modified melodic intonation therapy and aphasia

1. 1st JOURNAL CLUB
2013-2014
1

2. Guide:
Mr. Abhishek,
Asst Professor,
Dept of SLP
Presenters:
Hemy Elsa Abraham,
Neethu K K,
I MASLP
2

3. DEFINITION
Aphasia refers to the
disturbance of any or all of
the skills, associations and
habits of spoken or written
language, produced by
injury to certain brain
areas that are specialized
for the function.
Goodglass and Kaplan(1983)
3

4. CLASSIFICATION
OF
APHASIA
4

5. Wernicke(1874), Geshwind (1969, 1971), and Benson(1967)
1.FLUENT APHASIA:
2.NON FLUENT APHASIA
Broca‟s aphasia

Wernicke‟s aphasia


Transcortical sensory

Transcortical motor aphasia

Mixed transcortical aphasia

Global aphasia
aphasia


Conduction aphasia
Anomic aphasia
5

6. • Expressive aphasia, anterior aphasia,
efferent motor aphasia, agrammatic
SYNONYMS aphasia, verbal aphasia
LESION
• Left middle cerebral artery territory, directly
or indirectly affecting the speech area
commonly referred to as Broca‟s area
(Broadmann‟s area 44,45 )
EFFECT
• Dominated by reduction or suppression of
speech output with relative sparing of
auditory comprehension
6

7. CHARACTERISTICS
OF
BROCA’S APHASIA
7

8. word-finding
difficulty
impaired fluency
mostly preserved
comprehension
cognitively intact
8

9. impaired reading and
writing
reduced syntactic
capabilities
Associated with right
hemiplegia or hemiparesis.
Speech output are often
slow, effortful, agrammatic,
and telegraphic.
9

10. PREVALENCE
OF
APHASIA
10

11. Approximately
800,000 people
have a stroke each
year, and of
these, 25%–35%
develop aphasia
(Dickey et al., 2010;
National Stroke
Association
Website, n.d.).
11

12. Therapeutic Approaches
for
Non fluent Aphasia
12

13. • Behavior modification
• Cognitive therapy
• Combinations of Behavior
modification and Cognitive therapy
• Pragmatic aproaches
13

14. Thematic Language Stimulation
Helm Elicited Program for Syntax
Stimulation
Voluntary Control of Involuntary
Utterances
Response Elaboration Training
De-blocking
Language Oriented Treatment
Promoting Aphasic‟s
communicative effectiveness
14

15. Melodic intonation therapy
Sparks et.al 1974
A treatment technique
developed for expressive
aphasia rehabilitation
which utilizes a patient‟s
unimpaired ability to
sing, to facilitate
spontaneous and
voluntary speech
through sung and
chanted melodies which
resemble natural speech
intonation patterns.
15

16. Candidacy for MIT
Auditory
comprehension
should be
better than
verbal
expression
Fairly good
emotional
stability
A reasonable
good attention
span
16

17. Levels of MIT
INTERMEDIATE
ADVANCED
ELEMENTARY
17

18. LIMITATIONS
OF
MIT
18

19. 19

20. Modified melodic intonation
therapy
expands upon the original MIT protocol.
modifications have the potential to make this
treatment more efficient.
Introducing MMIT within first few weeks after a stroke
help to facilitate the recruitment, leading to faster and
more meaningful recovery.
20

21. The first change is
that therapists
compose and
employ novel
melodic phrases
that closely match
the prosody of the
phrases in both
pitch and rhythm.
The next
modification is the
use of full phrases
during initial
treatment to
allow for access to
those intact areas
that enable
patients to sing
full lines of song.
21

22. AIM
To determine efficacy of
MMIT in individuals with
Broca‟s aphasia
22

23. Hypothesis
 Broca‟s aphasia patients on an acute care unit
receiving MMIT will demonstrate a greater
positive change in post-test scores after one
treatment session when compared to a control
group without treatment
 Those patients receiving MMIT will
demonstrate greater positive change from their
pre-test scores over multiple sessions when
compared to the control group.
23

