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1st JOURNAL CLUB2013-2014

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THE EFFECTS OF MODIFIED MELODIC INTONATION THERAPY ON

NONFLUENT APHASIA:A PILOT STUDY

DWYER CONKLYN, ERIC NOVAK, ADRIENNE BOISSY, FRANCOIS BETHOUX AND KAMAL CHEMALIB

JOURNAL OF SPEECH, LANGUAGE AND HEARING RESEARCH; VOL.55; 2012

Guide:

Mr. Abhishek,Asst Professor,

Dept of SLP

Presenters:

Hemy Elsa Abraham,Neethu K K,

I MASLP

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Aphasia refers to the disturbance of any or all of the skills, associations and habits of spoken or written

language, produced by injury to certain brain areas that are specialized for the function.

Goodglass and Kaplan(1983)

DEFINITION

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CLASSIFICATION

OF

APHASIA

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Wernicke’s aphasia

Transcortical sensory

aphasia

Conduction aphasia

Anomic aphasia

1.FLUENT APHASIA:

Broca’s aphasia

Transcortical motor aphasia

Mixed transcortical aphasia

Global aphasia

2.NON FLUENT APHASIA

Wernicke(1874), Geshwind (1969, 1971), and Benson(1967)

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SYNONYMS

• Expressive aphasia, anterior aphasia, efferent motor aphasia, agrammatic aphasia, verbal aphasia

LESION

• Left middle cerebral artery territory, directly or indirectly affecting the speech area commonly referred to as Broca’s area (Broadmann’s area 44,45 )

EFFECT

• Dominated by reduction or suppression of speech output with relative sparing of auditory comprehension

BROCA’S APHASIA

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CHARACTERISTICS

OF

BROCA’S APHASIA

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word-finding difficulty

impaired fluency

mostly preserved comprehension

cognitively intact

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impaired reading and writing

reduced syntactic capabilities

Speech output are often slow, effortful, agrammatic, and telegraphic.

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PREVALENCE

OF

APHASIA

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Approximately 800,000 people

have a stroke each year, and of these, 25%–35% develop aphasia (Dickey et al., 2010; National Stroke Association

Website, n.d.).

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Therapeutic Approaches

for

Non fluent Aphasia

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• Behavior modification

• Cognitive therapy

• Combinations of Behavior

modification and Cognitive therapy

• Pragmatic aproaches

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Thematic Language Stimulation

Melodic Intonation Therapy

Helm Elicited Program for Syntax Stimulation

Voluntary Control of Involuntary Utterances

Response Elaboration Training

De-blocking

Language Oriented Treatment

Promoting Aphasic’s communicative effectiveness

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Melodic intonation therapy

A treatment technique developed for expressive

aphasia rehabilitation which utilizes a patient’s

unimpaired ability to sing, to facilitate spontaneous

and voluntary speech through sung and chanted melodies which resemble natural speech intonation

patterns. Sparks et.al 1974

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Candidacy for MIT

Auditory comprehension should be better

than verbal expression

Fairly good emotional stability

A reasonable good attention

span

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Levels of MIT

ADVANCED

INTERMEDIATE

ELEMENTARY

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LIMITATIONS OF MIT

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it takes 75–90 hour-long sessions to see the full benefits of

this treatment

Beginning treatment with 1 or

2 small words or phrases of 2-3

syllables

Use of small

range of pitches.

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Modified melodic intonation therapy

expands upon the original MIT protocol. modifications have the potential to make this treatment more efficient.Introducing MMIT within first few weeks after a stroke help to facilitate the recruitment, leading to faster and more meaningful recovery.

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The next modification is the use

of full phrases during initial

treatment to allow for access to

those intact areas that

enable patients to

sing full lines of song.

The first change is

that therapists compose

and employ novel

melodic phrases

that closely match the prosody of

the phrases in both

pitch and rhythm.

