Just Accepted by International Journal of Neuroscience

Singing can improve speech function in aphasics
associated with intact right basal ganglia and
preserved right temporal glucose metabolism:
Implications for singing therapy indication
Kyoko Akanuma, PhD, Kenichi Meguro, MD, PhD, Masayuki Satoh,
MD, PhD, Manabu Tashiro, MD, PhD, Masatoshi Itoh, MD, PhD
doi:10.3109/00207454.2014.992068

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Abstract
Clinically, we know that some aphasic patients can sing well despite their speech
disturbances. Herein, we report 10 patients with non-fluent aphasia, of which half of
the patients improved their speech function after singing training. We studied ten
patients with non-fluent aphasia complaining of difficulty finding words. All had
lesions in the left basal ganglia or temporal lobe. They selected the melodies they
knew well, but which they could not sing. We made a new lyric with a familiar melody
using words they could not name. The singing training using these new lyrics was
performed for 30 minutes once a week for 10 weeks. Before and after the training,
their speech functions were assessed by language tests. At baseline, 6 of them
received positron emission tomography to evaluate glucose metabolism. Five
patients exhibited improvements after intervention; all but one exhibited intact right
basal ganglia and left temporal lobes, but all exhibited left basal ganglia lesions.
Among them, three subjects exhibited preserved glucose metabolism in the right
temporal lobe. We considered that patients who exhibit intact right basal ganglia and
left temporal lobes, together with preserved right hemispheric glucose metabolism,
might be an indication of the effectiveness of singing therapy.

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Singing can improve speech function in aphasics associated with intact
right basal ganglia and preserved right temporal glucose metabolism:
Implications for singing therapy indication

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1) Division of Geriatric Behavioral Neurology, CYRIC, Tohoku University, Sendai,
Japan
2) Division of Nuclear Medicine, CYRIC, Tohoku University, Sendai, Japan
3) Sendai Medical Imaging Center, Sendai, Japan

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Address correspondence to: Kenichi Meguro, MD, PhD
Division of Geriatric Behavioral Neurology, CYRIC, Tohoku University, 4-1,
Seiryo-machi, Aoba-ku, IDAC, 980-8575 Sendai, Japan
Email: k-meg@umin.ac.jp

Abstract

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Running head: singing training for aphasics

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Clinically, we know that some aphasic patients can sing well despite their speech
disturbances. Herein, we report 10 patients with non-fluent aphasia, of which half
of the patients improved their speech function after singing training. We studied
ten patients with non-fluent aphasia complaining of difficulty finding words. All
had lesions in the left basal ganglia or temporal lobe. They selected the melodies
they knew well, but which they could not sing. We made a new lyric with a
familiar melody using words they could not name. The singing training using
these new lyrics was performed for 30 minutes once a week for 10 weeks.
Before and after the training, their speech functions were assessed by language
tests. At baseline, 6 of them received positron emission tomography to evaluate
glucose metabolism. Five patients exhibited improvements after intervention; all
but one exhibited intact right basal ganglia and left temporal lobes, but all
exhibited left basal ganglia lesions. Among them, three subjects exhibited
preserved glucose metabolism in the right temporal lobe. We considered that
patients who exhibit intact right basal ganglia and left temporal lobes, together
with preserved right hemispheric glucose metabolism, might be an indication of
the effectiveness of singing therapy.

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Kyoko Akanuma, PhD1) , Kenichi Meguro, MD, PhD1), Masayuki Satoh, MD,
PhD1), Manabu Tashiro, MD, PhD2), Masatoshi Itoh, MD, PhD3)

