AJSLP Research Article A Case Study Using a Multimodal Approach to Melodic Intonation Therapy Dianne Slavina and Renee Fabusb Purpose: The purpose of this study was to assess the efficacy. of increasing spontaneous expressive language using a modified melodic intonation therapy (MIT) approach with a male participant diagnosed with acquired aphasia and apraxia who was 10 years post onset. Method: A therapeutic protocol consisting of vocal and linguistic tasks was administered. The participant attended two 50-min individual sessions and a 4-hr/week socialization program for three 12-week semesters. Measures of speech and language were administered before intervention and at the completion of each of the 3 semesters. Results: At the completion of the study, the participant demonstrated reduced apraxia of speech as measured by The Apraxia Battery for Adults, Second Edition (Dabul, 2000). He also showed improvements in auditory comprehension skills as measured on the Boston Diagnostic Aphasia Evaluation (Goodglass, Kaplan, & Barresi, 2000). His spontaneous utterances were characterized by an increased number of complete sentences and questions. Several language parameters including mean length of utterance, total number of spontaneous (untrained) utterances, and number of different words spoken were also improved as revealed through language analysis. Conclusions: Integration of melodic intonation therapy through the addition of musical elements may result in improved speech and expressive language skills when administered over a 9-month period in conjunction with a group socialization program. M functions in a tandem relationship with the left hemisphere for both encoding and emission of propositional language. However, the final integrative process takes place in the temporal lobe of the left hemisphere” (p. 320). Gordon (1972) speculated that reorganization of this process may occur only when spontaneous recovery of normal language processing was very slow, or incomplete, and interhemisphere language pathways were preserved. Activation of the right hemisphere using MIT may increase the probability of linguistic reorganization (Sparks & Deck, 2008, in Hallowell & Chapey, 2008). Using an MIT approach, clinicians instructed patients to say words and phrases while simultaneously tapping and intoning (exaggerating) the melodic phrases with or without the clinician’s assistance. The primary intent of the MIT program was to achieve some expressive language recovery in patients with severe, nonfluent aphasia close to onset. The primary emphasis of this program was the recovery of spontaneous expressive language; specific attention to syntax and articulation skills were not of primary importance. For many years, researchers have sought to examine the efficacy of MIT and identify the aspects of MIT that account for its effectiveness. Schlaug, Marchina, and Norton (2008) studied the roles of intoning and tapping in two people with severe nonfluent aphasia 1 year post onset. One person received MIT, and the other, speech illions of people now survive stroke and other disorders that result in aphasia and/or apraxia of speech (AOS; http://www.aphasia.org). When these two impairments co-occur, a person may be left nearly devoid of verbal expression. There have been, over a period of many years, reports of people with nonfluent aphasia who have retained the ability to sing with a degree of verbal fluency not evident when speaking (Dickey et al., 2010). In recognition of this phenomenon, Sparks and Holland (1976) developed a treatment approach, melodic intonation therapy (MIT), to assist patients diagnosed with expressive aphasia in recovering expressive language abilities. The original assumption of this approach was intoning speech, which would stimulate language areas of the right hemisphere of the brain in a compensatory manner. On the basis of a review of literature regarding the role of the right hemisphere in speech and language processing, Sparks et al. (1974; as cited by Sparks & Deck, 2008, in Hallowell & Chapey, 2008) concluded that, for most people, “the right hemisphere a LIU Post, Brookville, NY Health Sciences Center, School of Health Technology and Management, Stony Brook University, NY b Correspondence to Dianne Slavin: Dianne.Slavin@liu.edu Editor-in-Chief: Krista Wilkinson Received March 3, 2017 Revision received May 15, 2017 Accepted April 16, 2018 https://doi.org/10.1044/2018_AJSLP-17-0030 Disclosure: The authors have declared that no competing interests existed at the time of publication. American Journal of Speech-Language Pathology • 1–11 • Copyright © 2018 American Speech-Language-Hearing Association Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx 1 repetition therapy with no intoning or tapping. These investigators reported a greater improvement for the person who received MIT and suggested that left hand tapping may be important for priming of the right-hemisphere sensorimotor network for articulation. The use of tapping to aid patients in pacing utterances is not a new technique and is known to be a useful way of tracking various stimuli. Smith (1973), for example, reported that subjects were more accurate in tracking a visual display when using their own hand movements than when the tracking was imposed by an external source. She suggested the possibility of a neural timing mechanism that integrated various forms of motor stimulation. Zumbansen, Peretz, and Hebert (2014) published a critical review of the literature on the efficacy of MIT. In doing so, they found that there were many studies in which the original goal of MIT had been changed. Several researchers incorporated intoned speech as a facilitation technique targeting a specific set of utterances to be trained rather than a formalized program meant to restore spontaneous speech. Of the 14 studies they reviewed, only five studies followed the original goals and rationale of MIT. The other investigators sought to instruct participants to produce a select set of functional phrases through the use of intoning (Baker, 2000; Goldfarb & Bader, 1979). Similarly, Hough (2010) trained participants to produce a set of utterances and reported an improvement on untrained phrases presented in formalized testing, but there was no generalization to propositional speech. Van Eeckhout and Bhatt (1984) instructed participants to use intoned speech as a strategy to elicit utterances. Zumbansen et al. (2014) concluded that studies of MIT and its variant treatments have been shown to improve speech-language skills in people with nonfluent aphasia and AOS based on the stated goals and outcomes measured. Techniques associated with MIT have also been used effectively as interventions with people with AOS. Efficacy studies of treatments for AOS have used tonal sequences of rhythmic patterns, feedback on rate, fluency, and pattern matching and tapping (Brendel & Ziegler, 2008; Wambaugh & Martinez, 2000) as well as singing of familiar songs and use of novel phrases using familiar melodies and clapping (Aitken Dunham, 2010). A systematic review of 25 recent studies of treatment approaches used