Melodic intonation therapy

Melodic Intonation Therapy (MIT) is a therapeutic process used by music therapists and speech pathologists to help patients with communication disorders caused by brain damage. This method uses a style of singing called melodic intonation to stimulate activity in the right hemisphere of the brain in order to assist in speech production (Carroll 1996).

History

Neurological researchers Sparks, Helm, and Albert developed melodic intonation therapy in 1973 while working with adults in the Aphasia Research Unit at the Boston VA Hospital (Marshal and Holtzapple 1976). MIT is based on the hypothesis of these researchers that "increased use of the right hemisphere dominance for the melodic aspect of speech increases the role of that hemisphere in inter-hemispheric control of language, possibly diminishing the language dominance of the damaged left hemisphere" (Marshal and Holtzapple 1976:115). In order to do this common words and phrases are turned into melodic phrases emulating typical speech intonation and rhythmic patterns (Davis et al. 1999, Marshal and Holtzapple 1976, and Carroll 1996). One study using PET (positron emission tomography) scans found that areas controlling speech in the left hemisphere were "reactivated" by the end of MIT (Belin 1996). Today MIT is commonly used with patients suffering from aphasia. The Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology labeled MIT as "promising"; however, there have not been many studies published that can truly support the effectiveness of MIT (Carroll 1996:12). Researchers are working to resolve this issue.

Recent evidence shows that MIT can result in significant changes in brain structure through the brain's own neuroplasticity. Axon connections in the right hemisphere (in right handed patients) were found to be increased in volume between the language areas after MIT. This would allow for more efficient processing in the right homologous language areas, suggesting that the right hemisphere can, indeed, compensate for an impaired left hemisphere by taking up language processing responsibilities (Schlaug, 2009).

Who Benefits from Melodic Intonation Therapy

The majority of research in melodic intonation therapy has been conducted with aphasia patients. Aphasia is a general diagnosis for communication disorders resulting from brain damage. There are different types of aphasia depending on the location of the damage. Patients that would benefit from MIT typically suffer from non-fluent aphasia or Broca’s aphasia. As the name suggests the damage to the brain in this category is mostly in the Broca’s area and thus speech production is affected. Sparks and associates found that adult patients meeting the following criteria achieved positive results with MIT (Marshal and Holtzapple 1976:115):

1. Good auditory comprehension
2. Facility for self correction
3. Markedly limited verbal output
4. Reasonably good attention span
5. Good emotional stability

Later researchers have also noted that for MIT to be effective the patient must not exhibit any “bi-lateral brain damage” (Roper,2003:1). Melodic intonation therapy is not appropriate for patients suffering form receptive aphasia or brain damage affecting the patient’s ability to read and comprehend language. The main goal is to help the patient speak in a comprehendible manner. MIT may also be an effective treatment for speech impairments caused by other disorders such as Down syndrome, but research on this topic is even more limited than general research in MIT (Carroll 1996).

How Melodic Intonation Therapy Works

The traditional melodic intonation therapy process is divided into four progressive stages. However, modifications are often made to meet the specific needs of the patient. This is one reason why it is difficult to obtain definitive research results in MIT. In the early stages, MIT was used solely for adult patients, but eventually therapists began to use MIT with children. Therapists found that the traditional procedure did not work well with children, so a new three level structure was developed by Helfrich-Miller (Roper 2003). The following sections will describe both the adult and child models of melodic intonation therapy.

Adult

As stated above this is a four level process. Speech pathologist Nicole Roper and Debbie Carroll, a music educator, both describe this method. As the patient progresses through the stages the role of the therapist decreases. In the first stage the therapist hums “intoned phrases” and the patient taps the “rhythm and stress of each pattern” with his/her hands or feet (Roper 2003:2). In the beginning of the second stage the patient joins the therapist in humming while continuing to beat the rhythms. As the patient progresses, the therapist begins to sing “intoned phrases” and the patient repeats them (Carroll 1996, Roper 2003:2). The third stage is the same as the final level of stage two except that now the patient is required to wait for a designated period of time before repeating the phrase or sentence. This helps to increase the patients ability to “retrieve” words (Carroll 1996:11). In the fourth and final stage the sentence length is increases and “sprechgesang” is used to facilitate the transition to normal speech. “This technique involves keeping the same melodic line as the intoned sentence of the proceeding step, except that the constant pitch of the intoned words is replaced by the variable pitch of speech” (Roper 2003:2). The ultimate goal is to remove the musical elements entirely so the patient presents normal speech.

Child

Roper (2003:2) provides an in depth description of MIT with children. She notes that this model was created by researchers working with children suffering from apraxia of speech, due to similarities between children with this disorder and adults with aphasia. This model is divided into three stages each with five or six progressive levels. Stage one is the same as that in the adult model, but instead of tapping the patient signs, using Signed English. The therapist also signs while singing the intoned phrases. This is step one of the process, by step six the patient will respond to an “intoned question” by singing and signing the “last words” of the question. The second stage is similar to the third stage of the adult model. In this stage the patient is required to wait roughly “six seconds” before repeating the intoned question. As this stage progresses the role of the therapist decreases. The final stage is the same as that of the adult model. As the patient moves through the steps of this stage “signing is faded out and the last two stages involve questioning, using normal speech” (Roper 2003:2).

Research

Research in melodic intonation therapy is continually being conducted. However as previously mentioned it is difficult to determine its overall level of effectiveness due to the need for modifications based on the patient. Most research in this area has been conducted with adults suffering from aphasia, but researchers are beginning to implement MIT with patients experiencing other language disorders. Nicole Roper (2003), mentioned above, and other researchers have conducted MIT research with children who have apraxia. Therapists have also been using MIT to help patients with speech impairment as a result of Down syndrome (Carroll 1996).

Melodic Intonation Therapy for Broca's Aphasia: Neuronal Basis

References

Carroll, Debbie. 1996. A study of the effectiveness of an adaptation of melodic intonation therapy in increasing the communicative speech of young children with Down syndrome. McGill University. <http://www.musictherapyworld.de/modules/archive/dissertations/pdfs/MA_DC.pdf>.

Davis, William, Kate Gfeller, and Michael Thaut.ed. 1999. An introduction to music therapy: Theory and practice. McGraw-Hill.

Marshal, Noel and Pat Holtzapple. 1976. Melodic intonation therapy: Variations on a theme. Minneapolis: Clinical Aphasiology Conference. <http://aphasiology.pitt.edu/archive/00000019/01/06-09.pdf>.

Roper, Nicole. 2003. Melodic intonation therapy with young children with apraxia. Bridges 1, no.3 (May): <http://www.evidencebasedpractices.org/bridges/bridges_vol1_no3.pdf>.

Bonakdarpour, Eftekharzadeh, Ashayeri (2003) Melodic intonation therapy in Persian aphasic patients; Aphasiology 17(1):75-95

Belin, P., Van Eeckhout, P., Zilbovicius, M., Remy, P., Francois, C., Guillaume, S., Chain, F., Rancurel, G. & Samson, Y. (1996). Recovery from nonfluent aphasia after melodic intonation therapy: A PET study. Neurology, 47(6), 1504-1511.

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(1), 385.