78 Case report

Singing therapy can be effective for a patient with severe
nonfluent aphasia
Satoshi Yamaguchia,b, Kyoko Akanumaa,b, Yuka Hatayamab, Masako Oterab
and Kenichi Meguroa,b
Patients with severe aphasia are rarely treated using
speech therapy. We used music therapy to continue to treat
a 79-year-old patient with chronic severe aphasia.
Interventions 1, 2, and 3 were to practice singing a song
that the patient knew, to practice singing a song with a
therapist, and to practice saying a greeting using a song
with lyrics, respectively. In addition, practice of uttering
names of body parts was initiated using touch and rhythm.
After intervention 1, the patient could sing spontaneously
and repeat lyrics. After intervention 2, she could sing with
the therapist, and sing spontaneously and repeat lyrics.
After intervention 3, she could memorize words with
meaning, say the words in context, and use them. The
patient could utter the names of two body parts after
therapy with touch and rhythm. These suggest that

rehabilitation therapy can still be used in patients with
severe cognitive impairment. International Journal of
Rehabilitation Research 35:78–81 c 2012 Wolters Kluwer
Health | Lippincott Williams & Wilkins.

Introduction

love for singing, and she often sang in karaoke. Her
medical history included hypertension, angina pectoris, and
dyslipidemia. Her present illness had started in December
1996, when she developed right hemiplegia and aphasia.
Large infarction lesions were found in the left anterior
communicating artery and middle cerebral artery, as illustrated in Fig. 1. She visited a doctor nearby and underwent
treatment and rehabilitation, but her paralysis did not
improved and speech therapy was difficult to perform. After
discharge from the hospital, she did not undergo rehabilitation. She has been cared for in a nursing home since May
1998. Neurological findings included paralysis of the right
upper and lower extremities and a positive Babinski reflex in
the right side. Neuropsychological findings indicated a state
of global aphasia. Table 1 shows the results from the western
aphasia battery short version (Kertesz and Poole, 2004;
Bakheit et al., 2005). The patient only nodded without
speaking in daily conversation, and did not speak when
receiving care. The patient occasionally said ‘I don’t know’.
Written informed consent was received from her family. The
study was approved by the Medical Ethics Committee and
Institutional Review Board of the Osaki-Tajiri SKIP Center
and Tohoku University.

Most patients with aphasia undergo speech therapy in the
subacute to chronic phases; patients with large lefthemispheric lesions that result in severe nonfluent aphasia
typically do not show good natural recovery and do not
appear to be very responsive to traditional speech therapy.
At present, there is no ‘gold standard’ for the treatment of
severe nonfluent aphasia. Nevertheless, most therapists
would probably agree that a treatment should be considered effective if a patient shows improvement in speech
output that generalizes to untrained language, structures,
or contexts (Home-Thompson and Grocke, 2007).
Singing is considered to be an effective means for
patients with nonfluent aphasia to produce words that
they are not able to pronounce otherwise (Schlaug et al.,
2010). Singing may facilitate speech at different stages of
processing: at the motor stage by reducing the speech
rate in patients with dysarthria (Hustad et al., 2003); at
the level of word retrieval by providing structural
constraints, such as the number of syllables per beat
(Poulin-Charronat et al., 2005); and at a motivational level
by engaging recreational skills. Determination of the
factors that make singing an effective treatment for
speech disorders is important to identify patients who can
be helped by musical interventions and to establish the
reasons for the efficacy of this therapy.

International Journal of Rehabilitation Research 2012, 35:78–81
Keywords: aphasia, left middle cerebral artery infarction, music therapy,
singing therapy, western aphasia battery
a
Department of Geriatric Behavioral Neurology, Tohoku University Graduate
School of Medicine, Sendai and bThe Osaki-Tajiri SKIP Center, Osaki, Japan

Correspondence to Kenichi Meguro, MD, Department of Geriatric Behavioral
Neurology, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi,
Aoba-ku, 980-8575 Sendai, Japan
Tel: + 81 22 717 7359; fax: + 81 22 717 7339; e-mail: k-meg@umin.ac.jp
Received 20 September 2011 Accepted 8 December 2011

Intervention 1: period December 2001
to August 2002
Methods

Patient
The patient was a 79-year-old right-handed woman with
8 years of school education. Her life history included a
0342-5282 c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

(1) The patient sang songs including nursery, folk, and
nostalgic popular songs together with a therapist
DOI: 10.1097/MRR.0b013e32835032f8

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Singing therapy can be effective for a patient with severe nonfluent aphasia Yamaguchi et al. 79

Fig. 1

MRI findings of the case. T2-weighted axial images (top three, orbitomeatal (OM) + 30, 70, 90 mm from the left) and a T1-weighted coronal image
(bottom) are shown.

Table 1

Results from the western aphasia battery short version

Date
Spontaneous speech (20)
Auditory comprehension (10)
Repetition (10)
Naming (10)
Reading (10)
Writing (10)

20/12/
2001

25/10/
2002

24/7/
2003

6/6/
2008

10/5/
2010

5
0
1.1
0
0
0

3
0
1.6
0
0
0

5
1.1
0.7
0.2
0
0

2
0.2
0.3
0.3
0
0

1
0
0.9
0
0
0

The scores on the western aphasia battery items are shown.