for AOS was conducted by Ballard et al. (2015). They concluded, on the basis of accumulated evidence, that both kinematic and rate/rhythm approaches to treating AOS were effective in improving speech production. The effect of music on the facilitation of speech and language skills for people diagnosed with aphasia and AOS continues to be of interest. Bradshaw (1989) described the similarities of hemispheric processing of music as being very similar to cognitive processing in general, with the left hemisphere processing music analytically, in sequence, and the right processing it more generally. More specifically, recent research into the physiology of music has shown music to involve activation of interfacing hierarchical neural networks including motor, 2 cognitive, speech, and language neural pathways in both the right and left hemispheres (Thaut, McIntosh, & Hoemberg, 2015). The role of right hemisphere structures involved in singing, speaking, and the production of melody has been confirmed in the magnetic resonance imaging studies of Ozdemir, Norton, and Schlaug (2006) and Jeffries, Fritz, and Braun (2003). With the onset of aphasia, homologous speech centers in the right hemisphere may become more active in response to damaged speech centers in the left hemisphere. Saur et al. (2006) reported that more intense activation of the homologous right brain centers was correlated with greater activation of the left hemisphere and language recovery. Belin et al. (1996) showed through PET scans that subjects trained in MIT had increased activation of Broca’s area compared with subjects who did not receive MIT. In addition, singing has been shown to incorporate several aspects of processing vital to the processing of speech and language including pitch, prosody, and temporal organization (Jungblut, Huber, Mais, & Schnitker, 2014). As such, music generally, and singing specifically, may optimize the retraining of shared brain functions including memory, attention, perception, motor control, and language. This may facilitate the development of new integrated neural networks reflective of a neuroplasticity unknown at the time MIT was first developed. One modification of MIT has been developed by practitioners of neurologic music therapy (Conklyn, Novak, Boissy, Bethoux, & Chemail, 2012). This modification encourages patients to sing words and phrases rather than intoning prosodic patterns as a means of differentiating one word or phrase from another. The idea was that there will be a stronger association of words to melodies if phrases being trained are sung with a variety of melodies rather than intoned patterns. For example, simple English declarative sentences have a falling prosodic pattern, so the intoned prosodic contour of “I open the window” and “She went to the store” would be similar. A recent study by Lim et al. (2013) reported significant improvements in spontaneous speech as well as comprehension and naming for 12 participants diagnosed with aphasia who received neurological music therapy compared with 12 participants diagnosed with aphasia who received traditional speech-language therapy. Rhythmic and tonal exercises that require memory and attention also have been used and included neurological music therapies. Jungblut (2009) developed a comprehensive music therapy program, SIPARI®, for people diagnosed with chronic aphasia that expands beyond the musical aspects of MIT. This intervention approach consists of singing, intonation, prosody, and breathing exercises. These exercises, along with improvisation tasks, are aimed at supporting phonation and segmentation of speech and promoting oral communication. Jungblut et al. (2014) examined the efficacy of this approach with three people diagnosed with severe aphasia many years post onset. All participants underwent a functional magnetic resonance imaging American Journal of Speech-Language Pathology • 1–11 Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx (fMRI) procedure examining changes in neural activity during singing of vowel sequences before and after 6 months of treatment. The results revealed that there were neurophysiological changes after intervention, in the left perilesional area and homologous areas in the right hemisphere. In addition, the participants’ scores improved on subtests of an aphasia battery specifically in the areas of repetition and naming. The participants also reportedly produced more spontaneous speech with less speech effort during the postintervention testing. Taken together, these studies demonstrate that the basic MIT approach may be embellished to incorporate a variety of techniques designed to maximize the contribution of right brain centers in the recovery of language in people with aphasia. For example, the addition of nonpropositional tasks such as tapping out different patterns may serve to focus attention and activate working memory; vocalizing with the singing of songs and trained phrases to MIT may more fully activate right hemisphere homologs of leftlanguage processing centers to facilitate language production. The findings of researchers discussed above document treatment possibilities for language improvement for people with limited expressive language skills due to nonfluent aphasia and AOS years post onset. There are a limited number of studies in support of adding musical tasks to MIT (Conklyn et al., 2012; Lim et al., 2013; Schlaug et al., 2008). The purpose of the current study was to examine the effect of an MIT approach, integrated with singing, vocal exercises, and rhythmic tasks, on the spontaneous expressive language of one male participant diagnosed with chronic aphasia and AOS, 10 years post onset. Method Speech-Language Measures Boston Diagnostic Aphasia Evaluation (Short Form) The Boston Diagnostic Aphasia Examination (BDAE; Goodglass, Kaplan, & Barresi, 2000) is a comprehensive test battery that examines and classifies the language profiles of individuals with aphasia. The test contains different sections that examine auditory comprehension, verbal expression, reading, writing, and conversational speech. Apraxia Battery for Adults, Second Edition The Apraxia Battery for Adults, Second Edition (Dabul, 2000) examines the presence and severity of AOS in adolescents and adults. It contains sections that examine diadochokinetic rates, increasing word length, limb apraxia, and oral apraxia. The test of “Increasing Word Length” consists of two subtests, A and B. Each of these subtests consists of three lists of words of increasing length. Scoring is predicated on the assumption that longer words will be more vulnerable to articulatory errors commonly present in AOS. To determine the severity rating, the number of correct responses from the third word list (longest words) is subtracted from the number correct on the first word list (shortest words); the smaller the remainder, the milder the level of impairment. Participant Characteristics After approval of the LIU Institutional Review Board, the participant, C. P., was recruited. C. P. was recruited from a population of people with aphasia who participate in an Extended Day Aphasia