st JOURNAL CLUB 2013-2014 1
Jun 03, 2015
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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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