(using songs to utter lyrics). Thirteen nursery songs
that the patient could easily sing the first few lyrics
for and three other songs were selected.
(2) The patient practiced singing the 16 songs together
with a therapist after listening to the name of the
song (to improve presentation of the lyrics).
Results

The patient could spontaneously sing the first verse of eight
songs after listening to the name of the song and receiving a
cue to sing. The patient could spontaneously sing the first
verse of eight songs after listening to the song name. The
patient could repeat the first verse of six songs by listening
to the song name and receiving a cue to sing after practicing
repetition of the verse without melody.
After intervention 1, almost the same steps were
performed until intervention 2 was started.

Intervention 2: period February 2008 to
May 2008
Methods

A song that had several bars, new lyrics, a melody that was
familiar to the patient, and was easy to sing was chosen.
The patient repeated singing this song to memorize and
utter the lyrics. Speech, language, hearing, and music
therapists conducted a 30-min practice session weekly
and biweekly for 3 months, for eight sessions in total.
Results

In the first practice session, the therapist tried to make
the patient repeat the lyrics alone or together; however,
the patient did not understand the directions given by
the therapist, and the practice failed. In the second
practice session, the therapist sang accompanied by a
guitar, and the patient showed an interest in singing and
sang a part of the song together with the therapist after
the therapist had sung several times. The patient sang
more parts of the song step by step, and finally the
patient could repeat the lyrics after receiving a cue to
sing. During singing, an emotional change in the patient
was observed. Table 2 summarizes the course of
intervention 2.
After intervention 2, almost the same steps as in
interventions 1 and 2 were performed until intervention
3 was started.

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80

International Journal of Rehabilitation Research 2012, Vol 35 No 1

Table 2

Summary of the course of intervention 2

Number of
practice
Repetition of
lyrics
Spontaneous
singing
Simultaneous
singing
During
singing

1

2

3

4

5

6

7

8

–

–

–

–

–

+

+

++

–

–

–

–

+

++

++

+++

–

+

++

++

+++

+++

+++

+++

Laughed when meeting
the therapist

Made time
to sing

Laughed at the reaction of
the therapist

– Showed interest
in singing

Laughed when
singing well

Distinguished singing from
repeating the lyrics

– , no response; + , mild response; + + , moderate response; + + + , very good response.

Table 3

Results

Summary of the course of intervention 3

Approach 1 (date)

6/2009

7/2009

12/2009

4/2010

Cue by music lexicon
Cue without melody
Cue by motion
Approach 2 (date)
Foot
Finger
Ear

+
–
–
6/2009
–
–
–

+
+
–
12/2009
+
–
–

+
+
–
4/2010
+
–
+

+
+
+
6/2010
+
±
+

– , no response; ± , very mild response; + , mild response.

Intervention 3: period June 2009 to June 2010
Approach 1

Of the songs that the patient could sing spontaneously
after receiving a cue to sing, a song including ‘Hello’ in
the lyrics was chosen. The therapist bowed down
simultaneously with singing of the word ‘Hello,’ and the
patient sang the word ‘Hello’ spontaneously after a cue,
which was the phrase ‘a weather loach appeared and’
preceding the word ‘Hello.’ A song including ‘Goodbye’ in
the lyrics was also chosen. The therapist waved goodbye
simultaneously with singing of the word ‘Goodbye’, and
the patient sang the word ‘Goodbye’ spontaneously after
a cue, which was the phrase ‘Sea’ preceding the word
‘Goodbye’. Subsequently, the patient practiced repeating
the lyrics after receiving the cue without the melody.
Finally, the patient practiced saying the words ‘Hello’ and
‘Goodbye’ with the cues being the therapist’s bow and
waving, respectively.
Approach 2

Words for body parts that were easy to understand (ear,
finger and foot) were chosen, and the patient practiced
repeating these words simultaneously with a rhythm and
then by touching and rhythm alone. Speech, language,
hearing, and music therapists facilitated the practice
together. First, the patient practiced singing a song
that the patient could sing spontaneously for 10 min and
then practiced tasks I and II without a break for 20 min
weekly and biweekly for 11 months: that is, 38 practices
in total.
Table 3 summarizes the course of intervention 3.

(1) The patient said ‘Hello’ spontaneously when entering the room for speech therapy and ‘Goodbye’ when
leaving the room.
(2) The patient could say the words ‘foot’ and ‘ear’.

Comments
Singing has a positive effect on patients with aphasia
(Racette et al., 2006). Music semantic memory is
associated with the left upper temporal area (Groussard
et al., 2010) and music intonation therapy is effective for
activating the left hemisphere (Breier et al., 2009; Norton
et al., 2009). In our patient, long-term singing practice and
melodic intonation therapy practice had effects on the
remaining function in the left upper temporal area
involved in music semantic memory and allowed the
patient to utter words using the music lexicon. The above
results suggest that music therapy can access and activate
the remaining function in a patient with chronic severe
aphasia who cannot be treated with normal speech
therapy. This suggests that rehabilitation therapy can
still be used in patients with severe cognitive impairment
(Thaut, 2005; Johansson, 2011).

Acknowledgements
Conflicts of interest

There are no conflicts of interest.

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