phrases simultaneously with the examiner; he could tap the rhythm if chosen but this
was not required, nor did he choose to do this behaviour. Tapping along with phrase
production was used by the clinician for cuing only to re-focus BR when productions
were inaccurate or to enhance precision of individual words. Additionally, the Eight-
Step Continuum (Rosenbek, 1985; Rosenbek, Lemme, Ahern, Harris, & Wertz, 1973)
was utilised to increase awareness of speech precision relative to the rhythmic
components of MIT. Specifically, if BR encountered difficulty with speech production
of a particular word, the Continuum was utilised with or without Sprechgesang.
Relative to actual implementation of the Continuum, steps were utilised sequentially
based on what cues BR required to establish accuracy for certain words in a phrase.
Steps 1 to 5 of the Eight-Step Continuum were implemented as needed. However,
primarily only steps 1 and 2 of the Continuum were needed to enhance accuracy of
production. Overall, for an average session with the automatic phrases, the contin-
uum was implemented approximately 6 times per session; for the self-generated
phrases, the Continuum was implemented approximately 10 times per session. The
Eight-Step Continuum is similar in nature to Auditory-Motor Feedback Training
(Norton et al., 2009), which recently has been used to complement the effectiveness
of MIT. This latter protocol was developed to restore volitional and purposeful
communication in adults with marked to severe AOS and moderate aphasia, through
use of both visual and auditory modalities as well as simultaneous and sequential
production strategies. A treatment trial included all stimulation directed towards
each individual treatment phrase in that particular phase of treatment. All phrases
within each phrase type for that phase of treatment were typically treated at each
treatment session, thus yielding approximately 15 trials per session.
MIT treatment began with the automatic phrases. Measurement of baseline data was
continued on the self-generated phrases until the criterion of 75% accuracy over two
consecutive sessions was achieved on the automatic phrases. Once this was attained,
treatment was implemented on the self-generated phrases, with maintenance probing on
automatic phrases. Accuracy of phrase production was the dependent variable; phrases
were considered accurate if each word in the phrase was produced and understandable,
regardless of whether BR utilised Sprechgesang during the particular production. Self-
corrections that were correct responses were judged as accurate. Intra-judge reliability
for response accuracy was determined via percentage of agreement of 10% of each ses-
sion’s productions; these responses were reviewed at least 2 weeks after the particular
session, yielding a 98.5% agreement. For inter-judge reliability, a graduate student
familiar with MIT judged response accuracy of 10% of each session’s productions; per-
centage of agreement was 96%. All responses were audio tape-recorded using a Marantz
PMD201 portable cassette recorder attached to a Shure SM58 vocal microphone.
The following tests were administered pre- and post-treatment: (1) Western
Aphasia Battery-Revised (WAB-R) (Kertesz, 2006), Aphasia Quotient (AQ), Cortical
Quotient (CQ); (2) American Speech-Language Hearing Association Functional
Assessment of Communication Skills (ASHA FACS) (Frattali, Thompson, Holland,
780 HOUGH
Behavior 1
90
Percentage of Accuracyll 80
70
60
50
40
30
20
10
0
11
F1
1
T2
T4
T6
T8
M
B
M
90
80
Percentage of Accuracy
70
60
50
40
30
20
10
0
1
11
T1
T3
T5
T7
F1
1
T9
T1
B
Sessions
Behavior 2
Figure 1. Accuracy percentage for automatic and self-generated phrases, including untreated probes, using
modified Melodic Intonation Therapy protocol for 8 weeks. Behaviour 1: Automatic phrases. Behaviour 2:
Self-generated phrases and Probe (untreated) phrases (untreated stimulus probes presented at end of each
week of treatment). B: Baseline; T: Therapy Sessions; M: Maintenance; F: Follow-up Sessions.
Wohl, & Ferketic, 1995); (3) American Speech-Language Hearing Association Quality
of Communication Life Scale (ASHA QCL) (Paul et al., 2003); and (4) Communicative
Effectiveness Index (CETI) (Lomas et al., 1989).
