Melodic intonation therapy

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The Melodische intonation therapy is a form of speech therapy , the song for the treatment of patients with non-liquid aphasia and Sprechapraxien used.

The beginnings

The first attempts to use singing to treat aphasia were developed in 1904 by the American neurologist Charles Mills . Based on the observation that people who are severely impaired in their speech production, but are still able to sing the text of songs they know with instrumental accompaniment or in a choir, Mills simply let his patients sing such songs while he accompanied them on the piano . It turned out, however, that this type of therapy did not enable patients to use words from the songs that they could pronounce perfectly while singing for propositional language because they were too closely connected to the melody of the song. Therefore, even non-aphasic patients find it difficult to continue the text of a familiar song if it is given to them starting somewhere in the middle of the verse. Apparently, there is a big difference between motorized movements of the articulators and the expression of thoughts in propositional language. In 1945 , the American speech pathologist Ollie Backus was the first to come up with the idea of ​​speaking individual words to aphasic patients in at least a rhythmic form. Melodic Intonation Therapy (MIT), however, essentially in the form it exists today, was developed in 1972 by Robert Sparks , Martin Albert and Nancy Helm .

Melodic intonation therapy

Candidates

Patients for whom MIT would make progress should show the following symptoms: The brain may only be damaged on one side, namely in the language-dominant hemisphere , predominantly in the area of Broca's area . The voice output is not fluent and articulated indistinctly, stereotypes and recurring utterances also occur. Repeating it hardly works, if at all, even for simple words. Speech comprehension, on the other hand, should be at least mediocre, the patient should be aware of his linguistic errors and thus also be able to correct himself. As with most therapies, with MIT the patient should be well motivated, emotionally stable, and have a large attention span. People with Wernicke or transcortical motor aphasia , in which speech production is impaired but repetition is retained, can in some cases complete MIT, but do not experience any noticeable improvements in everyday communication. Most aphasic patients have had several months of unsuccessful therapy before they are treated with MIT and their disease has already reached a chronic stage.

preparation

The corpus of items to be presented should consist of polysyllabic words, phrases and sentences that come from everyday communication and that are frequently used. It is clear that this usually has to be adapted individually for the patient. A large selection of items is definitely required in order to keep the range of stimuli wide and thus prevent perseveration . Each item is assigned a melody pattern that corresponds to its natural prosody and extends over three to four pitches, whereby it is not a question of exact note values, but the distinguishability of high and low tones, and it is important to ensure that the melody pattern is correct don't sound too similar to popular songs. Finally, the items are to be sorted according to increasing complexity, i.e. with regard to the number of syllables, syntax (e.g. imperatives are easier to process) and the ability to visualize the sounds (e.g. bilabial ones such as / o /, / b / or / m /, are preferable in the first phases of MIT), and alternate in the order in terms of structure and melody pattern. In addition, an image can be selected for each item and presented to the patient.

execution

The therapist sits across from the patient and goes through the training corpus one after the other over several levels, which are explained below. Unless otherwise requested, each item is sung consistently voiced, overly clear and slowly. The patient should thus have the opportunity to grasp the structure and the sound image of what is heard. This is further supported by the fact that the therapist lightly beats the rhythm and emphasis of the item on the patient's left hand. With the other hand the therapist gives the signs to speak or to listen, because nothing else may be conveyed verbally during and between the intonation of items, as this could throw the patient out of rhythm.

In addition to the individual sessions, there can also be group sessions that can encourage social interaction, speaking initiative and spontaneous speech.

construction

The therapy is structured in three levels, each consisting of four to five steps. All items that are assigned to the levels according to increasing complexity should go through all steps within their level. Only when the last step has been reached or the patient does not provide the necessary increase in performance, the next item is switched on and step 1 is started again. Points are awarded for successfully completing a step, 90 percent of which must be achieved on average in order to allow the patient to advance to the next level. In the following MIT model presented, I refer to that of Sparks and Holland (1976), which has four instead of three levels. The other models deviate only slightly from this (e.g. in that they do not specify Level 1 as a separate level, but as a single step).

Level 1

This level is used to introduce the patient to this unusual form of therapy. The therapist just hums a few melody patterns and suggests the appropriate rhythm. During this and in between, he has to encourage the patient by hand signals to join in, that is, to hum along and to keep up with the rhythm. As soon as he has gotten used to the therapy, feels quite safe and is eager to participate, the next level can be passed. Until then, of course, no points will be awarded.

Level 2

The second level consists of five steps.