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AIM

To determine efficacy of MMIT in individuals with Broca’s aphasia

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Broca’s aphasia patients on an acute care unit receiving MMIT will demonstrate a greater positive change in post-test scores after one treatment session when compared to a control group without treatment

Those patients receiving MMIT will demonstrate greater positive change from their pre-test scores over multiple sessions when compared to the control group.

Hypothesis

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METHOD

Participants:

» All potential participants were assessed by their treating neurologist using the National Institutes of Health Stroke Scale (NIHSS)

» Most potential participants were assessed by a speech language pathologist prior to being approached for this study.

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Inclusion criteria:

18 years of age or older

damage to the left MCA

territory of the brain

mild to severe aphasia

no previous documented infarcts, any dysarthria

noted to be less than their

aphasia

ability to sing at least 25% of

the words of “Happy

Birthday”, and demonstrated self-awareness

of speech deficits

ability to follow

commands

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Exclusionary

criteria

severe cognitive

deficits

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Speech Assessment (Pre/Post Test)

The Western Aphasia Battery has two subtests that were deemed appropriate,

Repetition Responsiveness

Both sections are designed to elicit short answers.

Because of the length of the phrases utilized in MMIT it was decided not to use the exact subtests from the WAB , but instead to design two similar tasks that would elicit longer responses.

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Responsive section …

(a)“When you are thirsty and need a drink of water, what do you say to the nurse when she comes in?”

(b) “If I come in and introduce myself: ‘Hello, my name is _____,’ how do you introduce yourself?”

(c) “If you’re sitting here and you realize you need to urinate or have a bowel movement, what do you say when you press the call button?”

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Scoring

• 0–3 scores per question• similar to WAB with the addition of a score of 3

as the questions were designed to elicit longer responses than those in the WAB

• the score range for the responsive section 0–9.• The three statements in this section were

always given first in an attempt to lessen the likelihood that the participants might remember one of the phrases used in the repetition section.

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Repetition section…

(a)“I need a drink of water” (b)“Hello, my name is _____________” (c) “I have to go to the bathroom”– each of which could correspond with

the questions in the responsive section. – Participants were instructed to repeat

the exact phrase as it was spoken to them.

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Scoring

• Identical to that used in the WAB• Score of 2 was given per correct word• the range for the repetition section 0–36• for a total possible score of 0–45 Each section’s scores were weighted so that

they had equal standing in an adjusted total score that also ranged from 0 to 45

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Procedure

• MMIT was administered by a Board-Certified Music Therapist trained in the technique.

• Those participants received a 10-15 minute music therapy session directly following their pre-test, consisting of the music therapist teaching the participant a melodic phrase.

• The first session only consisted of the first phrase listed above (I need a drink of water). The music therapist spoke the phrase 1 time when introducing the procedure to the participant, after which the participant only heard the phrase sung.

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The music

therapist

modelled the

phrase multiple

timesInstructed the participant to

sing the phrase.

• music therapist assisted the participant in tapping

• to provide an added cue

• 2nd

session never consisted of more than the first two phrases

• 3rd session the participant had the possibility of learning the third phrase.

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To control for possible placebo

effects in the treatment group

participants enrolled in the control group

received 10-15 minutes with the music therapist

Discussed the participant’s impairment, different forms

of treatment, different outcomes and various issues,

such as depression and withdrawal.

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Study design

• The study followed a randomized controlled single blind design.

• The randomization table was generated by a biostatistician prior to the start of the study.

• Random assignment was provided by the music therapist following enrollment by the nursing manager who had no prior knowledge to the ordering of participants.

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Statistical analysis

• Descriptive statistics were generated (mean, standard deviation, frequency counts).

• Each primary measure was evaluated at visits 1, 2, and 3, separately. For each visit, the change score (post less pre) within group was tested.

• A two-sample t-test was used to compare the change between groups.

