Melodic Intonation Therapy

Many stroke survivors and people with aphasia are left with little or no speech. However, they are often able to sing, sometimes with the same fluency and clarity they had before the onset of illness. In 1973, researchers developed a therapy based on the fact that speech and singing are stored in different parts of the brain. We use the left side of the brain for speech and movement. Music uses large areas of the brain and ‘as patients learn to put their words to melodies, the crucial connections form on the right side of their brains.’¹

Tapping out the rhythm

Melodic Intonation Therapy (MIT) aims to convert singing into speech; the term ‘intonation’ simply means ‘singing’. It emphasises the melodic patterns that already exist in normal speech. There are usually three levels of treatment built around useful common words and phrases. As the therapy progresses, the phrases become longer. For example, you might begin with “I love you” and progress to “I love my daughter and son.” Traditionally, these phrases would be sung in two pitches, so that your voice would rise and fall on specific words.²However, at the moment, there is a great deal of diversity in the way each therapist runs his or her sessions.

Some use as many as nine different pitches; some accompany the patient on a musical instrument.Many use familiar songs, while others write a new song for each person.³ Most therapists ask you to tap out the rhythm of the syllables with your left hand while you are singing and repeating the phrases. This is believed to bring in the motor and auditory systems.⁴ Other techniques a therapist might use include the following: you sing with the therapist and then alone, or you hum and use the song to answer a question, such as “What did you just say?”⁵

The intensity and frequency of MIT can vary. In certain circumstances, it might be offered five days a week for approximately 90 minutes per session. Most therapists decide on the duration and number of sessions that best suits their client. The leading researcher in a recent study, neuroscientist Dr Gottfried Schlaug, believes that MIT is both useful and easy to offer. He hopes to make it possible for family members and carers to provide MIT at home. He writes:

‘The great advantage of this technique is that it is very simple. You don’t have to be trained opera singer, a trained musician to apply it.’⁶

• Possible benefits of Melodic Intonation Therapy for stroke

  Melodic Intonation Therapy appears to work best for those who have suffered a left-hemisphere stroke and have the ability to produce some words when they are singing familiar songs.⁷ There are numerous cases where MIT has helped people to regain their speech sometimes years after a stroke, even when traditional speech therapy has failed.

  Recent advances in technology have helped to explain why this form of therapy can succeed where others so often fail. A small study in 2009 tested participants after 75-80 daily therapy sessions. Gottfried Schlaug and his colleagues wanted to see whether MIT would lead to functional improvement and change the structure of the brain. They chose six right-handed participants, each of whom had experienced a stroke approximately a year before the trial. They all ‘had moderate to severe non-fluent aphasia’ but their understanding of language was reasonably good. The team performed both behavioural tests and diffusion tensor imaging (DTI) before and after the treatment to measure changes in the brain.⁸

  ‘“One patient was unable to speak voluntarily but after therapy could sing the phrase ‘I am thirsty.’ Another patient could only manage the letters N and O before receiving the treatment, but after undergoing training sessions was able to sing the words ‘happy birthday to you’,” Schlaug told the American Association for the Advancement of Science meeting in San Diego.’⁹

  When they compared results before and after the therapy, they found a measurable change for the better. In particular, they wanted to measure any change in AF fibres (arcuate fasciculus) because AF fibres are often seen as the link between two areas in the brain that are essential for language.¹⁰ They reported:

  ‘All six patients showed a significant increase in the absolute number of fibres in the right AF [arcuate fasciculus].

  … All six patients showed a significant improvement in speech outcome measures, such as the CIUs, while eliciting spontaneous speech through conversations with the patient and description of complex pictures as well as common procedures, the picture-naming test, and the number of syllables per phrase (Fig. 3). … [Their findings suggest] that intense, long-term MIT leads to remodelling of the right AF and may provide an explanation for the sustained therapy effects that were seen in these six patients.’ ¹¹

  Another small study in 2009 used the imaging technique magnetoencephalography to show how Melodic Intonation Therapy could change the brain structure of two aphasic patients. Each participant had two blocks of MIT therapy. Improvement was measured by recording their brain patterns during naming tasks. The study showed that one person improved, while the other did not. However, it also showed that the differences in the two participants could be clearly seen:

  ‘Both patients exhibited increased left hemisphere activation after MIT. The patient who responded positively to therapy exhibited decreasing activation within areas of the right hemisphere homotopic to left hemisphere language areas compared to baseline after both blocks of MIT. In contrast, the patient who did not show improvement after therapy exhibited increasing activation in these areas of the right hemisphere after therapy. Results are consistent with hypotheses that melodic intonation therapy acts through promotion of left hemisphere activation’¹²

  This is important because it shows how MIT works. It changes the brain ‘map’ so that you can re-build the connections necessary for speech.