RESULTS
BR’s performance on the automatic and self-generated phrases using MIT without tap-
ping relative to percent accuracy is displayed in Figure 1. As can be observed, BR
reached the established criterion of 75% on the automatic phrases at approximately 4
weeks (nine treatment sessions) into the MIT treatment programme. This level of accu-
racy was generally retained throughout the maintenance phase and was apparent at both
follow-up sessions several weeks after the entire treatment programme was completed.
Treatment on the self-generated phrases was initiated once BR reached criterion
on the automatic phrases. At 8 weeks post-baseline, BR’s performance accuracy on
the self-generated phrases was 55%. Although he had not achieved the established
75% accuracy criterion, BR made noticeable improvement from baseline, which was
MELODIC INTONATION THERAPY AND APHASIA 781
TABLE 2
Pre- and post-treatment test scores on the Western
Aphasia Battery-Revised
TABLE 3
Pre- and post-treatment ratings on the ASHA FACS
Communication Independence Scales
DISCUSSION
The purpose of the current investigation was to examine the effectiveness of the
techniques of a modified version of MIT as a means of enhancing verbal output in a
patient with chronic Broca’s aphasia of extensive duration. Overall, BR significantly
increased his ability to produce short phrases using the MIT protocol without the
MELODIC INTONATION THERAPY AND APHASIA 783
TABLE 4
Pre- and post-treatment testing and difference scores on the ASHA Quality
of Life Communication Scale
TABLE 5
Pre- and post-treatment testing and difference scores on the CETI
tapping component. Although pre-determined criterion was reached only for the
automatic phrases, remarkable increases were observed for both the automatic and
self-generated phrases throughout the treatment protocol. Furthermore, improved
phrase production was maintained at follow-up sessions at 2 and 4 weeks post-treat-
ment for both types of phrases. Some generalisation to the untreated phrase stimuli
784 HOUGH
was observed. This increase for the self-generated probe phrases was maintained at
both follow-up sessions. Increases were not as remarkable for the untreated as the
treated stimuli; however, improved production was evident. Statistical analyses on
the untreated stimuli were not conducted because there were too few data points.
Although tapping has been considered an integral part of MIT, this component of
the technique was not used with BR, as he found this behaviour to be distracting and
disruptive to his verbal output performance. Tapping in MIT or any other therapy
approach (i.e., pacing board, gestural reorganisation, etc.) has been considered a
form of inter-systemic reorganisation (Duffy, 2005; Rosenbek & LaPointe, 1985). In
inter-systemic reorganisation a non-speech motor activity, such as tapping, is intro-
duced to accompany production of the impaired act. Thus the impaired act is paired
with internal cues generated by this more intact function (tapping). Consequently,
the intact system functions as an organiser relative to enhancing verbal output.
Although Schlaug et al. (2008) indicated that tapping is a critical element of MIT, it
may not be essential to increase abilities in verbal output for all individuals with
aphasia and/or AOS. Thus in BR’s case, an additional tool such as Norton et al.’s
(2009) inner rehearsal was not beneficial because of the tapping aspect of this pro-
cess. Tapping may be as impaired as BR’s ability to produce speech; thus attempting
to use this behaviour to facilitate verbal output may be more of a hindrance than an
assistive tool. Rosenbek’s Eight-Step Continuum (Rosenbek, 1985; Rosenbek, et al.,
1973) was utilised intermittently with BR throughout treatment, particularly during
stages 1 and 2 of the MIT treatment protocol. Interestingly, it is during these stages
that the tapping component of MIT is typically helpful in modulating and enhancing
accuracy of production for most patients with aphasia and/or AOS. Thus it appears
that BR did require some additional stimulation to increase accurate phrase produc-
tion; however, he benefited from direct manipulation of his articulatory skills, rather
than an inter-systemic reorganisation approach such as tapping. Thus, the successful
use of the Eight-Step Continuum (Rosenbek, 1985) in conjunction with MIT with
BR supports the simultaneous implementation of other similar approaches that
enhance articulatory precision and volitional use of speech along with techniques
addressing manipulation of the melodic and intonation components of speech
(Norton et al., 2009).
