BRAIN AND LANGUAGE 2, 483-488 (1975)

Singing as Therapy for Apraxia of Speech and Aphasia: Report of a Case ROBERT L. K E I T H 1 AND A R N O L D E . ARONSON Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55901 A 48-year-old woman suffered a stroke, with sudden onset of apraxia of speech, aphasia, right hemiplegia, and right hemianopsia. Conventional speech and language therapy was undertaken for 1 mo, but progress was limited. Then a form of singing therapy was introduced, and the patient found herself able to sing words and phrases that she was unable to say. The patient can function in her home environment with her limited speech ability, but the pitch, melody, and quality of her voice are different from that prior to her cerebral vascular accident.

It is not uncommon for aphasic patients to be able to sing a melody or hum a tune. Dalin (Benton & Joynt, 1960, pp. 211-212), Head (1926 [ 1963, p. 409] ), and Loebell (1940) have described the singing and humming of patients with aphasia. Whether this ability can be useful, therapeutically, in helping the patient regain his speech remains a question. REPORT OF A CASE Our patient was a 48-year-old woman who, on November 23, 1972, experienced a sudden episode of right hemiplegia and hemianoPsia, severe apraxia of phonation and articulation, and aphasia. In 1949, she had undergone surgical removal of an adenocarcinoma of the left parotid gland, during which the left hypoglossal nerve was inadvertently compromised, resulting in left hemiparesis of the tongue. Language therapy was begun on November 28, 1972, in an attempt to improve auditory comprehension and volitional movements of the articulators. This conventional approach to therapy continued until December 18, 1972, during which time the following gains had been made: (1) the patient could produce phonated sound on request, primarily/a/; (2) she could produce the following phonemes and dipthongs, although only after first hearing them from the therapist,/m/, /a/, [ai/, In/,/o/, a n d / m a i / a s discrete sound; and (3) she showed improved ability to point to objects in response to visual-verbal stimulation, doing so correctly 80% of the time. Because progress had been disappointingly slow, we thought that some other therapeutic approach might be more successful. On December 20, 1972, singing therapy was introduced for the first time. The therapist sang the words, "My Bonnie Lies Over the Ocean," and the patient was asked to do the same. The patient was able to sing the melody and articulate the words although she still was unable to speak any words. This response occurred on the first attempt and was articulated essentially within normal limits. The decision was then made to continue the singing therapy. It was requested in song, 1 Address reprint requests to Mr. Keith. 483 Copyright@ 1975by AcademicPress, Inc. All tightsof reproductionin any form reserved.

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with a melody provided by the therapist, that the patient name, in song, certain objects as indicated by the therapist. For example, the therapist would sing, "This is my " while pointing to her hand, and the patient in turn would complete the sentence by singing, "hand." The patient also could sing, "I want coffee," "Goodbye," "See you tomorrow," "I'm fine," and "How are you?" but was unable to say these words or phrases without a melody pattern. At this point in time the patient was still hemiplegic and aphasic, as determined by the PICA and modified Schuell test of aphasia. Therapy using the singing approach was continued, and the patient was encouraged to use this form of communication in the hospital ward. After being dismissed from the hospital, she continued to receive therapy once a week as an outpatient, and she continued to work at home on assigned sections of her workbook (Keith, 1972) and on reading short articles in the daily paper. Results of the PICA on January 12, 1973, showed gains in comparison with the results of December 19, 1972 (Table 1). The patient was now able to produce speech, by her own initiation, in most situations without singing, but the rhythm and pitch patterns of her speech had a definite musical quality, although not always grammatically correct. Her language showed aphasic errors: she misnamed objects that she was talking about or could not recall the names, but was able to talk about how they were used. Her intonation for questions or showing of surprise were of proper inflection. Her apraxic errors consisted of false starts, substitutions of one sound for another, dropping of a final consonant, and adding or dropping syllables in multisyllabic words. On the gestural subtests of the PICA, given on December 19, 1973, she was relatively effective in test situations that offered the most cues, such as in matching, copying, or imitating tasks other than verbalizing. As therapy progressed, she improved and became very effective in all gestural tasks, but she required more than the normal amount of time to complete these tasks. The graphic subtests were affected in that she was now using her left hand; she was severely arthritic, and this also limited her abilities to hold a pen and coordinate the movements necessary for these tasks. Consequently, limited effort was put forth owing to the discomfort caused by these tasks. She continued as an outpatient on a weekly basis for 1 hr of therapy and discussion of home assignments. The PICA on February 15, 1973, showed additional TABLE 1 PORCH INDEX OF COMMUNICATIVE ABILITY (PICA) SCORES AT DIFFERENT POINTS IN APHASIA THERAPY Date Dec. 19, 1972 Score Percentile Jan, 12, 1973 Score Percentile Feb. 15, 1973 Score Percentile