Key words: aphasia, singing therapy, music therapy, PET

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Aphasia is a condition that is characterized by a disability to verbally
communicate with others, and is divided into fluent and nonfluent categories.
Nonfluent aphasia generally results from a lesion in the frontal lobe, including the
Broca’s area. At present, there is no ‘gold standard’ for the treatment of aphasia.
Nevertheless, most speech therapists would probably agree that a treatment
should be considered effective if a patient exhibits improvement in speech output
that can be generalized to untrained language structures and/or contexts [1].
The neurological basis for language recovery remains unknown. To
date, functional neuroimaging studies have focused primarily on spontaneous
recovery [2]. Some studies have emphasized the role of preserved language
function in the left hemisphere [3], whereas others have proposed that language
function is restored when the right hemisphere compensates [4,5]. Roles for
both hemispheres in language processing [6-8] have also been reported. Only a
few studies have examined the neurological basis for the effectiveness of
treatment [7,9]. Two recovery routes have been considered: for patients with
small lesions, there tends to be more activation of the left hemisphere
peri-lesional cortex and variable right hemisphere activation, and for patients
with large left hemisphere lesions that involve the language regions, there tends
to be more activation of the homologous language-capable regions in the right
hemisphere. Language recovery may be facilitated by undamaged portions of
the left hemisphere language areas or language-capable regions in the right
hemisphere.
Clinically, it is known that patients with nonfluent aphasia can sing
despite the fact that they cannot speak [10]. Historically, this dissociation has
been considered to be based on the differences in neurological function between
speech and music. However, the view on the neurological basis of language
function has moved from the classical Broca or Wernicke’s areas to a network,
and the contribution from several brain regions have been emphasized in
various aspects of language [11]. Different musical features have also shown
that it may be processed in widely distributed neural networks [12]. Singing is
considered to be an effective means for patients to produce words that they
cannot pronounce otherwise [13]. Singing may facilitate speech at different
stages of processing: at the motor stage, by reducing the speech rate in patients
with dysarthria [14], at the level of word retrieval, by providing structural
constraints, such as the number of syllables per beat [15], and at a motivational
level, by engaging recreational skills. It is important to determine the factors that
make singing an effective treatment for speech disorders in order to identify
patients that can be helped by musical interventions and to establish the
rationale for the efficacy of this therapy.

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Introduction

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Participants
The participants with chronic aphasia were recruited from the Miyagi Association
of Aphasia. The number of the association was 16 in the recruiting period April
2010 to March 2011. They all met the entry criteria as follows: 1) right-handed; 2)
they had suffered from aphasia after stroke attack for more than 3 years; 3) their
symptoms were stable in the chronic phase, mainly complaining of word finding
difficulty in daily living. After asking all members to participate in the study, 13 of
them agreed. Finally, we were able to examine 10 patients, since 2 patients were
not able to sing at all, and 1 patient dropped out after the study. They consisted
of 8 mild, 1 moderate, and 1 severe degree of aphasia. Eight of them were
non-fluent type as assessed by a trained speech pathologist (K.A). They all
received MRI for assessing the lesions by a board-certified neurologist (K.M).
The demographics and clinical characteristics of the cases are shown in Table 1.
Informed consent was obtained from each patient and/or the family
members of each patient. The ethical committee of the Tohoku University
Graduate School of Medicine and Cyclotron Radioisotope Center approved the
study.

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Tomanio summarized findings to illustrate the strength of different
techniques emphasizing rhythm, pitch, memory, and vocal/oral motor
components dealing with different symptoms. The efficacy of each component is
enhanced or diminished by the choice of music and the way it is interactively
delivered [16].
However, there have been no systematic reviews of the effectiveness of
music or singing therapy for aphasia. Thus, the accumulation of new case
reports will provide vital information for future systematic investigations. We have
previously reported a case with severe nonfluent aphasia [17], who initially
attained the ability to spontaneously sing and repeat lyrics, followed by attaining
the ability to sing with the therapist, and spontaneously sing and repeat lyrics.
Ultimately, she was able to memorize words with meaning, say the words in
context, and use them. These observations suggest that rehabilitation therapy
can still be used in patients with severe cognitive impairment. Herein, we report
ten patients with non-fluent aphasia with different severities of symptoms, who
improved their speech function, especially word finding, after singing training.
We analyzed the cerebral glucose metabolism in the Broca’s and Wernicke
areas, and the right hemisphere, to investigate the neurological foundation of
singing therapy.