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Results

Parameters considered for comparison

• Within control group and experimental group

• Between control group and experimental group

across repetition scores and responsive scores

• Changes observed after visit 1 and visit 2

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14 contr

ol group

16 treatment group

30 participant

s

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• Out of the 14 controls, 10 had both pre and post scores at visit 1, 8 had

pre and post scores at visit 2. For the treatment group, 14 out of the 16

had both pre and post scores at visit 1, 9 had pre and post scores at visit

2.

• The difference in change in adjusted total score between the treatment

and control groups was also significant at Visit 1

• Except for repetitive score, the treatment group change was always

greater than that of the control group, but only the responsive score

change was found to be significantly greater.

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Discussion

• In comparing Modified Melodic Intonation Therapy

(MMIT) versus no treatment in acute stroke patients

with non-fluent aphasia, there were significant

immediate improvements in speech output after one

session of MMIT training, supporting their first

hypothesis.

• Both groups showed significant improvements

when comparing their pre-test scores from visit

1 with those from visit 2, the control group

showed an improvement in their repetition

scores, while the treatment group showed similar

gains in repetition and responsiveness scores,

partially supporting our second hypothesis

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Improvements in speech output

Damage to the left-brain speech areas is limited

Recruitment of right-brain structures

assists in the facilitation as left

regaintheir function

Damage to the left brain speech areas is severe, or

total

Right brain structures attempt to “take

over” the facilitation of speech processes.

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Right brain recruitment process

Efficient and

consistent.

Early interventio

n

Smoother transition

MMIT

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• Of the 16 participants who received MMIT training as part of the treatment group, all but one participant were able to sing at least part of the first phrase ‘I need a drink of water’.

• Of the remaining 15 participants who were able to sing at least part of the phrase, 12, or 75%, sang at least one complete and accurate phrase during the first session.

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providing MMIT training early

lessen frustration and withdrawal

Patient can produce

meaningful and accurate words.

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•

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Merits

Help to lessen frustration and withdrawal.

Evidence based study.

Help to make the rehabilitation more efficient and consistent.

Limitations

• Not explaining regarding the patients language ability such as bilingual or mono lingual.

• Not included the detailed demographic data with respect to age and literacy.

52Cont...

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• Scheduling challenges present in hospital stay limited the data collected.

• Relatively small sample size and absence of long-term follow-up.

• They did not perform a precise assessment of the brain damage caused by the stroke.

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ConclusionsDemonstrates the feasibility of MMIT and suggests it has

short-term beneficial effects.

Demonstrates significant positive results in patients’ overall ability to verbally respond

Follow up research is needed to identify MMIT’s long term potential.

Role of speech language therapist is not specified.

It is a pilot study and not carried out in a full pledged manner.

The number of therapy sessions required for optimization of therapy is not specified.

Ethically single blind study is not well appreciated method to study therapy efficacy..

Critical analysis

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References…….

• Melodic intonation therapy for aphasia. Archives of Neurology, 29,130–131,Albert, M. L., Sparks, R. W., & Helm, N. A. (1973)

• Recovery from nonfluent aphasia after melodic intonation therapy: A PET study. Neurology, 47, 1504–1511, Belin, P., Van Eeckhout, P., Zilbovicius, M., Remy, P., Francois, C., Guillaume, Samson (1996).

• Music and language side by side in the brain: A PET study of the generation of melodies and sentences. European Journal of Neuroscience, 23, 2791–2803, Brown, S., Martinez, M. J., &Parsons, L. (2006).

• DTI tractography of the human brain’s language pathways. Cerebral Cortex, 18, 2471–2482. Ethofer, T., Anders, S., Erb, M., Herbert, C., Wiethoff, S., Glasser,M.F.,&Rilling, J. K. (2008).

• Treatment for aphasia following stroke: Evidence for effectiveness. International Journal of Language & Communication Disorders [Supplement], 33, 158–161.Greener, J., Enderby, P., Whurr, R., & Grant, A. (1998).

TOPIC OPEN FOR

DISCUSSION

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