Sing something simple: the therapy that helps stroke victims to speak

    20 October 2016

    Before training as a speech therapist, I was a volunteer with an aphasia support group.-Aphasia is a catch-all term to describe the loss of spoken or written communication skills, usually due to brain damage caused by a stroke or head injury, so my group had many kinds of-difficulty: problems finding words, problems forming them, problems with-reading or writing. Some could talk at length, yet understood little of what they were saying.

    They came from all walks of life: a policeman, an hotelier, a mathematician, a teacher. They felt diminished by their impairments but were determined to find a way to continue living full and productive lives.

    One day I took a friend who is a singer. She sang for the group, then handed round a microphone. I was shocked at how many people found their voices and joined in. People who could not speak could still sing the words of familiar songs. So far so great. This effect is now well known, but the tricky bit is turning it into a therapy that will benefit normal speech.

    I was reminded of the episode last week when a patient’s husband asked me about melodic-intonation therapy (MIT), which was developed in the 1970s as a systematic way to take melody and rhythm and use them to support speech and language. A stroke had left his wife with severe language impairment. She had very little verbal output but could communicate a little using gestures and facial expressions.

    The husband had read an article in the Daily Mail by a stroke victim who told of his own experience of aphasia. Peter Trollope could not speak, but found he could sing along to a Beatles song as he lay in his hospital bed. This felt miraculous; the emotion of hearing words forming to music when they won’t form in speech is extraordinary and it led him into a course of MIT.

    The therapy starts with learning to sing to a familiar melody. New words and short phrases are introduced to the same melody, tapping out the syllables in time. At first, everyday phrases are taught, then the vocabulary is increased until the patient can use this melody and rhythm to support anything they want to say.

    But MIT fell out of favour because there was no strong evidence base to support it. Early research did not indicate clear benefits-— there were many promising single-case studies, but attempts to prove consistent success failed. This may be due to the fact that no two cases of speech impairment after a stroke are the same. To generate a seemingly simple phrase like ‘I am cold,’ the brain must form an intention to say it, find the words, sequence the sounds into a grammatical structure, create a motor programme for the muscles to make the sounds, then execute it-accurately, involving co-ordination of breath, vocal cords and oral/facial movements. Difficulties at any stage result in problems, and because the combinations vary so much there can be no universally effective therapy. For most patients, a tailored mixture of techniques will be used.

    Even this is not the whole story. For therapy to work, it must be something that you feel-motivated to do. People are motivated by things they enjoy, things they have faith in, or it can all come down to making your own decision about what you want to do. Peter Trollope discovered for himself that he could still sing, and this led his speech therapist to try MIT; he had inspired his own therapy and I have no doubt that this was a significant factor in its success.

    I have used MIT myself with varying results. Some patients hated it, mortified at the ‘sing-y-ness’. But I have also seen it gradually help to restore speech with just the faintest hint of the melody we used behind it: undetectable unless you are listening for it.

    Recently, MIT has regained some popularity. This is because whizzy neuro-imaging has shown what it achieves in terms of neural activity. Normally the left hemisphere of the brain processes language and the right one handles music. When the left-side language area has been damaged, music encourages neuroplasticity; the brain starts to process language on the right side. As a result, MIT is being reconsidered.

    This makes me wonder. Therapy is not the same as medicine and in this case the evidence-based approach led to a viable technique being abandoned then reinstated simply thanks to changes in research methods. Perhaps we should be thinking more simply.

    In therapy as in so much of life, it’s finding the thing that keeps you hooked, the spoonful of sugar that keeps you going, that’s the real trick. The most effective approach is the one you stick to. You don’t need neuro-imaging to know this.