Program (EDAP) at LIU Post. C. P. was a 63-year-old, college-educated man who presented with a mild to moderate nonfluent aphasia, severe word-finding deficit, and AOS. He was 10 years post onset from a left cerebrovascular accident and was neurologically stable. His therapy history consisted of traditional speech-language therapy (no singing and/or intoning of utterances) once or twice a week for 8 years at university speech and hearing clinics. The areas that were addressed in previous aphasia therapy included auditory comprehension, word finding, and syntactic skills. At the time of testing, improvements in his expressive language were described by his speech-language pathologist as “plateaued,” and therapeutic efforts focused on a multimodality approach to communication that included supported conversation and use of iPad applications. C. P.’s participation in the EDAP provided him with ongoing socialization opportunities consisting of several group activities over the course of each 4-hr session. The activities that he consistently participated in included meet and greet, current events, Living with Aphasia (counseling group), sports, and Wii bowling. Graduate students administered the activities under the supervision of licensed speech-language pathologists certified by the American Speech-Language-Hearing Association and were trained as communication partners (Kagan, 1998). At the onset of this study, C. P. was attending individual speech-language therapy once a week and also had been attending the EDAP for 6 years. He produced single words that often lacked content (e.g., “here” and/or “you know”), “empty” speech, and automatic phrases (e.g., “How are you?”). During two pretesting sessions, the client made the following comments: “Yeh, come here, sure, what is this, this is one, show me, yourself, no, no, backwards (meaning say it back), okay, but more, not that’s it, put one, what that’s…and take it down, no forget about it.” C. P. exhibited fewer errors in automatic speech compared with volitional speech, and he had significant difficulty initiating speech. Paraphasic errors were infrequent possibly because he gave up the speech attempt. His nonverbal communication skills consisted of vocalizations and ineffectual gestures. Writing was limited to signing his name and copying letters and words. In regard to musical abilities, C. P. was able to sing familiar songs fluently. Before the cerebrovascular accident, he played the guitar but had no formal musical education. The speech and language measures were administered before intervention and at the end of each of three semesters in a quiet room. One of the investigators and a student clinician were present during the testing. Session data were Slavin & Fabus: A Multimodal Approach to MIT Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx 3 maintained to track C. P.’s ability to meet the criterion level of five consecutive correct responses for each task. Spontaneous utterances were also recorded and defined as follows: self-initiated comments including questions (e.g., “Where are you going?”), elaborations of trained utterances (e.g., “Hey, Sue, let’s go out for dinner tonight” from the trained phrase “What’s for dinner tonight?”), and untrained conversational comments (e.g., “We watched baseball”). Spontaneous utterances elicited during sessions were recorded and transcribed by graduate clinicians trained in this task. The primary investigator reviewed session tapes to confirm their accuracy. C. P.’s utterances were categorized into sentence types: declarative and imperative questions (wh and others), overlearned/automatic phrases, and fragments or empty utterances. Only utterances meeting the previously stated criteria as spontaneous were included in the language analyses. Intervention Program The treatment sessions were administered by graduate clinicians trained in these tasks, under the direct supervision of the primary investigator. All sessions were videorecorded. The participant received individual therapy for 50 min twice weekly and attended a 4-hr socialization program once per week at LIU Post for the duration of the intervention. In preparation for this study, the first author attended a 35-hr neurological music therapy certification training workshop offered by the Neurologic Music Therapy Training Institute at Colorado State University, Fort Collins. A multimodal approach to MIT was developed that incorporated singing and rhythmic patterns used there. The treatment sessions consisted of a series of nonlinguistic and rhythmic tasks followed by linguistic musical tasks. The sequence of intervention activities each semester consisted of the following: 1. The clinician led the participant in a three-step breathing exercise (inhale, hold, and exhale). 2. The clinician led the participant in singing a scale while tapping a steady rhythm. 3. The clinician led the participant in sustaining vowels. 4. The clinician modeled various rhythmic patterns (four to seven taps); humming melody and tapping rhythm were used with the participant using handover-hand technique. 5. The clinician presented phrases using the MIT multistep approach, singing phrases with hand-over-hand tapping (modeling), unison tapping and singing of phrases, and singing as the clinician faded out and the client sang the phrase alone; C. P. sang the phrase alone and spoke the phrase when prompted by the clinician: The rate of sung elements was slowed if needed to provide more time for articulatory adjustments; that is, pace was reduced primarily by prolongation of vowels. 6. The participant sang familiar songs. 4 7. The clinician prompted the participant with questions to probe phrase mastery from sung to spoken utterances. 8. The clinician prompted the participant with conversational topics including sports, food, pets, and free time. Not all topics were addressed in all sessions nor were a target number of utterances per session designated. Spontaneous utterances were counted as they occurred during the sessions, not only during the designated conversational periods. Nonlinguistic/rhythmic tasks included breathing exercises, sustaining /a/, singing up and down a pitch scale, upward and downward glides, and imitating patterns of three to seven taps with hand tapping. A criterion level of five correct productions for each of these tasks was determined for the participant to achieve mastery. After C. P. mastered the task, he was still instructed to perform the task as a warm-up for each session. The singing portion of the sessions included singing familiar tunes that were overlearned and brief (e.g., “Row, Row, Row Your Boat” and “Happy Birthday”), songs with less familiar and/or longer lyrics (e.g., “Take Me Out to the Ball Game” and “This Little Light of Mine”), and functional phrases using the five steps adapted from MIT (Helm-Estabrooks, 1983), which included the following: 1. Humming melody and tapping rhythm with the participant using hand-over-hand technique; 2. Singing phrases with hand-over-hand tapping; 3. Unison tapping and singing of phrases; 4. Singing as the clinician fades out and the client