Disclaimer: this resource is intended for speech and language therapists and students of this profession. If you require therapy for aphasia please contact a speech and language therapist.
Melodic Intonation Therapy (MIT)
Summary: An approach that builds upon the preserved singing ability exhibited by many people with non-fluent aphasia (Schlaug et al., 2009). Melodic Intonation Therapy (MIT) exaggerates the melodic and rhythmic qualities of speech and seeks to stimulate ‘language-capable’ regions in the right hemisphere of the brain (Norton et al., 2009). Initially phrases are intoned on two-pitches whilst tapping (or prompting the client to tap) the syllable pattern on the client’s left hand.
Criteria for Treatment: Clients who meet the following criteria are likely to respond positively to MIT:
Adapted from Naeser & Helm-Estabrooks (1985) & Helm-Estabrooks & Albert (2004).
- Good auditory comprehension
- Facility for self-correction
- Very limited verbal output
- Relatively good attention span
- Good emotional stability
- Unilateral brain damage affecting language-dominant hemisphere
Adapted from Naeser & Helm-Estabrooks (1985) & Helm-Estabrooks & Albert (2004).
Example:
Elementary Level
1) The therapist shows the client a visual cue for the target phrase, e.g. “Good morning”, and hums the phrase once at a rate of one syllable per second. Then the therapist sings the phrase twice while tapping the syllable structure on the client’s left hand. Whilst humming/singing in MIT the therapist produces the target phrases across two pitches with stressed syllables sung on the higher pitch.
2) The therapist and client sing the target phrase in unison. The therapist again taps the syllable structure on the client’s left hand.
3) The therapist and client sing the target phrase in unison (again with the therapist tapping the syllable structure on the client’s left hand), however the therapist fades out at the midpoint of the phrase leaving the client to sing the remainder of the phrase alone (with only hand tapping to support).
4) The therapist sings the target phrase. The client repeats the target phrase with only hand tapping to support.
5) The therapist responds to the client’s successful repetition in step 4 by singing a question that requires the client to repeat the target phrase (e.g. “What did you say?”). The client then sings the target phrase with only hand tapping to support.
Advanced Level
1) The therapist sings the target phrase whilst tapping the client’s left hand. Following a six second delay the patient repeats the target phrase with only hand tapping to support.
2) The therapist produces the target phrase in what is known as sprechgesang twice whilst tapping the client’s left hand. When producing ‘sprechgesang’, which translates to English as ‘spoken singing’, the target phrase should be produced ‘slowly with exaggerated emphasis on rhythm and stressed (accented) syllables’. The client does not need to produce the target phrase during this step.
3) The therapist produces the target phrase using sprechgesang whilst tapping the client’s left hand. At the midpoint of the phrase the therapist fades out and leaves the client to complete the phrase.
4) The therapist speaks the target phrase with normal prosody and no hand tapping. Following a six second delay the client repeats the target phrase in normal speech.
5) The therapist responds to the client’s successful repetition in step 4 by asking a question that requires the client to again repeat the target phrase (e.g. “What did you say?”). The client then speaks the target phrase using normal speech with no support.
Steps from Helm-Estabrooks et al. (1989). See Norton et al. (2009) for a discussion of variations in the delivery of MIT and guidance on melodies and pitches used.
Elementary Level
1) The therapist shows the client a visual cue for the target phrase, e.g. “Good morning”, and hums the phrase once at a rate of one syllable per second. Then the therapist sings the phrase twice while tapping the syllable structure on the client’s left hand. Whilst humming/singing in MIT the therapist produces the target phrases across two pitches with stressed syllables sung on the higher pitch.
2) The therapist and client sing the target phrase in unison. The therapist again taps the syllable structure on the client’s left hand.
3) The therapist and client sing the target phrase in unison (again with the therapist tapping the syllable structure on the client’s left hand), however the therapist fades out at the midpoint of the phrase leaving the client to sing the remainder of the phrase alone (with only hand tapping to support).
4) The therapist sings the target phrase. The client repeats the target phrase with only hand tapping to support.
5) The therapist responds to the client’s successful repetition in step 4 by singing a question that requires the client to repeat the target phrase (e.g. “What did you say?”). The client then sings the target phrase with only hand tapping to support.
Advanced Level
1) The therapist sings the target phrase whilst tapping the client’s left hand. Following a six second delay the patient repeats the target phrase with only hand tapping to support.
2) The therapist produces the target phrase in what is known as sprechgesang twice whilst tapping the client’s left hand. When producing ‘sprechgesang’, which translates to English as ‘spoken singing’, the target phrase should be produced ‘slowly with exaggerated emphasis on rhythm and stressed (accented) syllables’. The client does not need to produce the target phrase during this step.
3) The therapist produces the target phrase using sprechgesang whilst tapping the client’s left hand. At the midpoint of the phrase the therapist fades out and leaves the client to complete the phrase.
4) The therapist speaks the target phrase with normal prosody and no hand tapping. Following a six second delay the client repeats the target phrase in normal speech.
5) The therapist responds to the client’s successful repetition in step 4 by asking a question that requires the client to again repeat the target phrase (e.g. “What did you say?”). The client then speaks the target phrase using normal speech with no support.
Steps from Helm-Estabrooks et al. (1989). See Norton et al. (2009) for a discussion of variations in the delivery of MIT and guidance on melodies and pitches used.