• Arguments against using Melodic Intonation Therapy for stroke

  Melodic Intonation Therapy is very intensive and the commitment of time and resources might make it difficult for some people to access. However, it may be possible for the therapist to work with a family member in some cases, so that he or she could help to provide the therapy at home.

  There is evidence that MIT can help people to regain speech. However, it often sounds more like singing than speech. Some people may be put off by the idea that they could sound unnatural at the end of the treatment, while others might be grateful to have some form of communication.

  As with so many emerging therapies, there is a need for more research and more high-quality clinical trials.

• Notes and references
  1. BBC News: Science and Environment, 21 February 2010
  2. Helm-Estabrooks, N., M. Nicholas & A. Morgan, Melodic Intonation Therapy. 1989. Pro-Ed., Inc. Austin, TX.
  3. ‘Melodic Intonation Therapy: Shared Insights on How It Is Done and Why It Might Help’ by Norton A, Zipse L, Marchina S, Schlaug G. In Ann NY Acad Sci 2009;1169:431-436. [PDF]
     1. A study conducted in 2010 showed that it is possible for Melodic Intonation Therapy to be effective in cases where tapping is not possible due to disability. Monica Strauss Hough studied a 69-year-old man who had suffered from chronic Broca’s aphasia for the previous four years. Although he had tried MIT before, his therapy was undermined by his inability to tap out the rhythms. However, when the therapy was modified to eliminate the tapping, his speech did improve:
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        ‘Conclusions: Overall, BR significantly increased his ability to produce short phrases using MIT without tapping. Thus MIT appears to be a viable option for enhancing verbal output for some individuals with non-fluent aphasia, regardless of time post-stroke’ (‘Melodic Intonation Therapy and aphasia: Another variation on a theme’ by Monica Strauss Hough. In Aphasiology, Volume 24, Issue 6-8 June 2010, pages 775-786)

  4. Helm-Estabrooks, N., M. Nicholas & A. Morgan, Melodic Intonation Therapy. 1989. Pro-Ed., Inc. Austin, TX.
  5. ‘AAAS: Singing helps stroke victims relearn language‘ by Richard Alleyne. The Telegraph, 21 February 2010
  6. Helm-Estabrooks, N., M. Nicholas & A. Morgan, Melodic Intonation Therapy. 1989. Pro-Ed., Inc. Austin, TX.
  7. DTI is a form of magnetic resonance imaging. It provides information about the diffusion of water molecules (Brownian motion) in the brain. ‘The diffusivity of water molecules provides information about the brain’s microstructure…’. ‘Evidence for Plasticity in White-Matter Tracts of Patients with Chronic Broca’s Aphasia Undergoing Intense Intonation-based Speech Therapy’ by Gottfried Schlaug et al. In The Neurosciences and Music III—Disorders and Plasticity. From: Music, Stroke Recovery, and Neuroimaging Laboratory, Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
  8. Cited in ‘Stroke patients regain the power of speech through singing’ by Ian Sample, San Diego. guardian.co.uk, Tuesday 23 February 2010 14.14 GMT
  9. ‘The role of the arcuate fasciculus in conduction aphasia’ (2009) by B. Bernal, A. Ardila. In Brain (2009) 132 (9): 2309-2316.
  10. ‘Evidence for Plasticity in White-Matter Tracts of Patients with Chronic Broca’s Aphasia Undergoing Intense Intonation-based Speech Therapy’ by G. Schlaug, S. Marchina, and A. Norton. In Annals of the New York Academy of Sciences, Volume 1169, The Neurosciences and Music III Disorders and Plasticity pages 385–394, July 2009.
  11. ‘Changes in maps of language activity activation following melodic intonation therapy using magnetoencephalography: Two case studies.’ By Breier JI, Randle S, Maher LM, Papanicolaou AC . In J Clin Exp Neuropsychol. 2009 Aug 5:1-6.

Aviva Cohen is the author and CEO of Neuro Hero