sings the phrase alone; and 5. The participant sings the phrase alone and speaks the phrase when prompted by the clinician. Rate reduction, modeling, and phonetic placement were teaching strategies employed during the intervention sessions. The phrases were developed based on what would be the most salient and functional for the participant’s communication skills. A unique melody was developed for each of the phrases. Sparks and Holland (1976) cautioned against changing the lyrics of well-known songs because of the possible intrusion of the original words. In this case, one of the phrases was based on a song without such intrusion. C. P. was not informed that lyrics had been changed, and perhaps he was not familiar with the song. Table 1 provides a list of songs and phrases by semester. Some of the phrases included “I live in Garden City,” “I am hungry,” “What’s for dinner tonight,” “I want a cup of coffee,” and “My son lives in Atlanta.” When the participant produced paraphasic or articulatory errors, in phrases or songs, the correct word was modeled by the clinician and repeated by the participant until five consecutive correct productions were achieved. Afterward, the participant produced the word in the context of the phrase or song. For example, in “Row, Row, Row Your Boat,” the word “merrily” became “melody.” American Journal of Speech-Language Pathology • 1–11 Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx Table 1. Phrases and songs used in the intervention sessions. Semesters Songs Phrases Semester 1 Sings scales using “La,” “Happy Birthday,” and ”Row, Row Your Boat”; refrain from “Old MacDonald [i, a, i, a, ou]” and “This Little Light of Mine” “Row, Row, Row Your Boat,” “You Are My Sunshine,” and three other popular songs Sings scales with wife’s name, “You Are My Sunshine,” “Take Me Out to the Ball Game,” and one other popular song “I live in Garden City,” “I am hungry,” “My son lives in Atlanta,” I want a cup of coffee” Semester 2 Semester 3 New songs were practiced phrase by phrase until he was able to sing each phrase independently. Once a song was mastered, the clinician would prompt the participant to sing that song. For example, the clinician would then ask the participant to sing “This Little Light of Mine.” In addition, approximately 5 min were allocated at the beginning and end of each session to engage the participant in spontaneous conversations. The interactions between clinicians and the participant were consistently congenial and at times humorous. Conversation was encouraged between tasks, providing additional opportunities for spontaneous speech between structured activities. As treatment progressed and C. P.’s mastery of trained phrases improved, the clinician would probe his ability to produce not only trained utterances but also expanded versions of them. For example: Clinician: “What would you say if you were ready to eat?” Participant: “I am hungry” (trained) Clinician: “What might you ask your wife about dinner?” Participant: “What’s for dinner tonight?” (trained) Clinician: “What do you want to eat?” Participant: “I want eggplant parm” (untrained) Data were recorded during each session to note mastery of the musical and linguistic tasks described above. The graduate transcribed spontaneous speech samples produced by C. P. each session and analyzed them at the end of each semester. The total number of utterances elicited varied each semester. The utterances were coded and analyzed using the Systematic Analysis of Language Transcripts (SALT) software (Miller & Iglesias, 2012). In addition, a descriptive language analysis was done to identify the grammatical forms expressed by C. P. over the course of the study. Results Results of repeated testing by semester are presented for the BDAE (Goodglass et al., 2000) in Table 2. These results reflect initial improvement in the completion of commands (verbal directives) and then regression for Posttest 2. C. P.’s performance on the comprehension of complex ideational material improved steadily from the pretest to Posttest 3. Word repetition remained unchanged across “I live in Garden City,” “I am hungry,” “My son lives in Atlanta,” “I want a cup of coffee” “I’d like a glass of wine,” “What’s for dinner tonight?” “I want a cup of coffee,” “Did you lock the door?” “I have a dog named Lucy” test administration at the 60th percentile. Regarding sentence repetition, the short form provides only two sentences: one sentence of three one-syllable words and one sentence of eight words composed of 10 syllables. The scoring reflects improvement on the first sentence as he repeated the three words correctly in the second and third administrations. He was unable to repeat the entire second sentence without error. It should be noted that C. P. refused to attempt the second sentence on the first administration and was able to produce five words (7/10 syllables) correctly on the subsequent administrations. Table 3 illustrates the results of the Boston Naming Test. Performance remained stable at the 10th percentile for all test administrations. Results of the Apraxia Battery for Adults (Dabul, 2000) are presented in Table 4. An anomalous score of −1 was obtained on the pretest administration of Subtest A, “Increasing Word Length.” This occurred as a result of scoring procedures. The total score on production of threesyllable words (Column 3), 15 of 20, was subtracted from the total score on production of one-syllable words (Column 1), 14 of 20. As the scoring system is based on the assumption that shorter words are more likely to be articulated correctly, this score is invalid. Severity ratings of subsequent administrations for “Increasing Word Length A” improved to the normal range over the course of the study. C. P.’s performance on the subtest “Increasing Word Length B” improved from moderate/severe to mild on the final retest. The limb apraxia subtest scores also improved from moderate to mild deficit. C. P. quickly achieved and maintained all vocal tasks including volitional breathing, singing a scale, upward and downward glides, and sustaining of vowels as well as imitation of patterns of three to five taps for five consecutive trials. He was not, however, consistently successful in imitating patterns of six to seven taps within the criterion level of five consecutive trials. Language samples compiled over 12-week intervals were analyzed. The SALT software was used to analyze the participant’s spontaneous utterances from treatment sessions during the course of the study. As the study progressed, C. P.’s spontaneous utterances gradually increased and improved in regard to length and complexity. The results of standard measures calculated by the SALT software are presented in Table 5. Slavin & Fabus: A Multimodal Approach to MIT Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx 5 Table 2. Percentile rank (raw scores) for four administrations of the Boston Diagnostic Aphasia Examination (BDAE, short form). Subtest of BDAE Auditory Comprehension Basic Word Discrimination Commands Complex Ideational Material (sentences and paragraphs) Recitation: Automatized Sequences (days