Evidence Base: Hurkmans et al. (2012) carried out a review of the use of Speech-Music Therapy for Aphasia. While all studies (9/15 of which involved MIT or a modified form of MIT) reported positive effects of treatment, there was variation in outcomes and the methodological quality of the studies was rated as low.
Additionally, a review of studies into MIT with individuals with aphasia (van der Meulen et al., 2012) indicated that, overall, MIT resulted in improvements in verbal production. The majority of participants in these studies had chronic aphasia. The authors note that limitations of the studies included, e.g. most studies were single case studies or case-series studies and the group studies often had poor methodological quality. A randomised controlled trial (van der Meulen et al., 2014) indicates that MIT is effective in individuals in the sub-acute phase of a stroke, with (16 participants received MIT, 11 participants were in a control group). MIT resulted in significantly improved repetition for trained words with variable generalisation to repetition of untrained words. It is not clear whether MIT is more effective when delivered in the sub-acute or chronic phases of stroke (van der Meulen et al., 2012).
Stahl et al. (2013), in a study into MIT with participants who had non-fluent aphasia and apraxia of speech, found no advantage of singing over rhythmic speech in the delivery of MIT.
Additionally, a review of studies into MIT with individuals with aphasia (van der Meulen et al., 2012) indicated that, overall, MIT resulted in improvements in verbal production. The majority of participants in these studies had chronic aphasia. The authors note that limitations of the studies included, e.g. most studies were single case studies or case-series studies and the group studies often had poor methodological quality. A randomised controlled trial (van der Meulen et al., 2014) indicates that MIT is effective in individuals in the sub-acute phase of a stroke, with (16 participants received MIT, 11 participants were in a control group). MIT resulted in significantly improved repetition for trained words with variable generalisation to repetition of untrained words. It is not clear whether MIT is more effective when delivered in the sub-acute or chronic phases of stroke (van der Meulen et al., 2012).
Stahl et al. (2013), in a study into MIT with participants who had non-fluent aphasia and apraxia of speech, found no advantage of singing over rhythmic speech in the delivery of MIT.
References
Helm-Estabrooks, N. & Albert, M., 2004. Manual of Aphasia and Aphasia Therapy. Austin, TX: PRO-ED Publishers
Helm-Estabrooks, N., Nicholas, M., & Morgan, A., 1989. Melodic Intonation Therapy program. Austin, Tx: PRO-ED Publishers
Hurksman, J., de Brujin, M., Boonstra, A.M., Jonkers, R., Bastiaanse, R., Arendzen, H., & Reinders-Messelink, H. A., 2012. Music in the treatment of neurological language and speech disorders: A systematic review. Aphasiology, 26(1), 1-19
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’s done and why it might help. Annals of the New York Academy of Science, 1169, 431-436
Schlaug, G., Norton, A., Marchina, S., Zipse, L., & Wan, C.Y., 2009. From singing to speaking: facilitating recovery from non-fluent aphasia. Future Neurology, 5(5), 656-665
Stahl, B., Henseler, I., Turner, R., Geyer, S., & Kotz, S.A., 2013,. How to engage the right brain hemisphere in aphasics without even singing: Evidence for two paths of speech recovery. Frontiers in Human Neuroscience, 7(35), 1–12
van der Meulen, I., van de Sandt-Koenderman, M.W., Heijenbrok-Kal, M.H., Visch-Brink, E.G., & Ribbers, G.M, 2014. The efficacy and timing of Melodic Intonation Therapy in subacute aphasia. Neurorehabilitation and Neural Repair, 28(6), 536–544
van der Meulen, I., van de Sandt-Koenderman, M.W., & Ribbers, G.M., 2012. Melodic Intonation Therapy: Present controversies and future opportunities. Archives of Physical Medicine and Rehabilitation, 93(1), S46-52
Helm-Estabrooks, N. & Albert, M., 2004. Manual of Aphasia and Aphasia Therapy. Austin, TX: PRO-ED Publishers
Helm-Estabrooks, N., Nicholas, M., & Morgan, A., 1989. Melodic Intonation Therapy program. Austin, Tx: PRO-ED Publishers
Hurksman, J., de Brujin, M., Boonstra, A.M., Jonkers, R., Bastiaanse, R., Arendzen, H., & Reinders-Messelink, H. A., 2012. Music in the treatment of neurological language and speech disorders: A systematic review. Aphasiology, 26(1), 1-19
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’s done and why it might help. Annals of the New York Academy of Science, 1169, 431-436
Schlaug, G., Norton, A., Marchina, S., Zipse, L., & Wan, C.Y., 2009. From singing to speaking: facilitating recovery from non-fluent aphasia. Future Neurology, 5(5), 656-665
Stahl, B., Henseler, I., Turner, R., Geyer, S., & Kotz, S.A., 2013,. How to engage the right brain hemisphere in aphasics without even singing: Evidence for two paths of speech recovery. Frontiers in Human Neuroscience, 7(35), 1–12
van der Meulen, I., van de Sandt-Koenderman, M.W., Heijenbrok-Kal, M.H., Visch-Brink, E.G., & Ribbers, G.M, 2014. The efficacy and timing of Melodic Intonation Therapy in subacute aphasia. Neurorehabilitation and Neural Repair, 28(6), 536–544
van der Meulen, I., van de Sandt-Koenderman, M.W., & Ribbers, G.M., 2012. Melodic Intonation Therapy: Present controversies and future opportunities. Archives of Physical Medicine and Rehabilitation, 93(1), S46-52
|
|