Interventions
Naming test to find target words
Naming ability was assessed using the Picture Naming of 400 words. For severe
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Singing training
The patients selected the melodies they knew well, but could not sing. We made
a new lyric with a familiar melody, using words they could not name. For
example, if a patient could not name the shaved ice in Japanese called
KAKI-GORI, we selected a familiar melody that the patient could not sing and
use the word that the patient could not name. The singing training using
melodies with these new lyrics was performed for 30 minutes once a week. The
total training session time was ten weeks. After the song training, naming ability
was assessed using the Picture Naming of 400 words (only Case #10 used 200
words) and the Picture Description.

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Naming training
After the 10-week singing training and the subsequent assessment, naming of
drawings, which is widely used in word finding training, was performed for 30
minutes per week for 10 weeks. Thereafter, language assessments were
performed in the same manner.

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Language assessments as outcomes
We measured speech function by using the following tests at baseline and after
the training sessions.
Naming test
Naming ability was again re-assessed using the Picture Naming of 400 words as
described above. The number of correct answers was used as the outcome.

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patients (Cases), 200 words were used. For each participant, the 400 words
were classified into their corrected words and false words. The false words were
then randomly divided into exercise words and non-exercise words for each
participant. The exercise words were used as the target words. We made new
lyrics with familiar melodies using the singing exercise words.

Word fluency
Patients were asked to produce as many words of “animals” as possible. The
number of correct words expressed was used as the outcome.
Picture (Manga) Description Test (Standard Language Test of Aphasia:
SLTA)
The picture (manga) description was used, which is one of the items of the SLTA.
Patients were asked to describe a four-frame cartoon and the response was
graded from 0 to 5. The grade was 5 when they correctly described the content
of the cartoon using several sentences, while the grade was 0 when they could
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not explain it at all. In accordance with the definition that the goal was improved
by 5% or more, the picture (manga) description of SLTA was applied with the
grading reference data.

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FDG-PET
We measured cerebral glucose metabolism (CMRglc) at baseline, since CMRglc
is considered to be associated with brain function. We used a PT-931 scanner
(CTI Inc., USA; axial/transaxial resolutions: 8 mm) and the method of
[18F]-fluoro-deoxyglucose (FDG). Forty minutes after the injection of 5 mCi of
FDG, the emission scan was performed and data were collected simultaneously
from each of seven contiguous axial sections. The detailed methodology has
been described previously [18].
Basic image processing and voxel-based data analysis were performed
using SPM 2 (Wellcome Department of Cognitive Neurology, London, UK) on a
Windows XP computer. PET data were subjected to an affine and non-linear
spatial normalization into the standard MNI PET template of SPM 2, and to a
re-slicing of 2×2×2mm. The PET images were smoothed using an isotropic
Gaussian filter, 12 mm in diameter, to compensate for intersubject gyral
variability and to reduce high-frequency noise. The anatomically standardized
images were then normalized by ANCOVA to a mean value of 50 mg/100 g/min
for relative comparison, as described previously [19].
Due to the limited schedule available at the center, six of the 10
participants were able to receive PET examinations. A board-certified radiologist
(T.K) assessed the PET images. The 3D-SSP images analysis was performed
with reference to the normal database.

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Calculating Intervention Scores
For each of the three above tests, the changes of scores were assessed as
three categories, i.e., 1: improved more than 5%, 0: changes between -5% and
5%, and -1: worsened more than 5%. The three test scores (1, 0, -1) were then
summarized as the total scores (possible scores: -3 through 3).

The total study procedure was illustrated in Figure 1.