of the week, counting) Repetition: Words Repetition: Sentences Responsive Naming (words of increasing length) Special Categories: Recall (letters, numbers, colors) The SALT analyses revealed a substantial increase in the total number of utterances in the third semester compared with the previous two semesters, from approximately 100 to 247 utterances. Mean length of utterance increased from 2 in Semester 1 to 4 in Semesters 2 and 3. This increase in speech production was also reflected in the increase in the total number of words across semesters. To control for bias due to the skewed distribution of utterances in the final speech sample, the utterances were reanalyzed using equalized samples composed of the central 90 utterances of each sample (see Appendix). On the basis of SALT results, Figure 1 illustrates the changes in mean length of utterance in words for total utterances and equalized utterances for the three semesters. These SALT results are comparable with the initial analyses except for the total number of different words elicited. The results of the descriptive language analysis presented in Table 6 elucidate the types and proportion of spontaneous utterances produced in each semester. On the basis of these data, it appears that during Semester 1, C. P.’s spontaneous utterances were primarily characterized by declarative sentences (e.g., “I don’t understand this” and/or “I’m okay”) and overlearned social phrases (e.g., “Bye, bye,” “Good morning,” and/or “Yeh, right”). During Semester 2, the number of sentences and questions increased and the number of overlearned social phrases decreased. In the third semester, the preponderance of utterances consisted of declarative sentences of varying length and complexity. Many were simple declarative sentences such as “It was good,” “We’ll meet outside,” and “We watched baseball.” Others were more elaborate, for example, “He never got it,” “It’s usually somewhere in the living room,” and “We went to a concert.” He asked wh-questions, interrogative reversals, tag questions, and statements with rising inflection. Despite persistent word-finding deficits reflected on the Boston Naming Test, the participant was producing Percentiles pretesting Testing 1: Semester 1 Testing 2: Semester 2 Testing 3: Semester 3 10th (10) 10th (3) 30th (3) 20th (2) 60th (4) 0 0 0 10th (10) 40th (8) 50th (4) 100th (4) 60th (4) 0 20th (1) 20th (7) 10th (10) 12th (5) 50th (4) 100th (4) 60th (4) 60th (1) 0 10th 10th (10) 12th (5) 100th 100th (4) 60th (4) 60th (1) 0 10th many more spontaneous utterances. Generally, he produced more grammatically complete spontaneous utterances, whereas before the intervention, he used empty utterances and brief automatic phrases to communicate. In addition, toward the end of the study, he was able to participate in brief conversational exchanges. For example, the clinician asked C. P. about a recent visit from his son who resides out of state. Clinician: “How was your visit with your son?” Participant: “He’s coming again.” Clinician: “When?” Participant: “In a few weeks.” Clinician: “What did you do this weekend?” Participant: “Not much, it was hot.” Discussion This study examined the speech and expressive language skills of a 63-year-old man diagnosed with aphasia and AOS, 10 years post onset. Speech and language measures were administered at three 12-week intervals during which a modified MIT approach was administered. At the initiation of the study, the participant exhibited minimal expressive language because of word-finding deficits, AOS, and mild to moderate auditory comprehension deficits, as evidenced by the results of the standardized testing. He had participated in traditional individual and group aphasia therapy programs through the years but had not achieved any appreciable change in his verbal communication. C. P. proved to be a good candidate for this integrated, multimodal MIT approach. He was able to sing familiar songs fluently. He readily mastered the vocal exercises presented to him and learned the lyrics to new or less familiar songs with practice. He mastered the sung phrases chosen for him, and over the course of 9 months, his auditory comprehension skills improved, as did his articulatory Table 3. Results of the Boston Naming Test during the different semesters. Pretest: # correct Three correct without cueing 6 Posttest, Semester 1: # correct Posttest, Semester 2: # correct Posttest, Semester 3: # correct Four correct without cueing Two correct without cueing Three correct without cueing American Journal of Speech-Language Pathology • 1–11 Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx Table 4. The scores on the Apraxia Battery for Adults during the different semesters. Apraxia Battery for Adults ratings Pretesting Posttesting Semester 1 Posttesting Semester 2 Posttesting Semester 3 Raw scores for Increasing Word Length A Raw scores for Increasing Word Length B Limb Oral apraxia Repeated trials −1: invalid 4: moderate 29: moderate 30: moderate 19: mild 2: mild 6: severe 25: moderate 25: moderate 27: mild 3: moderate 9: severe 40: mild 25: moderate 29: none 0: none 2: mild 37: mild 26: moderate 22: mild precision and expressive language skills. Singing allowed him to enjoy a verbal fluency he had not experienced in years. The treatment administered in this study was composed of techniques including tapping, rate reduction, modeling, and phonetic placement, all of which may be included in the administration of MIT (Sparks & Deck, 2008; Sparks & Holland, 1976) as well as in the treatment of AOS (Dworkin & Abkarian, 1996; Wambaugh & Martinez, 2000). The introduction of singing as a primary component of the treatment is relatively new, and it addresses a limitation of MIT discussed by Conklyn et al. (2012). They asserted that the use of intoned speech that mirrors normal speech prosody results in a restricted range of pitches and rhythms that preclude the full engagement of the right hemisphere areas that mediate prosody and melody. Singing, as discussed by Thaut et al. (2015), may expand the engagement of neural networks entraining internal pathways that cross hemispheres and facilitate temporal sequencing, motor patterning, and other functions that underlie speech. Temporal organization, in particular, is basic to the processing of speech and language and is often impaired after damage to the left hemisphere (Jungblut et al., 2014). There has been an increased interest in documenting the supporting role of the right hemisphere involvement in speech and language production. Thaut et al. (2015) concluded that hand tapping, as speech is sung, activates priming for verbal production through rhythmic anticipation or entrainment; as one listens to a melody, foot or hand tapping and humming may spontaneously occur. In addition, neural imaging studies have documented neural plasticity in the brains of participants diagnosed with aphasia after a variety of treatments. Ludlow et al. (2008) reviewed seven principles of neural plasticity and the neural bases of rehabilitation with individuals with neurological communication disorders. Application of the principles of