Overall

Gestural

Verbal

Graphic

7.93 26

10.96 27

3.55 12

6.78 40

10.99 54

13.21 61

10.55 8.2

8.33 60

11.93 67

13.61 71

12.50 58

9.32 69

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improvement (Table 1). By this time, the patient had completely given up singing for her communication needs. She now showed improvement in all modalities, as indicated by the PICA. The family reported that she gets along well at home in all speaking situations but that her speech often lacks completeness of grammar, for example, omissions of connectives and misuse of tense; and she is often slow in responding to many specific questions. They also reported that her voice seems higher in pitch and is not as forceful as it was prior to her cerebral vascular accident. Her voice quality is more like her singing voice prior to her cerebral vascular accident, yet is not true singing, because her singing voice is pitched even higher.

COMMENT

In 1736, Olof Dalin (Benton and Joynt, 1960, pp. 211-212) wrote a description of an aphasic patient who could sing: Jon Persson, a farmer's son from Ofvankihl, in the parish of Juleta in Sormanland, born in 1703, brought up in the usual simple way to know his Christianity and to read; in 1736, after he had been married for three years, he had an attack of a violent illness which resulted in a paralysis of the entire right side of the body and complete loss of speech. After almost half a year in bed, he began to move to some degree but he limped and carried his right arm in a sling. For two years he went to a mineral spring at Juleta parsonage which many people had found to be helpful. However, he did not note any improvement except that he was able to walk more steadily and to pronounce correctly the small but often important word, "yes." However, he gained one advantage, which was later observed and which is the occasion for his present notoriety. He can sing certain hymns, which he had learned before he became ill, as clearly and distinctly as any healthy person. However, it should be noted that at the beginning of the hymn he has to be helped a little by some other person singing with him. Similarly, with the same type of help, he can recite certain prayers without singing, but with a certain rhythm and in a high-pitched, shouting tone. Yet this man is dumb, cannot say a single word except "yes" and has to communicate by making signs with his hands. To be sure, he has always been somewhat simple-minded and nz/ive. Yet now, as in the past, he is quite normal in his own way, in his ability to hear and understand, and he is God-fearing, quiet and well behaved. The vicar of Juleta parish, Joh. Ihering, whose personal and signed statement is the source of my information, has kept him in the vicarage for eight years and has made every effort to determine whether this is a deception or illusion on the part of the man for the purpose of providing himself with food more easily. However, the vicar has found the case to be completely genuine. Parishioners of higher and lower rank offer the same testimony. I have also personally seen this man and have heard him sing. The strange and varied effects that accompany a stroke are only too familiar. I wish to add nothing to this account other than to make the comment that people who stammer are able to sing without impediment and quite distinctly although they cannot utter ten whole words in succession when they speak.

In Head's discussion (1963, p. 409) of his soldier patient with aphasia, he stated, The patient can still recall a melody and sing in time and tune . . . .

Given the

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KEITH AND ARONSON opening notes of a song previously known to him, he sang it through accurately without words; time, tune and modulation were perfect and his voice had the full volume of a high baritone. He could not, however, sing any song, if he attempted to pronounce the words.

