However, most of these studies were case studies or case series in chronic aphasia Van der Meulen et al. To our knowledge, there are three non-randomized group studies on MIT in chronic aphasia. In two of them, data from a control group are lacking: Bonakdarpour et al. Cortese et al. A third, recent group study was done by Wan et al.
They examined the effects of MIT in a group of 11 chronic non-fluent English-speaking aphasic patients and reported improved communicative effectiveness and verbal fluency after MIT, associated with structural changes in the white matter underlying the right inferior frontal gyrus. However, they do not report any statistical analyses comparing therapy success in the treated and untreated groups. Despite its widespread use, the quality of the evidence remains poor Hurkmans et al.
The results of the trial in subacute aphasia have been published earlier Van der Meulen et al. In summary, in subacute severely non-fluent aphasic patients MIT yielded improved repetition of trained as well as untrained utterances. In addition, we found indications of a generalization toward improved verbal communication in daily life. Thirdly, treatment intensity and time post stroke were related to MIT success, but no patient-related determinants were observed.
In the present study, we used the same study design to evaluate MIT efficacy in chronic aphasia and examine whether the results observed in subacute aphasia could be replicated in a chronic aphasic population. We used a computer-generated allocation sequence, placed in consecutively numbered sealed opaque envelopes. Patients in the control group received no individual aphasia treatment.
All participants or a close relative gave written informed consent. For obvious reasons, patients and therapists could not be blinded to treatment conditions. The researchers assessing and scoring the tests were blinded for group allocation and test moment. Between and , patients were recruited through the Dutch National Association of Persons with Aphasia and from several outpatient aphasia centers in the Netherlands.
MIT candidacy was based on earlier studies Sparks et al. Exclusion criteria were: prior stroke resulting in aphasia, bilateral lesion, intensive MIT prior to start of the study, severe hearing deficit, psychiatric history relevant to language communication. The program consisted of several levels with increasing difficulty. At the first level target utterances were short, formulaic phrases e. As the therapy proceeded, the trained utterances became more complex and less frequent in daily life e.
For each utterance, a melodically intoned pattern was developed, based on the natural prosody of the utterance [see Sparks et al. Utterances were trained in a hierarchy of steps: patients and SLTs first produced the melodically intoned utterance together, while hand tapping the rhythm of the utterance.
Gradually, the SLT provided less support and the intoned pattern was replaced by the normal prosody. The final step consisted of independent spoken production of the target utterance. The therapy was given by experienced SLTs in nine rehabilitation centers and aphasia centers.
The protocol comprised a list of Dutch target utterances for each level, along with their intoned pattern. In addition to this standard set, the SLT and the patient or a close relative developed a set of personally relevant utterances, such as utterances related to hobbies or favorite food.
Patients or a close relative recorded the time spent on homework assignments and SLTs recorded therapy time for each session. In the control condition, no individual treatment was offered. Many of the patients were recruited from aphasia centers, where they participated in aphasia groups, offering opportunities for social interaction, as well as low intensity group therapy to support verbal and non-verbal communication e.
Participation in these groups was allowed in both conditions. The MIT repetition task was designed for our two MIT trials and comprised 11 trained and 11 untrained matched sentences. When evaluating the effect of aphasia treatment, it is crucial to distinguish between improvement on trained items direct effect , improvement on non-trained items indirect effect , and generalization to functional language use Van der Meulen et al. In this study, we selected outcome measures to evaluate the effect of MIT at different levels: 1 improvement in repeating trained items MIT repetition task, trained items , 2 generalization to untrained items MIT repetition task, untrained items and AAT subtest repetition , 3 generalization to word retrieval AAT subtest naming , 4 further generalization to verbal communication ANELT and Sabadel.
The goal of MIT is to improve verbal fluency and connected speech, i. In addition to these measures for language production, we also included a language comprehension task AAT subtest auditory comprehension because several studies have reported improved auditory comprehension after MIT Sparks et al. Since no data from chronic aphasic patients were available, we performed an a priori power analysis based on Sabadel Van Eeckhout, data from subacute severe non-fluent patients participating in a small pilot study Paul and Pijnenburg, , unpublished.
For this small subacute sample, the effect size was 0. Because the data were not normally distributed, we used non-parametric tests. The efficacy of MIT was evaluated for each outcome measure at T2 by means of univariable regression analyses, adjusted for baseline T1 , with group assignment experimental vs.
Because there was heterogeneity in both groups with regard to the severity of the aphasia, all regression analyses were also adjusted for aphasia severity, as expressed by the score on the AAT Token Test. We further examined whether, as a group, patients showed language improvement after MIT. For this, we used the Wilcoxon signed rank test to examine change from pre-MIT scores T1 experimental group, T2 control group to post-MIT scores T2 experimental group, T3 control group in all patients.