repetition, saliency (training personally functional phrases and familiar songs), and transfer may give credence to the improvements made by C. P. Meinzer et al. (2004) measured changes in delta dipole density before and after intensive speech-language therapy, using constraint-induced aphasia therapy or “massed model-based aphasia therapy” for 28 patients diagnosed with chronic aphasia, more than a year post onset. The results illustrated that there was a correlation between language function, as measured on standardized tests, compared with changes in magnitude of reduction of delta activity in perilesional areas, in 16 of the 28 participants. They concluded that, because both treatments produced comparable results, then other similar treatments, administered with the same intensity, would also prove effective with persons diagnosed with chronic aphasia over a year post onset. Schlaug, Marchina, and Norton (2009) reported evidence of neuroplasticity in six patients at least 1 year post onset, with severe nonfluent aphasia and large left-hemisphere lesions, who participated in an intensive MIT program. This program was administered as originally intended using intoned speech and three criterion levels (Albert, Sparks, & Helm, 1973; Sparks, Helm, & Albert, 1974). The program was administered 1.5 hr a day, 5 days a week until all three levels were mastered. Results of diffusion tensor imaging showed a significant increase in the number of fibers and volume of arcuate fasciculus of the right hemisphere in all six patients posttreatment, thus providing a physiological and anatomical support for the improved language produced by their subjects. Changes in brain function have also been documented after the administration of “applied rhythmic–melodic Table 5. Results of the Systematic Analysis of Language Transcripts (SALT) analysis during the different semesters. SALT standard measures analyses Transcript length Fall 2015 Spring 2016 Summer 2016 Syntax/morphology Semantic Total utterances Analysis set All words (with mazes) MLU in words MLU in morphemes Number of total words Number of different words Type-token ratio 109 94 247 106 92 240 268 348 988 2.29 3.62 3.88 2.46 4.05 4.31 243 333 930 103 120 224 0.42 0.36 0.24 Note. MLU = mean length of utterance. Slavin & Fabus: A Multimodal Approach to MIT Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx 7 Figure 1. Results of the Systematic Analysis of Language Transcripts analyses for nonequalized and equalized utterances for the mean length of utterance (MLU; in words) for the three semesters (S1, S2, and S3). voice training” (Jungblut et al., 2014, p. 5). As described by Jungblut et al. (2014), their treatment protocol was designed for people diagnosed with chronic aphasia and apraxia to stimulate spontaneous speech production by improving motor, linguistic, and cognitive functions including planning, programming, and sequencing—functions that support speech motor processes and language-systematic processes. These researchers examined three participants diagnosed with chronic aphasia and AOS, using fMRI. Posttreatment fMRI data revealed significant perilesional activations in all patients, specifically the left temporal gyrus, without any sign of activation of the right hemisphere. In addition, they reported improvements in the vocal rhythm production, language, and speech motor performance of all three participants after 6 months of intervention, in addition to improvements in spontaneous speech. The above studies support the notion of neural plasticity as it relates to aphasia rehabilitation and recovery of speech motor function. Although we have no direct evidence of changes in brain function for our subject, the degree to which he was able to produce untrained utterances in conversational contexts may be a manifestation of neural change. There is evidence that MIT administered with either intoned phrases or sung phrases may be effective (Stahl, Henseler, Turner, Geyer, & Kotz, 2013; Stahl & Kotz, 2014). In the case presented here, given the time post onset and the years of treatment C. P. received, the use of songs and the inclusion of repetition of patterns of taps as a precursor to propositional language were chosen as a novel approach for him. These modifications theoretically maximized the contribution of the homologous areas of the right brain for language facilitation. At the end of this study, C. P. demonstrated improved auditory comprehension skills, as measured by the BDAE (Goodglass et al., 2000), specifically in the areas of following verbal directives (commands) and answering questions after listening to paragraphs (complex ideational material). This may in part be explained by improved attention skills. The work of researchers including but not limited to Robertson, Ward, Ridgeway, and Nimmo-Smith (1984); Murray (2004); and Nicholas, Sinotte, and Helm-Estabrooks (2011) reveals the vulnerability of attention and other cognitive functions to deficits that often coexist with aphasia. Many tasks used in our protocol, including imitation of vocal patterns, scales, and tapping out patterns of taps, required sustained attention during 50-min sessions over a 9-month period. According to Ludlow et al. (2008), the principle of repetition of training “states that changes in neural substrates will occur only as Table 6. Descriptive analysis of spontaneous utterances. Descriptive analysis of spontaneous utterances N = 90 Semester 1 Semester 2 Semester 3 Decl sentences Imp. Wh-questions Other Overlearned social phrases Sentence fragments 19 27 42 11 19 11 11 18 14 6 9 4 28 15 16 14 2 3 Note. Decl = declarative; Imp. = imperative. 8 American Journal of Speech-Language Pathology • 1–11 Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx a result of extensive and prolonged practice and that neural changes may not become consolidated until later in the training process” (p. S243). The number of repetitions/session, and the length of time required for repetition to change the brain and take effect, has not been established. It may, in this case, be that the need for sustained attention rather than number of sessions per week was the salient factor because the treatment schedule was not considered to be intensive. Over the 9 months, C. P. also reduced AOS as measured by the Apraxia Battery for Adults. Again, the principle of repetition was important because there were many practice trials for all treatment tasks, especially for the singing of songs and phrases. The principle of salience is also relevant. The songs and phrases were specifically chosen because they were relevant to him. C. P. was motivated because he experienced some immediate success in performing the nonlinguistic tasks such as humming scales and vocal glides and singing familiar songs. In instances when he made articulatory errors, he asked to practice those words until he eventually corrected them. Finally, C. P. began to produce clear, appropriate grammatical utterances in and outside the therapy room. At the end of the study, C. P. was producing many more spontaneous utterances, many of which were syntactically correct, including