THE NEUROSCIENCES AND MUSIC III: DISORDERS AND PLASTICITY

Melodic Intonation Therapy

Shared Insights on How It Is Done and Why
It Might Help
Andrea Norton, Lauryn Zipse, Sarah Marchina,
and Gottfried Schlaug
Music, Stroke Recovery, and Neuroimaging Laboratory, Beth Israel Deaconess
Medical Center/Harvard Medical School, Boston, Massachusetts, USA

For more than 100 years, clinicians have noted that patients with nonfluent aphasia are
capable of singing words that they cannot speak. Thus, the use of melody and rhythm
has long been recommended for improving aphasic patients fluency, but it was not until
1973 that a music-based treatment [Melodic Intonation Therapy (MIT)] was developed.
Our ongoing investigation of MITs efficacy has provided valuable insight into this
therapys effect on language recovery. Here we share those observations, our additions
to the protocol that aim to enhance MITs benefit, and the rationale that supports them.

Key words: Melodic Intonation Therapy; nonfluent aphasia; language recovery; brain
plasticity; music therapy

Introduction ter MIT (based on the descriptions of Helm-

Estabrooks et al.3,4 ), share our additions to the
According to the National Institutes for protocol, and explain how it may exert is ther-
Health (NINDS Aphasia Information Page: NINDS, apeutic effect.
2008), approximately 1 in 272 Americans suf-
fer from aphasia, a disorder characterized by
the loss of ability to produce and/or com- What Exactly Is MIT?
prehend language. Despite its prevalence, the
neural processes that underlie recovery remain The original program of music intonation
largely unknown and thus have not been specif- therapy is designed to lead nonfluent aphasic
ically targeted by aphasia therapies. One of the patients (Fig. 1) from intoning (singing) simple,
few accepted treatments for severe, nonfluent 23 syllable phrases, to speaking phrases of 5
aphasia is Melodic Intonation Therapy (MIT),16 or more syllables1,3,4 across three levels of treat-
a treatment that uses the musical elements of ment. Each level consists of 20 high-probability
speech (melody and rhythm) to improve expres- words (e.g., water) or social phrases (e.g., I
sive language by capitalizing on preserved func- love you) presented with visual cues. Phrases
tion (singing) and engaging language-capable are intoned on just two pitches, melodies
regions in the undamaged right hemisphere. are determined by the phrases natural prosody
In this chapter, we describe how to adminis- [e.g., stressed syllables are sung on the higher
of the 2 pitches, unaccented syllables on the
lower pitch (Fig. 2)], and the patients left hand
Address for correspondence: Gottfried Schlaug, M.D., Ph.D., Beth is tapped 1 per syllable. Although it may ap-
Israel Deaconess Medical Center, Department of Neurology Palmer
127, 330 Brookline Avenue, Boston, MA 02215. Voice: 617-632-8917;
pear that the primary difference between the
fax: 617-632-8920. [email protected] levels is phrase length, the more important
The Neurosciences and Music III: Disorders and Plasticity: Ann. N.Y. Acad. Sci. 1169: 431436 (2009).
doi: 10.1111/j.1749-6632.2009.04859.x  c 2009 New York Academy of Sciences.

431
432 Annals of the New York Academy of Sciences

Figure 1. Ideal candidates for Melodic Intonation Therapy.

Summarized from Helm-Estabrooks et al .3

Figure 2. Melodic phrase construction: Phrases are sung on just two pitches; melodic
contour is determined by the natural prosody of speech (e.g., stressed syllables are sung
on the higher of the two pitches); phrases increase in length and difficulty (Elementary: 23
syllables; Intermediate: 46 syllables; Advanced: 69 syllables) as patients progress through
the three levels of treatment. Summarized from Helm-Estabrooks et al .3

distinctions are the administration of the treat- across the United States) shows a number of
ment and degree of support provided by the therapists using the technique, and no two ses-
therapist (Figs. 35). sions are alike. Some use 2 pitches separated
Interestingly, there appear to be almost by a perfect 4th or 5th, while others write a
as many interpretations of the original pro- new tune for each phrase using as many as 78
tocol as there are people using it. While pitches in a specified key. Still others accom-
early reports6,7 depict phrases using 3 pitches pany their patients on the piano, use familiar
rather than the originally specified 2, anecdo- song melodies, or rapidly play 45 notes up
tal evidence (DVDs from prospective patients and down the patients arm as they sing words
Norton et al.: Melodic Intonation Therapy 433

Figure 3. Elementary Level steps and procedures in MIT.