The influence of these variables on all outcome measures was examined through univariable regression analyses. For these analyses, we used the post-MIT scores of all patients T2 experimental group, T3 control group as the dependent variable, adjusted for the pre-MIT scores of all patients T1 experimental group, T2 control group.
All analyses were performed on an intention-to-treat basis using SPSS version Of the 44 chronic aphasic patients referred to the study, 17 Ten participants were allocated to the experimental group that received MIT first and 7 to the control group receiving MIT after a waiting period of 6 weeks.
We were unable to achieve the aim of 15 patients per group. Inclusion took considerably longer than anticipated and, after extending the inclusion period once, no further funding was available. There were no drop-outs in the experimental group. In the control group there was one drop-out after the assessment at T2.
This patient did not start MIT for personal reasons. There were no significant differences between groups. Mean scores on all outcome measures T1 and T2 and group comparisons per outcome measure at T2.
No significant improvement was observed on any of the other outcome measures. This observation is difficult to explain, since this group did not receive any language production treatment. On all other outcome measures no significant effect of MIT was observed. After adjustment for aphasia severity, as expressed by the score on the AAT Token Test at baseline, outcomes did not change.
Visual inspection of these graphs shows a similar pattern after MIT in the control group i. As a group, patients improve significantly on both trained and untrained items after MIT. As can be seen in this table, there is a large amount of individual variation, with some patients showing no language improvement at all patients 4, 6, 12, and 14 while others benefit from MIT. Further, after MIT, repetition of trained items improved in 8 out of the 16 participating patients, but generalization to untrained items or functional language only occurred in a small subset of these patients for instance patients 2, 7, and 9.
No significant differences between responders and non-responders were observed. Higher intensity yielded greater improvement on trained items. None of the other variables was significantly related to MIT success.
We investigated its efficacy at several levels, and found that, as a group, patients improved on both trained and untrained items after MIT.
When language improvement after MIT in the experimental group was compared to language improvement in the untreated control group, MIT appeared to be only effective on the repetition of trained material, without generalization effects to untrained material, word retrieval or verbal communication in daily life.
This effect was transient: 6 weeks after finishing MIT, patients had been unable to maintain their MIT-related language gains. The study was, however, underpowered and the results therefore have to be considered as preliminary. This is all the more important, because our results contrast with findings from previous studies, in which long term improvement of naming and verbal communication was reported Bonakdarpour et al.
Also contrary to some studies Sparks et al. There are several possible explanations for these differences. First of all, the lack of generalization effects might be due to the small sample size and the unequal number of patients in the two groups. We used the design of a RCT, but because the study was underpowered, potential positive effects of MIT might have remained unnoticed.
Alternatively, the results of our study, albeit small, suggest that MIT has only a limited effect in chronic aphasia. The previous case studies show that individual chronic aphasic patients do benefit from MIT, but at the group level, its effect is small and temporary. Note that there is a considerable inter-subject variation in our study, with some patients obtaining substantial gains on functional tasks, while others did not benefit at all from MIT.
All participants in our study fitted the criteria for MIT-candidacy as defined in the literature Sparks et al. In order to implement MIT more effectively, stricter criteria are needed.
We were, however, unable to find any patient-related variables that were significantly related to MIT success. Hence, the question which patients benefit most from MIT remains open. The only variable significantly related to improvement after MIT was treatment intensity.
More intensive training yielded larger improvement on trained items. This is in line with other studies and reviews showing that higher intensity of aphasia therapy yields larger language improvement Robey, ; Bhogal et al. It is possible that a longer and more intensive treatment would have yielded generalization to verbal communication.
However, not all aphasic patients are able to engage in an intensive language production therapy for such a long period of time. The latest Cochrane review on aphasia therapy showed that studies with high intensity treatment have a larger number of drop-outs than studies in which therapy is provided less frequently Brady et al. In our study, there were no drop-outs, suggesting that following MIT in this intensity is feasible, even in severe non-fluent aphasic patients.
The optimal timing of aphasia therapy is an important topic in current aphasia rehabilitation research. Although several studies point to a larger effect of aphasia therapy if applied in the first 3 months after stroke, Robey, ; Bakheit et al. The contradictory findings may be related to differences in study populations, e.
Studies examining the efficacy of one specific treatment at different stages post stroke are rare. The beneficial effects of MIT observed in the present study with chronic stroke patients are less favorable than the effects in the subacute stage post stroke, where MIT yielded improved repetition of trained as well as untrained items, with a trend to improved verbal communication Van der Meulen et al. This difference has to be interpreted cautiously. It may suggest that MIT is more effective in the subacute stage post stroke.
However, our data do not allow statistical analyses comparing the effect of MIT in both stages post stroke. Carefully designed studies with large sample sizes are needed to determine the optimal timing of MIT.
The small sample size of this study is a clear limitation and confirmation from larger studies is required. Further, we were unable to collect data on the size and location of the lesion of each participant as well as on the severity of their stroke. It has been suggested that these variables are related to MIT success Lazar et al. Hence, this information might have led to a better definition of MIT candidacy.