pronouns, prepositions, and verbs, which is unusual in persons diagnosed with nonfluent aphasia. We speculate that the treatment resulted in the creation of enhanced or newly established neural pathways resulting in his improved spontaneous speech production that went beyond the trained phrases. The principle of transfer of behaviors resulting from neural plasticity has not been well researched in humans (Ludlow et al., 2008). The fact that C. P. has been able to generalize his improved verbal communication should be viewed as a result of the integrative nature of the tasks presented to him, rather than a single element. In addition, his ongoing participation in an aphasia socialization program provided him with many opportunities to communicate with many people. Our findings support the growing evidence of neuroplasticity in people with chronic aphasia. Persons diagnosed with chronic aphasia and AOS may be able to improve their speech and language skills when undamaged right hemisphere areas associated with singing are engaged in the retraining of the motor and cognitive aspects of speech and language during the process of speech and language rehabilitation for aphasia. Our findings, however, should be viewed in the context of a single-subject design with the limitation inherent in it. Our participant was selected in part because of his ability to sing fluently despite limited verbal expression. Questions remain as to whether or not retained singing ability is a prerequisite for language elicitation through songs. In addition, our procedures may have been strengthened through collaboration with a neurological music therapist. In addition, our procedures may have been strengthened through collaboration with a music therapist whose expertise in using more melodic complexity and improvisation, for example, might further enhance clinical outcomes. In addition, our formal testing methods may have been strengthened by using the standard form of the BDAE, as the short form requires very few items per subtest, possibly creating a distorted picture of C. P.’s strengths and weaknesses, and the ABA did not provide the baseline level of apraxia we had anticipated. Our findings, although limited by a single participant, revealed the improvement of speech and expressive language skills that may be achieved for a person diagnosed with chronic aphasia and AOS. The addition of musical elements to MIT appears to be important, creating a more personalized program that proved to be novel and enjoyable. The results of our study contribute to the evidence that using singing tasks in conjunction with MIT may result in improved long-term outcomes for a subgroup of people with limited speech secondary to aphasia and AOS many years post onset. Research into the efficacy of music enhancements should be continued. MIT and its variants constitute a vital component in the rehabilitation of individuals with neurological communication disorders many years post onset. Acknowledgments The first author is employed at LIU and receives financial compensation for her employment. The second author has not received any financial compensation. We would like to thank Mr. and Mrs. P for agreeing to take part in this study. Living with aphasia and the aftermath of stroke present many challenges. The road to recovery is long and hard. We are still headed toward the silver lining. We would also like to thank Harriet Ryan for her vital role in the design and administration of activities at the beginning of the study and Nicole Iorio and Ingrid Gicou for their time and the commitment they demonstrated to this project as research assistants. References Aitken Dunham, D. J. (2010). Efficacy of using music therapy combined with traditional aphasia and apraxia of speech treatments (Master’s thesis). Retrieved from http://ezproxy.library. usyd.edu.au/login?url=http:search.proquest.com/docview/ 5775958097?accountid=14757 Albert, M. L., Sparks, R. W., & Helm, N. A. (1973). Melodic intonation therapy for aphasia. Archives of Neurology, 29, 130–131. Baker, F. A. (2000). Modifying the melodic intonation therapy program for adults with severe non-fluent aphasia. Music Therapy Perspectives, 18(2), 110–114. Ballard, K. J., Wambaugh, J. L., Duffy, J. R., Layfield, C., Maas, E., Mauszycki, S., & McNeil, M. R. (2015). Treatment for acquired apraxia of speech: A systematic review of intervention research between 2004–2012. American Journal of SpeechLanguage Pathology, 24, 316–337. https://doi.org/10.1044/ 2015_AJSLP-14-0118 Belin, P., Van Eeckhout, P., Zilbovicius, M., Remy, P., Francois, C., Guillaume, S., . . . Samson, Y. (1996). Recovery from nonfluent aphasia after melodic intonation therapy: A PET study. Neurology, 47, 1504–1511. Slavin & Fabus: A Multimodal Approach to MIT Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx 9 Bradshaw, J. L. (1989). Hemispheric specialization and psychological function. Chichester, England: Wiley. Brendel, B., & Ziegler, W. (2008). Effectiveness of metrical pacing in the treatment of apraxia of speech. Aphasiology, 22, 77–102. Conklyn, D., Novak, V., Goissy, A., Bethoux, F., & Chemail, K. (2012). The effects of modified melodic intonation therapy on nonfluent aphasia: A pilot study. Journal of Speech, Language, and Hearing Research, 55, 1463–1471. Dabul, B. L. (2000). Apraxia Battery for Adults, Second Edition. Austin, TX: Pro-Ed. Dickey, L., Kagan, A., Lindsay, M. P., Fang, J., Rowland, A., & Black, S. (2010). Incidence and profile of inpatient strokeinduced aphasia in Ontario, Canada. Archives of Physical Medicine and Rehabilitation, 91, 196–202. Dworkin, J. P., & Abkarian, G. G. (1996). Treatment of phonation in a patient with apraxia and dysarthria secondary to severe closed head injury. Journal of Medical Speech-Language Pathology, 2, 105–115. Goldfarb, R., & Bader, E. (1979). Espousing melodic intonation therapy in aphasia rehabilitation: A case study. International Journal of Rehabilitation Research, 2(3), 333–342. Goodglass, H., Kaplan, E., & Barresi, B. (2000). Boston Diagnostic Aphasia Examination. Philadelphia, PA: Lippincott. Gordon, H. W. (1972). Verbal and non-verbal cerebral processing in man for audition (Doctoral thesis). California Institute of Technology, Pasadena, CA. Hallowell, R., & Chapey, R. (2008). Introduction to intervention strategies in adult aphasia. New Baltimore, NY: Lippincott, Williams & Wilkins. Helm-Estabrooks, N. (1983). Exploiting the right hemisphere for language rehabilitation: Melodic intonation therapy. In E. Perecman (Ed.), Cognitive processing in the right hemisphere (pp. 229–240). New York, NY: Academic Press. Hough, M. S. (2010). Melodic intonation therapy and aphasia: Another variation on a theme. Aphasiology, 24(6–8), 775–786. Jeffries, K. J., Fritz, J. B., & Braun, A. R. (2003). Words in melody. An H2150 PET study of brain activation during singing and speaking. NeuroReport, 14, 749–751. Jungblut, M. (2009). SIPARI®: A music therapy intervention for patients suffering with chronic, nonfluent aphasia. Music and Medicine, 1(2), 102–105. Jungblut, M., Huber, W., Mais, C., & Schnitker, R. (2014). Paving the way for speech: Voice-training induced plasticity in chronic aphasia and apraxia of speech—Three single cases. Neural Plasticity, Article ID 841982. Kagan, A. (1998). Clinical forum: Supported conversation for adults with aphasia: Methods and resources for training conversation partners. Aphasiology, 12(9), 816–830. Lim, K. B., Kim, Y. K., Lee, H. J., Yoo, J., Hwang, I. Y., Kim, J. A., & Kim, S. K. (2013). The therapeutic effect of neurologic music therapy and speech language therapy in poststroke aphasic patients. Annals of Rehabilitation Medicine, 37(4), 556–562. Ludlow, C. L., Hiot, J., Kent, R., Ramig, L. O., Shrivastav, R., Strand, E., . . . Sapienza, C. M. (2008). Translating principles of neural plasticity into research on speech motor recovery. Journal of Speech, Language, and Hearing Research, 51, S240–S258. Meinzer, M., Elbert, T. E., Wienbruch, C., Djundja, G., Barthel, G., & Rockstroh, B. (2004). Intensive language training enhances brain plasticity in chronic aphasia. BMC Biology, 2, 20. 