Summarized from Helm-Estabrooks et al .3

or phrases. While all such variations might higher of the 2 pitches, unaccented syllable(s)
have the potential to engage right-hemisphere on the lower pitch (Fig. 2). The starting pitch
regions capable of supporting speech, it may should rest comfortably in the patients voice
be just such complex interpretations of the pro- range, and the other pitch should be a minor
tocol that prevent therapists with little or no 3rd (3 semitones) above or below (middle C and
musical background from using the treatment. the A just below it works well for most peo-
Thus, we aim to simplify the process so any ple). For those unfamiliar with this terminol-
therapist can administer it, and well-trained ogy, think of the childrens taunt, Naa-naa
patients and caregivers can learn to apply the Naa-naa. These 2 pitches create the interval of
method when intensive treatment ends. Be- a minor 3rd, which is universally familiar, re-
cause the focus is not on performance, one does quires no special singing skill, and provides a
not need to be a musician or even a good singer good approximation of the prosody of speech
to administer or participate in this treatment. that still falls into the category of singing.
The goal is to uncover the inherent melody in
speech to gain fluency and increase expressive
output. What Else Is New?

Getting Started While it has been shown that MIT in its orig-
inal form leads to greater fluency in small case
Seated across a table from the patient, the series,5 sustaining treatment effects can be a
therapist shows a visual cue and introduces challenge for any intervention. Thus, we have
a word/phrase (e.g., Thank you). The ac- instituted the use of Inner Rehearsal and Auditory-
cented/stressed syllable(s) will be sung on the Motor Feedback Training to help patients gain
434 Annals of the New York Academy of Sciences

Figure 4. Intermediate Level steps and procedures in MIT.

Summarized from Helm-Estabrooks et al .3

Figure 5. Advanced Level steps and procedures in MIT.

Summarized from Helm-Estabrooks et al .3
Norton et al.: Melodic Intonation Therapy 435

maintainable independence as they improve them as they speak, and thereby decrease de-
expressive speech. pendence on the therapist.

Inner Rehearsal How Does MIT Work?

So that patients learn to establish their own
Preliminary data comparing MIT to an
target phrases, the therapist models the pro-
equally intense control therapy that uses no
cess of Inner Rehearsal by slowly tapping the pa-
intoning or left-hand tapping indicate that
tients hand (1 syllable per second) while hum-
those two elements add greatly to MITs effec-
ming the melody, then softly singing the words,
tiveness.5 While its developers suggested that
explaining that s/he is hearing the phrase
tapping and intoning could engage homolo-
sung inside. If the patient has trouble un-
gous language regions in the right hemisphere,
derstanding how to do this, s/he is asked to
they did not explain how this would occur.2
imagine hearing someone sing Happy Birthday
Additionally, since ideal candidates for MIT2
or a parents voice saying, Do your homework.
(Fig. 1) are patients with Brocas aphasia, a pop-
Once the concept is understood, the therapist
ulation with both linguistic and motor speech
taps while softly singing the phrase and indicat-
impairments, the extent to which MIT ad-
ing that the patient should hear his/her own
dresses aphasia, apraxia, or both is not yet clear.
voice singing the phrase inside. This inner
Below is a brief discussion of MITs critical el-
rehearsal (covert production) of the phrase cre-
ements and how they may contribute its thera-
ates an auditory target with which the overtly
peutic effect.
produced phrase can be compared. Those who
master this technique can eventually transfer
the skill from practiced MIT phrases to expres- Intonation
sive speech initiated with little or no assistance.
The intonation at the heart of MIT was
originally intended to engage the right hemi-
Auditory-Motor Feedback Training sphere, given its dominant role in processing
spectral information, global features of music,
Because re-learning to identify and produce and prosody.2,8,9 The right hemisphere may
individual speech sounds is essential to patients be better suited for processing slowly modu-
success, training them to hear the difference be- lated signals, while the left hemisphere may be
tween the target phrase and their own speech is more sensitive to rapidly modulated signals.10
a key aspect of the recovery process. In the early Therefore, it is possible that the slower rate
phases of treatment, patients listen as the thera- of articulation and continuous voicing that in-
pist sings the target, and learn to compare their creases connectedness between syllables and
own output as they repeat the words/phrases. words in singing may reduce dependence on
Sounds identified as incorrect become the fo- the left hemisphere.
cus of remediation. Once a problem is cor-
rected, the process of singing, listening, and Left-hand Tapping
repeating begins again. As patients learn to
create their own target through Inner Rehearsal, Tapping the left hand may engage a right-
Auditory-Motor Feedback Training allows them to hemisphere sensorimotor network that con-
self-monitor as thoughts are sung aloud. Over trols both hand and mouth movements.11
time, they learn to use the auditory-motor feed- It may also facilitate sound-motor mapping,
back loop to hear their own speech objec- which is a critical component of mean-
tively, identify problems and adjust to correct ingful vocal communication.12 Furthermore,
436 Annals of the New York Academy of Sciences