Improved performance on standardised tests relative to language structure and
communication skills was observed. Although some improvement was found relative
to spontaneous speech and naming, most notables increases were observed for
auditory comprehension and reading and writing skills. It is interesting to note that
this similar pattern of improvement on standardised tests also has been observed
with other chronic aphasic patients (Hough & Johnson, 2009; Hough & King, 2008;
Johnson, Hough, King, Jeffs, & Vos, 2008; Steele, 2008). Furthermore, in the current
investigation, improvement in perception of communicative effectiveness was
reported independently by both BR and his spouse. These observations included
enhanced general and functional aspects of communication as well as increased
initiation of interaction with others.
There are several limitations regarding the current study that restrict the extent to
which findings may be generalised to other patients with chronic Broca’s aphasia
and/or AOS. Although probe phrases were included in the investigation, generalisation
to other spontaneous and natural contexts relative to BR’s verbal output was not
examined. Furthermore, maintenance data for the self-generated phrases was
obtained only in follow-up sessions; unlike the data available for the automatic
MELODIC INTONATION THERAPY AND APHASIA 785
REFERENCES
Baker, F. A. (2000). Modifying the melodic intonation therapy program for adults with severe non-fluent
aphasia. Music Therapy Perspectives, 18(2), 110–114.
Belin, P., Eeckhout, V., Zilbovicius, M., Remy, P., Francois, C., Guillaume, S., et al. (1996). Recovery
from non-fluent aphasia after melodic intonation therapy: A PET study. Neurology, 47(6), 1504–1511.
Bonakdarpour, B., Eftekharzadeh, A., & Ashayeri, H. (2000). Preliminary report on the effects of melodic
intonation therapy in the rehabilitation of Persian aphasic patients. Iranian Journal of Medical
Sciences, 25, 156–160.
Bonakdarpour, B., Eftekharzadeh, A., & Ashayeri, H. (2003). Melodic intonation therapy in Persian
aphasic patients. Aphasiology, 17(1), 75–95
Carlomagno, S., Van Eeckhout, P., Blasi, V., Belin, P., Samson, Y., & Deloche, G. (1997). The impact of
functional neuroimaging methods on the development of a theory for cognitive remediation.
Neuropsychological Rehabilitation, 7, 311–326.
Duffy, J. (2005). Motor speech disorders (2nd ed.). Boston: Elsevier Mosby
Dunham, M. J., & Newhoff, M. (1979). Melodic intonation therapy: Rewriting the song. In R. H. Brookshire
(Ed.), Clinical Aphasiology Conference Proceedings (pp. 286–294). Minneapolis, MN: BRK Publishers.
Frattali, C. M., Thompson, C. M., Holland, A. L., Wohl, C. B. & Ferketic, M. M. (1995). ASHA
Functional Assessment of Communication Skills (FACS). Rockville, MD: American Speech-Language-
Hearing Association.
Gates, A., & Bradshaw, J. L. (1977). The role of the cerebral hemispheres in music. Brain and Language, 4,
403–431.
Goldfarb, R., & Bader, E. (1979). Espousing melodic intonation therapy in aphasia rehabilitation: A case
study. International Journal of Rehabilitation Research, 2(3), 333–342.
Goodglass, H., & Calderon, M. (1977). Parallel processing of verbal and musical stimuli in right and left
hemisphere. Neuropsychologia, 15, 397–407.
Hebert, S., Racette, A., Gagnon, L., & Peretz, I. (2003). Revisiting the dissociation between singing and
speaking in expressive aphasia. Brain, 126, 1–13.
Helm-Estabrooks, N. & Albert, M. (2004). Manual of aphasia and aphasia therapy (2nd ed.). San Diego,
CA: Singular Publishing Company.
786 HOUGH
Helm-Estabrooks, N., Nicholas, M., & Morgan, A. (1989). MIT, melodic intonation therapy manual. San
Antonio, TX: Special Press.
Hough, M. S., & Johnson, R. K. (2009). Use of AAC to enhance linguistic communication skills in an
adult with chronic severe aphasia. Aphasiology, 23(7), 965–974.
Hough, M. S., & King, K. A. (2008). Enhancing word retrieval in three adults with chronic fluent aphasia.
Paper presented at the annual Clinical Aphasiology Conference, Jackson Hole, May.
Johnson, R., Hough, M. S., King, K. A., Jeffs, T., & Vos, P. (2008). Use of an augmentative system as a
functional communicative device for adults with severe chronic nonfluent aphasia. Alternative and
Augmentative Communication, 24(4), 1–12.