24. METHOD
Participants:
» All potential participants were
assessed by their treating neurologist
using the National Institutes of
Health Stroke Scale (NIHSS)
» Most potential participants were
assessed by a speech language
pathologist prior to being approached
for this study.
24

25. mild to severe
aphasia
no previous
documented
infarcts, any
dysarthria noted
to be less than
their aphasia
damage to the
left MCA
territory of the
brain
18 years of age
or older
Inclusion
criteria:
ability to sing at
least 25% of the
words of “Happy
Birthday”, and
demonstrated
self-awareness of
speech deficits
ability to follow
commands
25

26. Exclusionary criteria
26

27. Speech Assessment (Pre/Post Test)
 The Western Aphasia Battery has two subtests that were
deemed appropriate,
 Repetition
 Responsiveness
 Both sections are designed to elicit short answers.
 Because of the length of the phrases utilized in MMIT it was
decided not to use the exact subtests from the WAB , but
instead to design two similar tasks that would elicit longer
responses.
27

28. Responsive section …
(a) “When you are thirsty and need a drink of water, what do you say to
the nurse when she comes in?”
(b) “If I come in and introduce myself: „Hello, my name is _____,‟ how do
you introduce yourself?”
(c) “If you‟re sitting here and you realize you need to urinate or have a
bowel movement, what do you say when you press the call button?”
28

29. Scoring
• 0–3 scores per question
• similar to WAB with the addition of a score of 3 as the
questions were designed to elicit longer responses than
those in the WAB
• the score range for the responsive section 0–9.
• The three statements in this section were always given
first in an attempt to lessen the likelihood that the
participants might remember one of the phrases used in
the repetition section.
29

30. Repetition section…
(a) “I need a drink of water”
(b) “Hello, my name is _____________”
(c) “I have to go to the bathroom”
– each of which could correspond with the questions in
the responsive section.
– Participants were instructed to repeat the exact
phrase as it was spoken to them.
30

31. Scoring
•
•
•
•
Identical to that used in the WAB
Score of 2 was given per correct word
the range for the repetition section 0–36
for a total possible score of 0–45
Each section’s scores were weighted so that they had
equal standing in an adjusted total score that also ranged
from 0 to 45
31

32. Procedure
• MMIT was administered by a Board-Certified Music Therapist
trained in the technique.
• Those participants received a 10-15 minute music therapy
session directly following their pre-test, consisting of the music
therapist teaching the participant a melodic phrase.
• The first session only consisted of the first phrase listed above (I
need a drink of water). The music therapist spoke the phrase 1
time when introducing the procedure to the participant, after
which the participant only heard the phrase sung.
32

33. • The music
therapist
modelled the
phrase
multiple times
• Instructed the
participant to
sing the
phrase.
• music
therapist
assisted the
participant in
tapping
• to provide an
added cue
• 2nd session
never consisted
of more than
the first two
phrases
• 3rd session the
participant
had the
possibility of
learning the
third phrase.
33

34. To control for possible placebo
effects in the treatment group
participants enrolled in the
control group received 10-15
minutes with the music
therapist
Discussed the participant‟s
impairment, different forms of
treatment, different outcomes
and various issues, such as
depression and withdrawal.
34

35. Study design
• The study followed a randomized controlled single blind
design.
• The randomization table was generated by a
biostatistician prior to the start of the study.
• Random assignment was provided by the music therapist
following enrollment by the nursing manager who had no
prior knowledge to the ordering of participants.
35

36. Statistical analysis
• Descriptive statistics were generated
(mean, standard deviation, frequency counts).
• Each primary measure was evaluated at visits
1, 2, and 3, separately. For each visit, the change
score (post less pre) within group was tested.
• A two-sample t-test was used to compare the change
between groups.
36

37. Results
Parameters considered for comparison
• Within control group and experimental group
• Between control group and experimental
group across repetition scores and responsive
scores
• Changes observed after visit 1 and visit 2
37