Results
Figure 2 illustrates the changes of speech function after singing training for each
patient.
Table 2 presents the intervention scores on singing, naming, and the
total, the presence of bilateral basal ganglia and left temporal lobe lesions, and
PET findings of the bilateral temporal lobes. The subjects were listed in the order
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subjects who exhibited no remarkable improvements.
For the five subjects who exhibited improvements after intervention (#4,
7, 1, 3, 8), all but one (#4, 7, 1, 3) exhibited intact left basal ganglia and left
temporal lobe, although all exhibited the left basal ganglia lesions. Among them,
three subjects (#7, 1, 3) demonstrated preserved glucose metabolism in the right
temporal lobe.
Regarding the remaining five subjects with no remarkable
improvements, all exhibited lesions in the left basal ganglia or temporal lobe.
The PET examinations revealed no increase in the right temporal lobe in the
improved subjects. In particular, those with bilateral basal ganglia lesions (#5, 8)
or with severe left temporal lesion (#7) demonstrated no improvement, and even
worsened.

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Case report
One case report will be presented for better understanding of the results.

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Case #10
The patient was a 63-year old right-handed man who developed aphasia
secondary to intracranial hemorrhage over the course of 41 months. The right
basal ganglia and the Broca’s area were damaged (Figure 3), which caused
severe aphasia. Significant word finding difficulty and semantic paraphasia were
observed, and he could only handle basic greetings and yes and no. He mostly
understood at the word level. He had difficulty in speech but sang songs quite
well with a steady rhythm and pitch. Furthermore, he could sing a test-piece (a
parody of a song) after he repeated the training three times. Table 3 shows the
result of the speech test before and after the singing training.
Post-intervention
The word finding difficulty was still observed but he responded with “Fishing” to
the question “What is your hobby?” According to his wife, it seemed that the
number of words had increased compared with those before the onset and that
he was more calm and patient than before.

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of those who improved after singing (#4, 7, 1), followed by two subjects who
improved after total intervention (singing and naming, #3, 8), followed by five

Discussion
Limitation of the study
We should note some methodological limitations. First, the number of patients
undergoing PET examination was small. Thus the effect of preserved glucose
metabolism in the right hemisphere was not conclusive. Second, the effect of a
series of activities, in which patients experienced a conversation and sang a
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song with the therapist weekly, remains unknown. Thus, it is difficult to
completely identify the effect of singing training.

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Intact right basal ganglia
Acoustic stimulation from both melody and rhythm likely plays an important role
in singing training. Rhythm is related to the basal ganglia [20,21]. This finding
demonstrated that the singing training was indicated in patients whose right
basal ganglia was not damaged, which suggested that the right basal ganglia is
important for the rhythm stimulation during the singing training.

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Intact left temporal lobe
The left temporal lobe, i.e., the language area, plays an important role in speech
ability. This finding demonstrated that the singing training was indicated in
patients with an intact left temporal lobe. It suggested that the left temporal lobe
played an important role in the improvement of speech and word finding with
respect to the outcome of singing training.

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Preserved right temporal glucose metabolism
There have been reports that preserved right temporal glucose metabolism
might improve aphasia through compensatory stimulation of the right
hemisphere activity following deficit in the language cortex in the left
hemisphere. This finding suggested that preserved metabolism of the right
hemisphere is also important among the criteria of the singing training.
Effect of music training
Singing has a positive effect on patients with aphasia [22]. Music semantic
memory is associated with the left upper temporal area [23] and music
intonation therapy is effective for activating the left hemisphere [24,25]. In our
patients, singing training had effects on the remaining function in the left upper
temporal area involved in music semantic memory, and allowed the patients to
speak words using the music lexicon. The above results suggest that music
therapy can access and activate 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 [26,27].

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Indication of singing therapy for aphasia patients
We considered that patients who exhibit intact right basal ganglia and left
temporal lobes, together with preserved right hemispheric glucose metabolism,
might be an indication of the effectiveness of singing therapy.

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Declaration of Interest
The authors report no conflicts of interest.