  1. The therapist hums the melody of the item and then intones it with words. Both times he supports the rhythm and the emphasis with handshakes. During this time, the patient is silent and no points are awarded.
  2. Then the therapist asks the patient to join in so that they intone the item several times together. If this is achieved and an improvement in performance can be recorded, two points are scored and the next step is taken, otherwise a new item follows in step 1.
  3. The further increase in difficulty consists in the fact that towards the end of the item and with each repetition, the therapist becomes increasingly quieter (but continues to beat the rhythm) and lets the patient sing the item alone. The therapist must not make the mistake of moving his lips further after he has fallen silent. But if the patient has any problems, he can get back on again, but in this case he has to adjust to the patient's pitch if they deviate slightly and as long as the melody pattern itself has not been affected. Two points can be awarded.
  4. In this step, the therapist first intones the item, then the patient alone. This is made clear by showing hands. Furthermore, rhythm and emphasis are conveyed through punches and two points are awarded if successful.
  5. The therapist asks a question sung, which asks the item: “What did you say?” The patient should also answer sung and if successful, receives two points for it.

Level 3

This level consists of four steps. The items include polysyllabic and phonologically more complex words and phrases.

  1. The therapist sings the item twice and accompanies it with handshakes to the rhythm without any further verbal involvement of the aphasic.
  2. The patient is asked to join in and sing with the therapist. This becomes quieter after a few repetitions, as long as the patient can go that far. The therapist has to assess whether there is an increase in performance, which is again rated with two points, or whether the patient is merely persevering.
  3. The therapist sings the item, suggests the rhythm, lets three to five seconds of silence pass, and only then is the patient allowed to repeat the sung item. If the performance is given, the fourth step follows (two points can be achieved). Otherwise, support ("backup") must be provided by repeating step 2. If the item succeeds, you return to the third step and the patient receives a point. If, on the other hand, it is not possible for the patient to repeat the item even after being supported by step 2, the next item must be moved to and step 1 must be started again. There are no more points for it.
  4. In the case of success, however, the therapist immediately asks a question in sung form, which requires a component of the last item presented. The patient should respond briefly and concisely and not simply repeat what he last said. For example, if the item was “I am hungry”, the therapist asks: “Who's hungry?”, Which the patient should answer with “I.”. If, on the other hand, the answer is “I'm hungry”, it must be explained to him that he should answer the question more precisely the next time. There is no point deduction for this. However, if there is no or an incorrect reaction, you can return to step 3 and then try again. In this case, points are awarded in the same way as for the backup under step 3. In addition, the brevity of the answer can lead to a return to normal prosody here.

Level 4

Level 4 consists of five steps. Items at this level can already be longer, less frequent sentences. In this last level the patient should find his way back to normal speech prosody.

  1. The therapist sings the sentence out once and suggests the rhythm to it and then, after a break, the length of which is adjusted by the therapist to the progress of the aphasic's performance. If this does not succeed, a backup is inserted by voicing the therapist together once and turning it down. Two points are awarded in the event of success at the first attempt, one point in the case of supporting measures.
  2. The item is presented in spoken chant, i.e. no longer sung, but rather with exaggerated language prosody, and with handshakes to the rhythm. Then both speak together and repeat the item until the therapist notices that the patient has mastered the transition to speaking chant. Then the therapist becomes quieter and lets the patient go on alone. Again, you can go back to the first step for support, the points are adjusted accordingly.
  3. The therapist speaks the item in chant, the patient has to repeat it after a short break in chant. The rhythm is also conveyed here by handshakes and backup can be used. Points are awarded as in the previous steps.
  4. This time the item is spoken in normal prosody and speed and after a pause, the length of which depends on the patient's progress (see step 1), he repeats it. Assistance with step 3 can be carried out.
  5. After a short break, the therapist asks two or more questions in normal prosody about the information contained in the last item presented. For example, if the item was “Go to town”, questions could be: “Where are you going?”, “How are you going to get there?” Or “What do you want to do there?”. Backup via step 4 can be performed.

The MIT is completed as soon as an average of 90 percent of all points per item have been achieved from the last level. It should be noted that there are slightly different forms of MIT in other authors or in previous papers on this subject. Nancy Helm-Estabrooks, for example, in “Manual of Aphasia Therapy” (1991) stipulates that the therapist may repeat items a maximum of four times. Sparks, Helm and Albert (1974) present a form of MIT in which Level 1 is the first step from Level 2 and Level 2 and Level 3 are combined into one level. The therapy pattern is the same for all: increasing complexity of the items through the steps of audition, singing along and singing afterwards with a slow transition from melody to prosody of speech towards the end of the therapy.