The results of this study suggest that the effect of MIT in chronic severe non-fluent aphasia is limited. At the same time, these results indicate that the expectations related to MIT in chronic aphasia should not be raised too high. IV has contributed substantially to the design of the study, conducted the research data acquisition, analysis and interpretation of the data. They have revised earlier versions of the manuscript critically. All authors approve this version to be published and agree to be accountable for all aspects of the work.
The publisher had no influence on the data collection, methods, interpretation of the data, and final conclusions. Rijndam rehabilitation Institute will receive revenues of the manual. All the other authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We thank all therapists in the participating centers for their participation and commitment. This study was supported by the Stichting Rotterdams Kinderrevalidatie Fonds Adriaanstichting grant no. National Center for Biotechnology Information , U. To make it easier, write down all the chosen phrases and sentences in order of syllable length, then underline the naturally emphasized words or syllables to determine your melody for intonation.
These elements are integral to the success of MIT. Studies that compared MIT to a control therapy without intoning and tapping indicated better results for MIT, as well as more global activation on fMRI studies than the control. This component can be particularly beneficial for individuals with AOS. By silently intoning the target phrase, it is thought to activate a higher-level cognitive-linguistic representation, which gives the speaker an additional attempt to correctly sequence motor commands.
It is vital for clients to be able to distinguish the difference between the target phrase and their own speech production. The added benefit to intoning allows for more isolated phonemes that are heard distinctly and sustained phonemes that provide time to think ahead to the next sound. Auditory-motor feedback training may begin with listening back to a recording of the target and end with self-evaluation during speech. Though Melodic Intonation Therapy has been studied over the past several decades, its effects and mechanisms continue to be questioned in reviews.
There are other music-based therapies offered to stroke survivors that are not MIT, but are often grouped with it. This article explains the protocol most speech-language pathologists use to provide Melodic Intonation Therapy. Visually signal the client to listen. Hum the target phrase alone one time then intone sing the phrase two times with hand-tapping, ask the client to rehearse in their head while listening. Signal for the client to join in unison repetition of the target phrase with hand-tapping.
Begin with unison intoning of the target phrase with hand-tapping. Fade your vocal participation but continue hand-tapping. Signal the client to listen. Intone the target phrase alone with hand-tapping. Signal the client to repeat the target alone with the assistance of hand-tapping. A phonemic cue can be provided if the client has difficulty initiating the target. If the client needs assistance, you may tap out the syllables of the target response. Think this method might be useful? In addition to receiving your free download, you will also be added to our mailing list.
You can unsubscribe at any time. Using this app at home can give people with aphasia a chance to practice speaking using highly-intoned speech in unison with a model that fades out, just like MIT performed by a clinician. Touch the Settings button in the top right corner of the home screen.
Select the Phrases activity. It contains hundreds of phrases and sentences that people need to say every day. Then select the phrases you wish to practice. They are sorted by syllable length into 7 levels. When starting with MIT it is recommended to choose phrases from levels 1 — 4.
Apraxia Therapy contains 6 steps, including listening, tapping, unison intoning, faded intoning, and independent intoning. Encourage the user to continue to tap during all steps of the protocol.
Auditory-motor feedback training is a fundamental part of the self-monitoring process for both aphasia and apraxia that promotes insight and awareness in real-time. Bonus features of using the Apraxia Therapy app:. Speak more easily and build independence with video-assisted speech therapy to help people with apraxia after a stroke. Melodic Intonation Therapy has been used by speech-language pathologists since the s when Nancy Helm-Estabrooks, Martin Albert, and Robert Sparks developed the protocol.
MIT is one of the most well-researched treatments for severely impaired verbal expression related to aphasia. A detailed overview with sample stimuli and data trackers is also available from Neuro Speech Solutions.
If you're looking for information on how to treat Wernicke's aphasia, it's probably because there isn't much. Learn where to start and what to do here. Read More. A step-by-step guide to doing phonological treatment for agraphia, an evidence-based speech therapy technique to improve writing in people with aphasia.
Free handout to guide you through identifying and training partners. A step-by-step guide to doing Spaced Retrieval SR , an evidence-based therapy technique to improve recall of information for people with memory impairments.
A step-by-step guide to doing Multiple Oral Re-Reading MOR , an evidence-based speech therapy technique to improve reading fluency in people with aphasia and alexia. A step-by-step guide to doing Response Elaboration Treatment, an evidence-based speech therapy protocol to improve sentences for people with aphasia. A step-by-step guide to doing Anagram, Copy, and Recall Treatment ACRT , an evidence-based speech therapy technique to improve writing in people with aphasia and agraphia.
A step-by-step guide to doing Phonological Components Analysis, an evidence-based aphasia therapy protocol to improve anomia after stroke or brain injury.
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