June 5, 2012 Features

Getting in Tune With Clients With Aphasia

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All 48-year-old June could say when first seen at the Boston VA hospital months after her left-hemisphere stroke was "ni-ni-na-na." But the former Army nurse said it with great intonation, says Nancy Helm-Estabrooks, who in 1972 had just begun working on the hospital's renowned aphasia unit.

Active ingredients of MIT treatment include slow, continuous intonation of words and hand-tapping syllables.

Active ingredients of MIT treatment include slow, continuous intonation of words and hand-tapping syllables.

"If you've worked extensively with people with aphasia, you've seen this sort of entrenched stereotypy," Helm-Estabrooks says. "June would ask questions, 'ni-ni na-na?' She'd express distress with loud versions of 'ni-ni na-na!' Or she might point to your bracelet and say, 'ni-ni na-na' in a complementary fashion to tell you that she liked it."

Helm-Estabrooks was assigned to give June the Boston Diagnostic Aphasia Examination, on which she produced no words whatsoever. "She 'ni-ni na-na'ed' her way through the 'cookie theft' picture, naming, repetition, even through counting and the alphabet, despite relatively preserved auditory comprehension," Helm-Estabrooks says.

Then, the day after the test, Helm-Estabrooks saw June do something that stopped her in her tracks: With her wheelchair pulled up next to a pianist visiting the unit, June was singing every word of the standards he played. It turned out that, as a teenager, June had played sheet music for customers at the Five and Dime. Now, here she was singing those songs like no time had passed.

"It was startling," Helm-Estabrooks says. "I had been so frustrated in testing her, thinking, 'What on earth am I going do to help her speak?' So I ran and I got two colleagues. I said, 'We've got to be able to do something about this. We've got to use that ability to get June speaking again.'"

The three of them—Robert Sparks, head of the hospital's Speech Pathology and Audiology Section, Helm-Estabrooks, and Martin Albert, a behavioral neurologist—wanted to see if they could harness June's musical words to say real words. They tried to have her count to 10 to the tune of "Happy Birthday." But it didn't work. She'd sing "one, two, three, four," to the tune and then lapse back into the usual words for "Happy Birthday."

"We couldn't separate the words from the song to make them productive because the words to familiar songs are attached to them and come automatically," Helm-Estabrooks says.

This team wasn't the first to investigate the singing-aphasia connection. A review of the literature shows it had been written about as early as 1745 (Benton & Joynt, 1960). Singing as aphasia treatment was mentioned at the turn of the 20th century in a seminal aphasia rehabilitation article published by Charles Karsner Mills in 1904 in the Journal of the American Medical Association. In a 1945 book chapter, Ollie Backus discussed the use of singing and rhythm for aphasia rehabilitation with World War II veterans (Backus, 1945). But in 1972, nobody had yet developed an organized music-derived treatment method, so the Boston VA team sought to develop one through its work with June.

"The idea was to help people with aphasia access the brain's non-regular speech output systems through the musical elements of stress patterns, rhythm, and intonation," Martin Albert explains. "Nancy was the perfect person to work with as we played with these ideas. She was able to transform some of those neurologically based ideas into meaningful systematic programs of speech therapy."

The team's first step was to separate words from a familiar tune and attach them to two rhythmically spaced, unassociated notes. They tried to teach June to say, "John ate an apple," tapping out the syllables with their hands as they "sang" the two notes.

"And we could get her to do that," Helm-Estabrooks says. "Then we produced the sentence in repetition and with fading, and we could get her to hold on to those words. We were able to break her stereotypy. But it took a lot of work, a lot of trial and error to refine and develop the method."

Next, they helped June melodically intone more practical phrases like "close the door" or "open the window." Over time, she needed less and less help with the intoning and could express herself unaided.

"Near the end of her stay, I asked her what she was doing next week, and she said, 'I'm going home!'" Helm-Estabrooks says. "Amusingly, when I asked her whether she thought we'd helped her, she said, 'Mmmm. Maybe.'"

Based on June's success, the team developed the treatment program melodic intonation therapy (MIT)—so named by Brown University neurolinguist Shelia Blumstein, a researcher at the Boston Aphasia Center. The hierarchically structured program is divided into three levels. In the first two levels, multisyllabic words and short, high-probability phrases are musically intoned. The third level introduces longer or more phonologically complex sentences. These longer sentences first are intoned, then produced with exaggerated speech prosody, and finally, spoken normally. On all intoned phrases, the clinician assists the person in tapping his or her left hand once for each syllable. Items are intoned slowly, with continuous voicing, using simple high-note/low-note patterns based on the normal speech prosody of the phrase.

After successfully using the method to break stereotypies in two men with aphasia, the three clinicians published their results in the Archives of Neurology (Albert, Sparks, & Helm, 1973). A year later, they published a paper on the results of the method with nine patients in Cortex (Sparks, Helm, & Albert, 1974).

The publications garnered media attention, and the method caught on among clinicians treating aphasia. However, many clinicians weren't using it with appropriate kinds of patients. "Some, but not all, patients with non-fluent aphasia are good candidates, usually those with relatively preserved comprehension," Albert says. "What's interesting is that the deficit can be quite severe—that is, severity is not a limiting factor. And the deficit may have been present for a long time, even years."

But to be effective, MIT must be used correctly, and, at first, it frequently wasn't, says Helm-Estabrooks. For example, many clinicians were producing the phrases in a staccato fashion, instead of with continuous voicing, or were not tapping the person's left hand for each syllable.

To help clinicians administer the method correctly, Helm-Estabrooks and Sparks headed out on the road, delivering workshops. Helm-Estabrooks and colleagues also wrote manuals for the method, accompanied by a videotape, and published it (Helm-Estabrooks, Nicholas, & Morgan, 1989; Helm-Estabrooks & Albert, 2004).

To this day, MIT continues to be widely used, with positive results with the right candidates, Helm-Estabrooks says. She notes that clinicians used the method, along with others, in the rehabilitation of former Congresswomen Gabby Giffords (see main interview).

Bridget Murray Law, managing editor of The ASHA Leader, can be reached at bmurraylaw@asha.org.

cite as: Murray Law, B. (2012, June 05). Getting in Tune With Clients With Aphasia. The ASHA Leader.


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

Backus, O. L. (1945). The rehabilitation of persons with aphasia. In R. West, L. Kennedy, & A. Carr (Eds.), The rehabilitation of speech (rev. ed.), (pp. 439–466). New York: Harper Bros.

Benton, A. L., & Joynt, R. J. (1960). Early descriptions of aphasia. Archives of Neurology, 3, 205–222.

Helm-Estabrooks, N., Nicholas, M., & Morgan, A. (1989). Melodic intonation therapyprogram. Austin, TX: PRO-ED.

Helm-Estabrooks, N. & Albert, M.L. (2004). Melodic intonation therapy. (pp. 221–234) Manual of Aphasia and Aphasia Therapy. Austin, TX: PRO-ED.

Mills, C. K. (1904). Treatment of aphasia by training. Journal of the American Medical Association, 43, 1940–1949.

Sparks, R., Helm, N., & Albert, M. (1974). Aphasia rehabilitation resulting from melodic intonation therapy. Cortex, 10, 303–316.


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