Kertesz, A. (2006). Western Aphasia Battery-Revised. New York: Grune & Stratton.
Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., & Zoghaib, C. (1989). The Communicative
Effectiveness Index: Development and psychometric evaluation of a functional communication
measure for adult aphasia. Journal of Speech and Hearing Disorders, 54, 113–124.
Marshall, N., & Holtzapple, P. (1976). Melodic intonation therapy: Variations on a theme. In R. H.
Brookshire (Ed.), Clinical Aphasiology Conference Proceedings (pp. 115–141). Minneapolis, MN: BRK
Publishers.
Naeser, M. A., & Helm-Estabrooks, N. (1985). CT scan lesion localization and response to melodic
intonation therapy with nonfluent aphasia cases. Cortex, 21(2), 203–223.
Norton, A., Zipse, L., Marchina, S., & Schlaug, G. (2009). Melodic Intonation Therapy: Shared insights
on how it is done and why it might help. Annals of the New York Academy of Sciences, 1169, 431–436.
Ozdemir, E., Norton, A., & Schlaug, G. (2006). Shared and distinct neural correlates of singing and
speaking. Neuroimage, 33, 628–635.
Paul, D. R., Frattali, C. M., Holland, A. L., Thompson, C. K., Caperton, C. J., & Slater, S. C. (2003).
ASHA Quality of Communication Life Scale (QCL). Rockville, MD: American Speech-Language-
Hearing Association.
Racette, A., Bard, C., & Peretz, I. (2006). Making non-fluent aphasics speak: Sing along! Brain, 129(10),
2571–2584.
Rosenbek, J. C. (1985). Treating apraxia of speech. In D. F. Johns (Ed.), Clinical management of
neurogenic communicative disorders (2nd ed.) (pp. 267–312). Boston: Little, Brown & Company.
Rosenbek, J. C., & LaPointe, L. L. (1985). The dysarthrias: Description, diagnosis and treatment. In D. F.
Johns (Ed.), Clinical management of neurogenic communicative disorders (2nd ed., pp. 151–210). Bos-
ton: Little, Brown & Company.
Rosenbek, J. C., Lemme, M. L., Ahern, M. B., Harris, E. H., & Wertz, R. T. (1973). A treatment for
apraxia of speech in adults. Journal of Speech and Hearing Disorders, 38, 462–472.
Schlaug, G., Marchina, S., & Norton, A. (2008). From singing to speaking: Why singing may lead to
recovery of expressive language function in patients with Broca’s aphasia. Music Perception, 25(4),
315–323.
Schlaug, G., Marchina, S., & Norton, A. (2009). Evidence for plasticity in white-matter tracts of patients
with chronic Broca’s aphasia undergoing intense intonation-based speech therapy. Annals of the New
York Academy of Sciences, 1169, 385–394.
Sparks, R. W., & Deck, J. W. (1994). Melodic intonation therapy. In R. Chapey (Ed.), Language
intervention strategies in adult aphasia (3rd ed.) (pp. 368–379). Baltimore: Williams & Wilkins.
Sparks, R. W., Helm, N., & Albert, M. (1973). Melodic intonation therapy for aphasia. Archives of
Neurology, 29, 130–131.
Sparks, R. W., Helm, N., & Albert, M. (1974). Aphasia rehabilitation resulting from melodic intonation
therapy. Cortex, 10, 303–316.
Sparks R. W., & Holland A. (1976). Method: Melodic intonation therapy for aphasia. Journal of Speech
and Hearing Disorders, 41, 287–297.
Steele, R. (2008). Changes in chronic global aphasia at impairment and functional communication levels
following SGD practice and use. Paper presented at the annual Clinical Augmentative and Alternative
Communication conference, Charlottesville, September.
Ventry, I. M., & Weinstein, B. E. (1983). Identification of elderly people with hearing problems. American
Speech-Language-Hearing Association, 25(7), 37–42.
Ventry, I., & Weinstein, B. (1992). Considerations in screening adults/older persons for handicapping
hearing impairments. American Speech-Language-Hearing Association, 34, 81–87.