tapping, like a metronome, may pace the Conflicts of Interest

speaker and provide continuous cueing for syl-
lable production. The authors declare no conflicts of interest.

Inner Rehearsal References

Inner rehearsal may be particularly effec-
1. Albert, M.L., R.W. Sparks & N.A. Helm. 1973.
tive for addressing apraxia (an impairment of Melodic intonation therapy for aphasia. Arch. Neurol.
the ability to sequence and implement serial 29: 130131.
and higher-order motor commands). Silently 2. Sparks, R., N. Helm & M. Albert. 1974. Aphasia re-
intoning the target phrase may reinitiate a cas- habilitation resulting from melodic intonation ther-
cade of activation from a higher level in the apy. Cortex 10: 303316.
3. Helm-Estabrooks, N., M. Nicholas & A. Morgan.
cognitive-linguistic architecture (e.g., from the 1989. Melodic Intonation Therapy. Pro-Ed., Inc. Austin,
level of a prosodic or phonologic representa- TX.
tion), thus giving the speaker another attempt 4. Helm-Estabrooks, N. & M.L. Albert. 2004. Melodic
to correctly sequence the motor commands. Intonation Therapy: Manual of Aphasia and Aphasia Ther-
apy, 2nd ed., chapt.16, pp. 221233. Pro-Ed. Austin,
TX.
Auditory-Motor Feedback Training 5. Schlaug, G., S. Marchina & A. Norton. 2008. From
singing to speaking: why singing may lead to recov-
In speech, phonemes occur so quickly that it ery of expressive language function in patients with
is difficult for severely aphasic and/or apraxic Brocas aphasia. Music Percept. 25: 315323.
patients to process auditory feedback in time 6. Marshall, N. & P. Holtzapple. 1976. Melodic in-
to self-correct. However, when words are sung, tonation therapy: variations on a theme. In Clin-
phonemes are isolated and thus, can be heard ical Aphasiology Conference, vol. 6. R.H. Brook-
shire, Ed.: 115141. BRK Publishers. Minneapolis,
distinctly while remaining connected to the MN.
word. In addition, sustained vowel sounds pro- 7. Sparks, R.W. & A.L. Holland. 1976. Method:
vide time to think ahead about the next melodic intonation therapy for aphasia. J. Speech Hear.
sound, make internal comparisons to the target, Disord. 41: 287297.
and self-correct when sounds produced begin 8. Zatorre, R.J. & P. Belin. 2001. Spectral and temporal
processing in human auditory cortex. Cereb. Cortex 11:
to go awry.
946953.
Whether learning to sing, play an instru- 9. Schuppert, M., T.F. Munte, B.M. Wieringa & E.
ment, recover language after stroke, or acquire Altenmuller. 2000. Receptive amusia: evidence for
any new skill, the key to mastery is in the cross-hemispheric neural networks underling music
process. Previous small, open-label studies ex- processing strategies. Brain 123: 546559.
amining patients with moderate to severely 10. Poeppel, D., W.J. Idsardi & V. van Wassenhove. 2008.
Speech perception at the interface of neurobiology
nonfluent aphasia have found MIT to be a and linguistics. Philos. Trans. R. Soc. Lond. Ser. B 363:
promising path to fluency, and we have outlined 10711086.
and discussed its critical elements and our en- 11. Gentilucci, M. & R. Dalla Volta. 2008. Spoken lan-
hancements to the protocol here. However, the guage and arm gestures are controlled by the same
efficacy of this technique and its potential ap- motor control system. Q. J. Exp. Psychol. (Colchester) 61:
944957.
plication to other disorders will require further
12. Lahav, A., E. Saltzman & G. Schlaug. 2007. Ac-
exploration, and more research will be neces- tion representation of sound: audiomotor recognition
sary to fully understand the neural processes network while listening to newly acquired actions. J.
that underlie MITs effect. Neurosci. 27: 308314.