#singingtherapy

Melodic Intonation Therapy (MIT)

Description: Hierarchical approach that utilizes patterns of inflection as a basis. Therapy involves synchronous clinician and patient performance with gradually fading of melodic support from clinician. The specific goals are to improve fluency, improve intelligibility, and increase length of utterances in verbal communication

Theoretical Foundation:

Originally, success was attributed to the therapy’s activation of intact right hemisphere (RH) linguistic functions to bypass left hemisphere (LH) damage in patients with unilateral LH lesions.

However, recent neuroimaging studies have had contradictory results indicating levels of RH versus LH activation during and therefore do not provide enough support for the original claim (van der Meulen et al., 2012).

It is also questioned whether the melodic component of MIT is the key to its reported success. The therapy includes components that are tactile, visual, and auditory (not just melodic, consider meter and rhythm) and have not been isolated from melody in studies of MIT efficacy.

Stimuli: functionally relevant words, phrases, and sentences, i.e. “good morning” and “I am tired”

paired with consistent and easily reproducible intonation patterns, about 3-4 tones (van der Meulen et al., 2012).

3 elements: melodic line, rhythm, and points of stress (Sparks & Holland, 1976)

stimuli are often melodic and rhythmic exaggerations of the target’s typical prosody

Methods: summarized from Sparks & Holland (1976): Progression from II to III and then to IV requires accuracy of “90% based on the mean of 10 consecutive scores” and trials are repeated until this level of performance is achieved.

Level I: Establish process of intoning melody patterns accompanied by tapping patient’s hand to denote rhythm and stress patterns. Though non-linguistic and passive for the patient, this level serves to orient them to therapy procedures.

Level II: 5 steps for clinician – hand-tapping used for stimulus and response, unless otherwise stated:

Hum melody while assisting patient in hand-tapping rhythm and stress.

Repeat first step and signal patient to join in unison.

Repeat second step, but fade your participation while encouraging patient to continue independently. Rejoin patient as needed.

No unison - Present target and cue patient to repeat after you have completed modeling.

Request target repetition with hand-tapping for response only.

Level III: 4 steps for clinician:

Present target sentence 2x with hand-tapping. Do not allow patient to respond.

Unison production of target. Fade your participation until patient is producing target independently.

Present target and then after delay of 2-3 seconds request its repetition. Go back to second step if patient does not succeed.

Ask question pertaining to target. Encourage patient to enhance response as opposed to merely repeating target sentence. Go back to third step as needed.

Level IV: 5 steps for clinician:

Present target sentence and then after delay permit patient to repeat target with hand-tapping for response and stimulus. Gradually increase delay with increased successful trials. Go back to unison plus fading as needed.

Present target sentence 1x and then ask patient to join unison for repetition. Fade your participation as patient transitions to more speech-like production of target. Continue hand-tapping throughout. Go back to first step as needed.

Present target sentence 1x with enforced delay before patient may repeat. Hand-tap rhythm stress with stimulus presentation. Patient may hand-tap independently during response, but do not assist. Go back to second step as needed.

Present target sentence with normal speech prosody and normal rate. After enforced delay, signal patient to repeat target with normal prosody. Delays should be gradually increased as patient demonstrates success. Go back to third step as needed.

1-2 second delay after step #4: Ask a question or two pertaining to information in target sentence you presented. Go back to step four as needed.

Pros:

Reported outcomes: Decrease distortions in connected speech, improvement in utterance repetition (van der Meulen et al., 2012). Reduces frequency of paraphasic errors (Sparks & Holland, 1976)

Progression through levels of therapy is determined by patient’s success on tasks not according to number of sessions or tasks completed allowing an individualized pace.

Ease of clinician training and administration, low cost

Stimuli are functional and can be modified to individualize therapy

Studies have been conducted with persons with chronic aphasia post stroke – therefore this is not a “no or never”/acute only therapy

Cons:

No guarantee of successful transition from singing to speaking

Requires intact auditory language comprehension

May not carryover to language improvement

Must avoid melodies of well-known songs because patient may sing lyrics instead of target utterance (Sparks & Holland, 1976).

Stimuli are language-dependent and can not be easily translated, therefore use for bi/multi-lingual patients is questionable

References:

van der Meulen, I., van de Sandt-Koenderman, M. E., & Ribbers, G. M. (2012). Melodic Intonation Therapy: Present Controversies and Future Opportunities. Arch Phys Med Rehabil, 93(S), S46–S52. doi:10.1016/j.apmr.2011.05.029

Sparks, R. W., & Holland, A. L. (1976). Method: Melodic intonation therapy for aphasia. Journal of Speech and Hearing Disorders, 41(3), 287