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1. Home-Thompson A, Grocke D. A project investigating music therapy referral
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severe dysarthria. J Speech Lang Hear Res. 2003;46(2):462-74.
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modulates semantic priming in vocal music. Cognition. 2005;94(3):B67-78.
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nonfluent aphasia. Ann NY Acad Sci 2012;1252:312-7.
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therapy for a patient with severe nonfluent aphasia. Int J Rehab Res.
2010;35(1):78-81.
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singing may not hold the key to recovery from aphasia. Brain.
2011;134:3083-93.
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Brain. 2006;129:2571-84.
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Years of

Months from

Stroke

education

onset

type

Rt

12

141

CH

Lt BG, Broca

mild

non fluent

M

Rt

12

68

CI

Lt BG, Broca

mild

non fluent

70
60

M
M

Rt
Rt

16
16

136
160

CI
CH

Lt BG, Broca
Lt BG, Broca

mild
mild

non fluent
non fluent

#5
#6

52
59

M
M

Rt
Rt

12
14

146
58

CH
CH

Blt BG, Broca
Lt BG, T

mild
mild

non fluent
fluent

#7
#8

67
82

M
F

Rt
Rt

12
8

79
118

CI
SAH

Lt T
Blt BG

mild
mild

fluent
non fluent

#9
#10

61
63

M
M

Rt
Rt

12
12

CH
CH

Lt BG, Broca
Lt BG, Broca, T

moderate
severe

non fluent
non fluent

#1

61

M

#2

62

#3
#4

Stroke lesion

EP

Handedness

C

Sex

AC

Case Age

168
41

Aphasia
severity

Aphasia type

ST

M = male, F = female, Rt = right, CI = cerebral infarction, CH = cerebral hemorrhage, SAH = subarachnoid hemorrhage, Lt =
left, Blt = bilateral, BG = basal ganglia, T = temporal

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Table 1. Demographics and clinical characteristics of the cases

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Lt Temporal

Rt Temporal

CMRglc

CMRglc

N

ND

ND

N
N

Decreased
No change

No change
No change

N
lesion

Decreased
Decreased

No change
No change

lesion
lesion

lesion
N

Decreased
ND

No change
ND

lesion
N

lesion
lesion

ND
ND

ND
ND

lesion

N

Decreased

No change

Naming

Total

Rt BG

Lt BG

#4

2

1

3

N

lesion

#7
#1

2
2

-1
-1

1
0

N
N

lesion
lesion

#3
#8

1
1

1
1

3
3

N
N

lesion
lesion

#6
#9

1
1

2
-1

2
1

N
N

#10
#5

0
-1

1
1

1
1

N
N

#2

-2

0

-1

lesion

Lt Temporal

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Singing

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AC

C

Case

Rt = right, Lt = left, BG = basal ganglia, CMRglc = cerebral metabolic rate for glucose, N = no lesion, ND = no data

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Table 2. Intervention scores on singing, naming, and the total, the presence of bilateral basal ganglia and
left temporal lobe lesions, and PET findings of the bilateral temporal lobes

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Naming Test (200 words)

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Word fluency

1

3

Picture (MANGA) Description Test

0

0

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after

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before

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Table 3. Speech test scores in Case #10

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1st assessment at baseline
Naming test, Word fluency, Picture (Manga) Description Test (SLTA)

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FDG-PET

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2nd assessment
Naming test, Word fluency, Picture (Manga) Description Test (SLTA)

AC

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2nd Intervention
Naming training or Singing training for 10 weeks

3rd assessment
Naming test, Word fluency, Picture (Manga) Description Test (SLTA)

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Figure 1: PET=positron emission tomography, SLTA = Standard Language Test
for Aphasia.

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1st Intervention
Singing training or Naming training for 10 weeks

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Pre
Post
Naming test

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1

Pre
Post
Word fluency

3
8
6
9

10
5
2

Pre
Post
Picture (Manga) Description Test

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Figure 2: The numbers are the ID of cases. Colored lines were of ID 4, 7, 1, 3, and 8, corresponding to the improved
participants noted in Table 2.

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ST

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Decreased glucose metabolism (3D-SSP)

Figure 3: MRI=magnetic resonance imaging, PET=positron emission

TE
D

tomography

EP

C

AC

Int J Neurosci Downloaded from informahealthcare.com by Nyu Medical Center on 02/04/15
For personal use only.

MRI

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