MIT with children

MIT can also be used for children who have practiced speaking. However, the structure of the pediatric version is somewhat looser and also requires more individual adaptation to the patient. There are three levels with five to six steps each. It is made as easy as possible for the child in the first level (level 1 in the form according to Sparks and Holland (1976) does not exist) and as little as possible is required. Rather, the therapist presents the stimuli (also visually, supported by images) until the child gets in by itself. The rhythm is not conveyed by handshakes, but by gestures accompanying spoken language . Only in level 2 does the therapist begin to take breaks between the items, as well as to become quieter and let the patient continue singing alone. Level 3 is designed to return the child to normal prosody in a similar way to adults: through the use of spoken word.

effectiveness

In many cases there is an improvement in speech production after just a few weeks: The patients can articulate a limited number of everyday, formulaic expressions in an understandable manner (“hello”, “all right”, “goodbye”). This means that patients are again limited in their ability to express simple basic needs, albeit often with outside help. However, the production of untrained, non-formulaic statements remains difficult. The latest research suggests that the practice of formulaic expressions should be integrated more strongly into current speech therapy than before. The 15 patients studied made considerable progress in the production of formulaic expressions through both singing and rhythmic speaking. However, improvements in the production of non-formulaic, grammatical statements could only be determined after common speech therapy.

Albert, Sparks and Helm (1973) describe three - not representative - case studies of patients with aphasia:

A 67-year-old man whose speech understanding was barely impaired for 18 months, but speech production was severely impaired: a three-month treatment for aphasia did not produce any improvement. Just two days after MIT he was able to utter a few words, two weeks later it was almost a hundred. After a month and a half at MIT, he was already able to have short, meaningful conversations, which he initiated himself. The articulation, however, had hardly improved.

A 65-year-old man with similar symptoms: after two weeks with MIT, he was able to produce understandable, sometimes grammatically correct answers to questions for the first time since the 14 months of his illness.

A 48-year-old woman with limited speech production but intact speech understanding: MIT made it easier to produce propositional , meaningful speech after only three therapy sessions. After a month and a half she was able to manage four- to five-word sentences, the grammatical structure of which was correct. The main problem remained dysarthria .

Sparks, Helm and Albert (1974) observed nine patients with aphasia. According to the authors, treatment with MIT followed three different patterns. A first group, consisting of patients with stereotypical, meaningless jargon but clear articulation with melody patterns, was able to produce meaningful short but still dysarthric sentences after the therapy . The second group, consisting of patients with symptoms similar to the first group but without pre-MIT stereotypes, was only able to produce one to two word sentences after therapy, but their linguistic quality was sufficient. The third group describes patients who hardly improved despite therapy.

Neurological explanatory approach

In right-handers, a number of linguistic aspects are ascribed to the left hemisphere, while the right hemisphere supports important functions in singing. After damage to the left hemisphere of the brain, patients are often still able to hum familiar song melodies and articulate well-known song texts and simple, everyday phrases. Albert, Sparks and Helm (1973) therefore assumed that there must be speech areas in the right hemisphere that can be activated by intense singing. In this way, the linguistic dominance of the left hemisphere could gradually decrease.

However, recent research points in a different direction. Singing itself does not seem to be decisive for speech production and therapy in patients with aphasia, but in particular the influence of rhythmic clocks. The key to Melodic Intonation Therapy is probably not in the interaction between the left and right hemispheres of the brain, but rather in the interaction between the cerebral cortex and subcortical areas - such as the basal ganglia . These are a kind of switching point in the brain in rhythmic language processing. A stroke in the left hemisphere usually extends to subcortical areas as well. This often manifests itself in a problem with processing rhythm. Patients with non-liquid aphasia often have considerable difficulties in initiating word production and then clocking in syllable by syllable. Rhythmic clocks - such as a metronome - or rhythmic speaking could help here and improve the patient's speech-motor planning.

Just as important as the rhythm are the familiarity of the lyrics and the targeted use of formulaic language. Formula-like language includes, among other things, a large number of automated phrases that are crucial for everyday communication - such as "hello", "all right" or "goodbye". Contrary to what might initially be assumed, phrases of this kind are not supported by the left but rather by parts of the right hemisphere (Sidtis et al., 2009). This is mostly intact in patients with non-liquid aphasia. This explains why the patients concerned can often articulate some formulaic phrases surprisingly well - be it sung or spoken rhythmically.

credentials

Individual evidence

  1. ↑ a b c Stahl et al., 2013
  2. ↑ a b Stahl et al., 2011 (PDF; 361 kB)
  3. ↑ Stahl & Kotz, 2014