Melodic Intonation Therapy (MIT) for Aphasia & Apraxia: A 'How To' Guide

How To:
Melodic Intonation Therapy (MIT)
for Severe Aphasia & Apraxia

 8 min read

Have you ever encountered a person with aphasia who struggles to say their name, but can sing Happy Birthday at a family party without a problem? It’s been found that melody and rhythm can be used in a systematic way to improve verbal fluency and speech output. But don’t worry, you don’t need to be a singer to use music in speech therapy.

Melodic Intonation Therapy makes use of the singing ability of aphasia often seen when singing Happy Birthday

The Problem: Aphasia & Apraxia

Aphasia is a language disorder commonly caused by a stroke or other brain injury which impacts a person’s ability to communicate. The type and severity of aphasia are different for every person. Those with Broca’s aphasia – or non-fluent aphasia – typically have restricted verbal output, relatively good auditory comprehension, and speech that is often slow & halting. 

Apraxia of speech (AOS) is a motor speech disorder that results in difficulty coordinating the muscles used to form speech. Both are commonly seen after damage to the left hemisphere of the brain.

The Treatment: Melodic Intonation Therapy (MIT)

Melodic Intonation Therapy (MIT) is an evidence-based treatment method that uses intoning (singing) to improve expressive language in people with aphasia. The approach takes advantage of the undamaged right hemisphere by engaging areas that are capable of language. It is thought that the melodic & rhythmic prosody, slower rate of articulation, and continuous voicing that result from MIT may reduce the dependence on the left hemisphere.

Who Melodic Intonation Therapy Helps

People with severe Broca’s aphasia have been found to be the best candidates for MIT. To use MIT successfully, the person must:

  • Have damage to only the left hemisphere of the brain
  • Demonstrate moderately good auditory comprehension
  • Have non-fluent speech with effortful speech production of only a few words or only nonsense syllables
  • Have poor ability to repeat even single words
  • Show some ability to produce words while singing familiar songs
  • Be alert, motivated, emotionally stable, and have a good attention span

Since Broca’s aphasia and apraxia are so commonly found together, it is unknown if MIT addresses aphasia, apraxia, or both.

What You’ll Need to Do Melodic Intonation Therapy

Phrases for Stimuli: Since the goal of MIT is to learn a new way to speak (not just learn & recall a set of sentences), stimuli must be abundant and varied. During the first stages, stimuli should be no longer than 4 syllables and gradually work to more complex statements made of 5+ syllables. 

Put time and thought into the phrases you choose by working with your client and their caregivers to determine ones that are personally relevant. Stimuli should have a high probability of being stated in everyday conversation (e.g., if the client dislikes coffee, you would not choose the phrase “cup of coffee” to practice). 

Melodic Patterns: Only 2 – 4 musical notes are to be used and should resemble natural prosody patterns. Therefore, emphasized syllables will be produced on higher notes. To make it easier, write down all the chosen phrases and sentences in order of syllable length, then underline the naturally emphasized words or syllables to determine your melody for intonation.

Underline the stressed syllables when creating stimuli for MIT

Key Components of Melodic Intonation Therapy

Intonation and Left-Hand Tapping

These elements are integral to the success of MIT. Studies that compared MIT to a control therapy without intoning and tapping indicated better results for MIT, as well as more global activation on fMRI studies than the control.

Inner Rehearsal

This component can be particularly beneficial for individuals with AOS. By silently intoning the target phrase, it is thought to activate a higher-level cognitive-linguistic representation, which gives the speaker an additional attempt to correctly sequence motor commands.

Auditory-Motor Feedback Training

It is vital for clients to be able to distinguish the difference between the target phrase and their own speech production. However, it is difficult for individuals with aphasia and/or AOS to self-correct in real-time. The added benefit to intoning allows for more isolated phonemes that are heard distinctly and sustained phonemes that provide time to think ahead to the next sound. Auditory-motor feedback training may begin with listening back to a recording of the target and end with self-evaluation during speech.

Controversy around MIT

Though Melodic Intonation Therapy has been studied over the past several decades, its effects and mechanisms continue to be questioned in reviews. Some of the challenges & controversies are as follows:

  • Frequent deviations from the original MIT protocol make research studies hard to compare: Some utilize MIT as a protocol, others reduce it down to a facilitation technique with intoned speech. Other variations include mouthing of words as cues and elimination of hand-tapping all together.
  • The role of the right hemisphere: Studies have shown inconsistent findings of right hemisphere activation. However, there are several factors that can explain these differing results including different imaging techniques, failure to use the correct protocol, no pre- and post-treatment comparisons, and individual differences. 
  • Aphasia v. Apraxia: Although originally thought to treat Broca’s aphasia, new research poses the hypothesis that MIT treats AOS rather than aphasia. Clinical markers of Broca’s aphasia and AOS are similar apart from agrammatism, and MIT has shown little effect on agrammatism. Could MIT actually be more of a motor speech treatment than strictly a language treatment?