10 Miller, J., & Iglesias, A. (2012). Systematic analysis of language transcripts (SALT) (Version 2012 research version) [Computer software]. Middleton, WI: SALT software. Murray, L. L. (2004). Cognitive treatments for aphasia: Should we and can we help attention and working memory problems? Journal of Medical Speech-Language Pathology, 12(3), xxv. Nicholas, M., Sinotte, M. P., & Helm-Estabrooks, N. (2011). C-Speak Aphasia alternative communication program for people with severe aphasia: Importance of executive functioning and semantic knowledge. Neuropsychological Rehabilitation, 21(3), 322–366. Ozdemir, E., Norton, A., & Schlaug, G. (2006). Shared and distinct neural correlates of singing and speaking. NeuroImage, 33, 628–635. Robertson, I. H., Ward, T., Ridgeway, V., & Nimmo-Smith, I. (1994). The Test of Everyday Attention. Edmunds, England: Thames Valley Test Company. Saur, D., Lange, R., Baumgaertner, A., Schraknepper, V., Willmes, K., Rijintjjes, M., & Weiller, C. (2006). Dynamics of language reorganisation after stroke. Brain, 129, 1371–1384. Schlaug, G., Marchina, S., & Norton, A. (2008). From singing to speaking: Why singing may lead to recovery of expressive language function in patients with Broca’s aphasia. Music Perception, 25(4), 315–323. Schlaug, G., Marchina, S., & Norton, A. (2009). Evidence for plasticity in white-matter tracts of patients with Broca’s aphasia undergoing intense intonation-based speech therapy. Annals of New York Academy of Sciences, 1169, 385–394. Smith, K. U. (1973). Feedback of the motor system. In J. D. Maser (Ed.), Efferent organization and the integration of behavior. New York, NY: Academic Press. Sparks, R. W., & Deck, J. W. (2008). Melodic intonation therapy. In B. Hallowell & R. Chapey (Eds.), Introduction to intervention strategies in adult aphasia. Baltimore, MD: Lippincott, Williams & Wilkins. Sparks, R., Helm, N., & Albert, M. (1974). Aphasia rehabilitation resulting from melodic intonation therapy. Cortex: A Journal Devoted to the Study of the Nervous System and Behavior, 10(4), 303–316. Sparks, R. W., & Holland, A. L. (1976). Method: Melodic intonation therapy for aphasia. Journal of Speech and Hearing Disorders, 41, 287–297. Stahl, B., Henseler, I., Turner, R., Geyer, S., & Kotz, S. A. (2013). How to engage the right brain hemisphere in aphasics without even singing: Evidence for two paths of speech recovery. Frontiers in Human Neuroscience, 7, 35. Stahl, B., & Kotz, S. A. (2014). Facing the music: Three issues in current research on singing and aphasia. Frontiers in Psychology, 5, 1033. Thaut, M., McIntosh, G. C., & Hoemberg, V. (2015). Neurobiological foundations of neurologic music therapy: Rhythmic entrainment and the motor system. Frontiers in Psychology, 5, 1185. Van Eeckhout, P., & Bhatt, P. (1984). Rhythm, intonation, accentuation: The rehabilitation of severe non-fluent aphasia. Reeduc Orthophon, 22, 311–327. Wambaugh, J. L., & Martinez, A. L. (2000). Effects of rate and rhythm control treatment on consonant production accuracy in apraxia of speech. Aphasiology, 14(8), 851–871. Zumbansen, A., Peretz, I., & Hebert, S. (2014). Melodic intonation therapy: Back to basics for future research. Frontiers in Neurology, 5, 7. American Journal of Speech-Language Pathology • 1–11 Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx Appendix Central 90 Utterances from Each of Three Spontaneous Speech Samples Semester 1 1. Close 2. Come here 3. Sure 4. What is this? 5. This is one 6. Show me 7. Your self 8. No, no 9. Backwards 10. Okay (4) 11. But more 12. Not 13. That’s it 14. Take it down 15. No forget about it 16. You’re cold 17. My son 18. PJ 19. Go away 20. Hello 21. Yeh (3) 22. No, no it’s okay 23. Come or 24. That’s it 25. Really 26. Is that? 27. Come on 28. Where are you? 29. How are you? 30. How’s it going? 31. I’m okay 32. This 33. Give me one 34. Of course 35. Happy 36. Morning good morning 37. I need a drink 38. What you do? 39. And you now? 40. Do it again 41. Do it again 42. Yeh, go 43. No 44. I call and talk to him 45. We call 46. Hi, how are you? (3) 47. How was your day? 48. Hi, honey 49. I would say nice 50. Could I have a drink? Semester 2 Semester 3 Come one Let’s keep going What happened to you yesterday? Where is your dog? Is that new? Thank you No more Are you going to go? I don’t know which ones Yes I can One more Where do you live? What do you call it? How are you? Where is gonna get a girlfriend? You’re off, right? Where are you going? Where are you? Let’s go to the next one? You dropped something What’s the matter with you? Call me later I’m hungry and I want to have pizza Go ahead I wanna get one more Oh yeh (3) What do you like? So what’s new with you? Get out Yeh, I like this What did you say? I’m going with my wife Boy, oh boy, that was good I’ll go with this I’ll eat this Make me eggplant parmesan Oh, shut up No carry it We’re gonna have this one tonight You finished You’re welcome You pick That’s fine with me What’s the matter? Get outta here What did you say? Open the door Sounds wonderful Really anything How about we have eggplant parmesan What’re they doing here? I don’t know We’ll have to see I want tea No, I want coffee with milk What happened to Sue? What happened? I do Yes but no I just know it I could eat that forever My son’s name is PJ Yeh I know So what’s new? You are good Yes I did All the things Now this Heh, right I don’t know What’s the difference? Now, what is it again? Alright, I get this How do you like that? What else? Play it again Can I do it again? How do ya like that? Give me another That’s all I’ll make more Sue lives in Garden City She’s gonna be gone Whatever he makes How about our house? I want sushi Let’s do this now Where were you? See you tomorrow How did you do? Will meet you outside It was good How was your weekend? Are you kidding me? But it was good Keep it No it’s not We watch baseball One is baseball and the other is Mets and Yankees We are going Slavin & Fabus: A Multimodal Approach to MIT Downloaded From: https://ajslp.pubs.asha.org/ by a University of South Dakota User on 08/15/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx 11