Lauryn Zipse, PhD, CCC-SLP, an Associate Professor in the Department of Communication Sciences and Disorders in the School of Health and Rehabilitation Sciences at the MGH Institute, recently contributed a chapter to a book entitled, Rhythms of Speech and Language, edited by Antje Strauss and Lars Meyer. Her chapter, Melodic Intonation Therapy: The ingredients that make it work, considers the evidence supporting the treatment ingredients that comprise a long-established music-based therapy for aphasia, and suggests that customizing these ingredients can improve its effectiveness.
What is Melodic Intonation Therapy?
It is a music-based treatment approach for aphasia, which is an acquired language disorder after brain injury, usually a stroke. Melodic Intonation Therapy, often called MIT, was developed the 1970’s for people with severe aphasia. The therapist guides the person with aphasia in singing short phrases on a limited number of pitches while tapping their left hand.
The developers of MIT incorporated music into aphasia therapy because for over 100 years, clinicians who worked with people with brain injuries noticed some people who couldn’t speak had relatively preserved singing. The question of why singing can be relatively preserved, and what exactly is preserved, is actually very complex. However, the original developers of MIT suggested that singing and left-hand tapping would engage the right hemisphere of the brain, which his typically not damaged in people with aphasia, and enable it to kind of take over, at least temporarily. We know now that's oversimplified, but this treatment approach is still used.
How did you become interested in it?
While doing my postdoc at Beth Israel under Gottfried Schlaug, I was struck by the effectiveness of these music-based techniques for people with severe aphasia. Dr. Schlaug was using MIT in a treatment study and evaluating people who were a year of more post-stroke. Some of these individuals couldn't say their name but using techniques like slowing down what they wanted to say, having them sing and tap their left hand, and having them sing in unison with the clinician, were surprisingly effective.
I was intrigued, but I worried that it was sort of like a party trick. Someone would bring in their loved one who couldn't say anything, and I could get them to sing happy birthday to their wife, or to sing their name. I sort of felt like, ‘OK, but now what? Does this result in any lasting change when we leave this room?’
And reading the research literature, the evidence is quite mixed. MIT includes a lot of different treatment ingredients, so there's a lot there to work with. That makes evaluating the evidence for it complicated, though, because different research studies customize the treatment in different ways and emphasize different components of it. We need to understand which of these treatment ingredients are working and for whom they are working. I developed a line of research looking at speech rhythm and timing, and at singing and speaking in unison, because I think these are important components of music-based treatments like MIT.
So is Melodic Intonation Therapy actually an effective treatment for people with aphasia?
The evidence for MIT overall is honestly not that strong when you consider results from randomized controlled trials, which are generally regarded as the best design to scientifically evaluate a treatment. However, large-scale randomized controlled trials of MIT may have 40 people with aphasia, with half of them getting the exact same MIT treatment protocol. That's not actually the best way to do therapy. The effort to maintain experimental control and to standardize the treatment as completely as possible is at odds with the clinician’s desire to adjust the treatment in response to how the client responds. Not surprisingly, I think, we see better results in the smaller sample size studies where the treatment is customized in certain ways, these changes are detailed, and improvement is evaluated in each individual client rather than across a group of 20 people all doing the same thing.
In rehabilitation more broadly, there’s this tension between customizing and standardizing our treatment approaches. We want our treatment decisions to be supported by evidence, and often envision standardized care pathways. But when you look at really good clinicians, there's an art to the science. They're reading the room, they're tweaking, they're adjusting. And that's not all in a decision tree that someone prints off and hands you, at least not yet.
I really like an approach that's being taken by the ACRM, the American Congress of Rehabilitation Medicine, developing something called the Rehabilitation Treatment Specification System, or RTSS. One of our affiliated faculty, Jarrad Van Stan, who's at the MGH Voice Center, has been doing a lot of really great work on this. With the RTSS, the aim is to identify the treatment ingredients that clinicians are using. What are all the different components that make up a particular treatment approach? This way, clinicians can customize a treatment for a particular patient’s needs, but also document what they're doing in replicable way. We need to value this customization as we move towards standardizing medicine, especially for complex things like language and cognition and motor recovery after brain injury. We can't just do a one-size-fits-all approach. It doesn't work.
When I wrote this chapter, I really wanted to show how this approach is useful for evaluating MIT. I looked across the literature and reflected on my own experience with the treatment to identify treatment ingredients — things like a slowed rate, hand tapping, unison production. I then evaluated the evidence for each one, setting up a framework to think about how to customize MIT for each client, but in an organized way.
How do you teach this to students?
If my students only learn one thing from me, I want it to be that you need to have a theory behind your practice. A clinician can’t just say, “Oh, my client has this type of aphasia, we do this type of treatment. Let me pull up my worksheets and plug and go.” You need to have a rationale, and you need to be watching and taking data as to how the client responds. You have to ask yourself, is it working? If not, what's my hypothesis about why not? What am I going to change?
In the Communication Sciences and Disorders Department here at the IHP, we really push our students to think critically. We educate them to have a solid understanding of speech, language, and cognitive functioning and impairment so that they are prepared to develop a theory-based treatment plan, and also to adapt it if it doesn’t work.
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