38. 14
control
group
30
participants
16
treatment
group
38

39. •
Out of the 14 controls, 10 had both pre and post scores at visit 1, 8 had
pre and post scores at visit 2. For the treatment group, 14 out of the 16
had both pre and post scores at visit 1, 9 had pre and post scores at
visit 2.
•
The difference in change in adjusted total score between the treatment
and control groups was also significant at Visit 1
•
Except for repetitive score, the treatment group change was always
greater than that of the control group, but only the responsive score
change was found to be significantly greater.
39

40. 40

41. 41

42. 42

43. 43

44. Discussion
• In comparing Modified Melodic Intonation
Therapy (MMIT) versus no treatment in acute
stroke patients with non-fluent aphasia, there were
significant immediate improvements in speech
output after one session of MMIT
training, supporting their first hypothesis.
44

45. • Both groups showed significant improvements
when comparing their pre-test scores from
visit 1 with those from visit 2, the control
group showed an improvement in their
repetition scores, while the treatment group
showed similar gains in repetition and
responsiveness scores, partially supporting our
second hypothesis
45

46. Improvements in
speech output
Damage to the leftbrain speech areas is
limited
Recruitment of rightbrain structures
assists in the
facilitation as left
regain
their function
Damage to the left
brain speech areas is
severe, or total
Right brain
structures attempt to
“take over” the
facilitation of speech
processes.
46

47. Right
brain
recruitme
nt process
Efficient
and
consistent.
Smoother
transition
Early
interventi
on
47

48. • Of the 16 participants who received MMIT training
as part of the treatment group, all but one
participant were able to sing at least part of the first
phrase „I need a drink of water‟.
• Of the remaining 15 participants who were able to
sing at least part of the phrase, 12, or 75%, sang at
least one complete and accurate phrase during the
first session.
48

49. providing
MMIT
training
early
lessen
frustration
and
withdrawal
Patient can
produce
meaningful
and accurate
words.
49

50. •
50

51. Merits
 Help to lessen
frustration and
withdrawal.
 Evidence based study.
 Help to make the
rehabilitation more
efficient and consistent.
51

52. Limitations
• Not explaining
regarding the patients
language ability such as
bilingual or mono
lingual.
• Not included the
detailed demographic
data with respect to age
and literacy.
Cont.. 52
.

53. • Scheduling challenges
present in hospital stay
limited the data collected.
• Relatively small sample
size and absence of longterm follow-up.
• They did not perform a
precise assessment of the
brain damage caused by
the stroke.
53

54. Demonstrates the
feasibility of
MMIT and suggests
it has short-term
beneficial effects.
Demonstrates
significant positive
results in patients‟
overall ability to
verbally respond
Follow up research
is needed to
identify MMIT‟s
long term potential.
54

55. Critical analysis
 Role of speech language therapist is
not specified.
 It is a pilot study and not carried
out in a full pledged manner.
 The number of therapy sessions
required for optimization of therapy
is not specified.
 Ethically single blind study is not
well appreciated method to study
therapy efficacy..

56. References…….
•
•
•
•
•
Melodic intonation therapy for aphasia. Archives of Neurology, 29,130–
131,Albert, M. L., Sparks, R. W., & Helm, N. A. (1973)
Recovery from nonfluent aphasia after melodic intonation therapy: A PET study.
Neurology, 47, 1504–1511, Belin, P., Van
Eeckhout, P., Zilbovicius, M., Remy, P., Francois, C., Guillaume, Samson (1996).
Music and language side by side in the brain: A PET study of the generation of
melodies and sentences. European Journal of Neuroscience, 23, 2791–
2803, Brown, S., Martinez, M. J., &Parsons, L. (2006).
DTI tractography of the human brain’s language pathways. Cerebral
Cortex, 18, 2471–2482.
Ethofer, T., Anders, S., Erb, M., Herbert, C., Wiethoff, S., Glasser,M.F.,&Rilling, J. K.
(2008).
Treatment for aphasia following stroke: Evidence for effectiveness. International
Journal of Language & Communication Disorders [Supplement], 33, 158–
161.Greener, J., Enderby, P., Whurr, R., & Grant, A. (1998).
56

57. TOPIC OPEN
FOR
DISCUSSION

58. 58