There are other music-based therapies offered to stroke survivors that are not MIT, but are often grouped with it. This article explains the protocol most speech-language pathologists use to provide Melodic Intonation Therapy.

How To Do Melodic Intonation Therapy (MIT)

Step 1: Humming

Visually signal the client to listen. Hum the target phrase alone one time then intone (sing) the phrase two times with hand-tapping, ask the client to rehearse in their head while listening.

Hum the melody first in MIT
Add the intoned words in Melodic Intonation Therapy

Step 2: Unison Intoning

Signal for the client to join in unison repetition of the target phrase with hand-tapping.

What's for dinner? is a good stimulus phrase for melodic intonation therapy

Step 3: Unison Intoning with Fading

Begin with unison intoning of the target phrase with hand-tapping. Fade your vocal participation but continue hand-tapping.

Leave out the final words in MIT

Step 4: Immediate Repetition

Signal the client to listen. Intone the target phrase alone with hand-tapping. Signal the client to repeat the target alone with the assistance of hand-tapping. A phonemic cue can be provided if the client has difficulty initiating the target.

Repetition is important for melodic intonation therapy

Step 5: Response to a Question

Following the client’s successful repetition of the target phrase from step 4, intone a probe question such as, “What did you say?” The client answers by intoning the target phrase alone. If the client needs assistance, you may tap out the syllables of the target response. 

Ask a question to hear the response again in melodic intonation therapy

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MIT Using the Apraxia Therapy App

Tactus Therapy’s Apraxia Therapy app incorporates several of the key principles of MIT including slow & prosodic speech, hand-tapping, and changes in length and complexity of stimuli using functional phrases. Using this app at home can give people with aphasia a chance to practice speaking using highly-intoned speech in unison with a model that fades out, just like MIT performed by a clinician.

Adjust the Settings

Touch the Settings button in the top right corner of the home screen. Here you can adjust the steps, speed, and cues to meet your client’s needs. To most-closely resemble MIT, make sure the Tap Cues are activated.

Choose Your Stimuli

Select the Phrases activity. It contains hundreds of phrases and sentences that people need to say every day. Then select the phrases you wish to practice. They are sorted by syllable length into 7 levels. When starting with MIT it is recommended to choose phrases from levels 1 – 4.

Begin Treatment

Apraxia Therapy contains 6 steps, including listening, tapping, unison intoning, faded intoning, and independent intoning. Encourage the user to continue to tap during all steps of the protocol.

Self-Evaluate

The Apraxia Therapy app will automatically record the user’s independent production and prompt them to indicate how well they did. Auditory-motor feedback training is a fundamental part of the self-monitoring process for both aphasia and apraxia that promotes insight and awareness in real-time.

Bonus features of using the Apraxia Therapy app:

  • Keep the text visible: While the MIT protocol doesn’t include the client reading the text at all, the app has the option to keep the text cues constantly on the screen if needed, and then switch to fading them out in the final steps. If you don’t want to see the text at all, position a thick piece of paper or sticky-notes over the top portion of the screen to block the text from view.
  • Adjust rate: You can make the video go a bit faster or slower as needed in the settings.
  • Try it for freeDownload the Apraxia Therapy Lite app to get 1 phrase in each level. That’s 3 phrases to get you started with MIT right away!
Apraxia Therapy

Apraxia Therapy

Speak more easily and build independence with video-assisted speech therapy to help people with apraxia after a stroke.

Resources for Melodic Intonation Therapy

Melodic Intonation Therapy has been used by speech-language pathologists since the 1970s when Nancy Helm-Estabrooks, Martin Albert, and Robert Sparks developed the protocol. MIT is one of the most well-researched treatments for severely impaired verbal expression related to aphasia. Nancy Helm-Estabrooks offers a Melodic Intonation Therapy Kit including examples of MIT at each level and other benefits. Her book Manual of Aphasia and Aphasia Therapy (3rd Edition) has a complete chapter dedicated to MIT with scoring and goal examples. A detailed overview with sample stimuli and data trackers is also available from Neuro Speech Solutions.

Selected research articles on MOR:

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Katie Brown, MA, CCC-SLP is a speech-language pathologist in Buffalo, NY. She is the owner of Neuro Speech Solutions, a private practice that specializes in treatment for adult speech, cognitive, & swallowing disorders. Katie is passionate about providing person-centered & functional therapy to help her patients meet their life goals.

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