In his discussion of musical ability, Head (1963, p. 409) wrote, Musical capacity, in the strict sense of the word, does not suffer in association with these disorders of speech; for it has no functional relation to word-formation or verbal understanding.

Goldstein (1948, pp. 57-146) explained that patients can sing, although they cannot speak because singing requires a lower intellectual level than does language; singing is predominantly emotional and more purely expressive than is the main informative purpose of language. Students of amusia, notably Ustvedt (1937a,b) stressed the symbolic function of language, which supposedly is not present in music. Music possesses points of resemblance to, and difference from, speech. In its simplest form it resembles speech in employing some or all of the muscles of articulation, as in singing, humming, or whistling a melody . . . . Music may be linked with speech, as in a song, and in general tends to evoke feelings of variable intensity. (Brain, 1965, p. 119)

Goldstein (1948, p. 146) said that regardless of the authority of Henschen, who assumed that the "motor singing center" is located in the pars triangularis of the third left frontal convolution anterior to Broca's area, one cannot say that the anatomic findings give definite evidence of this. The difference between singing and speaking probably is due to the different physiologic and psychologic structures of both performances. Eisenson (1971, pp. 33-36) said that evidence indicates that the right brain is the processor of nonverbal content or, stated more conservatively and in keeping with experimental findings, the perception of nonverbal auditory stimuli such as musical tones and tonal patterns depends more on right hemisphere (temporal lobe) activity than on left temporal activity. Kimura (1967, pp. 163-178), in his study of a melodies test presented dichotically to 20 normal subjects, found that a significantly greater number of accurate identifications were made by the left ear than by the right. Butler and Norrsell (1968, p. 793) and Trevarthen (1969) have asserted that patients can describe pictures of simple objects presented to the right hemisphere. The problems of interpreting these have been discussed extensively, but, in general, simple cross-cuing strategies can account for the results. Gazzaniga and Hillyard (1971, pp. 273-280) believed that the extent and nature of verbal structure processing in the right hemisphere remain unknown, but it conceivably has become locked in an infantile mode, wherein only simple naming is possible, and "no" is the most deeply entrenched concept.

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There were no indications that our patient had any right hemispheric involvement. The results of E E G and the neurologic examinations indicate that the damage was confined to the left hemisphere. The explanation as to the patient's ability to sing but not speak during the early stages of therapy might be explained on the theory that the nondominant hemisphere subtends the singing function, the right hemisphere having been found intact by E E G findings. In 1940, Loebell reported an unusual case of audimutitas. A 61/2-year old boy, the product of a difficult labor, came from a family with a history of visual, neurologic, and language disorders, as well as familial lefthandedness. His physical development was retarded by many illnesses, including a prolonged attack of whooping cough when he was 2 years old. Although he could not speak at all, he expressed his desires and feelings by humming the beginnings of certain songs. He knew many songs and selected the appropriate melody for each communication in such a manner that the pertinent text made obvious what he wanted. He described pictures correctly by humming certain passages of songs that consistently alluded to the objects, actions, or relationships shown in the pictures. Goldstein (1948, pp. 57-146) speculated that, because of the more primitive character of singing and the close relationship of singing to expressive movements and emotional language, brain-damaged patients probably preserve their singing abilities longer than they do their language abilities. Whether singing is preserved when there is a language deficit depends on such factors as how near the singing is to the total personality of the concerned person and to his emotional life as well as on the degree to which the person has developed automatisms in this field. Goldstein believed that retention of singing ability despite a language deficit might be explainable in the same way as is the better preservation of emotional language. Albert, Sparks, and Helm (1973, p. 131) reported on three cases in which melodic intonation therapy for aphasia was used. In their discussion they wrote, Neither spontaneous recovery nor development of new language areas in the right hemisphere can account for the improvements noted, since the recovery of grammatical structure and vocabulary was too rapid following the beginning of melodic intonation therapy. We propose as one possible explanation that melodic intonation therapy facilitates use of language by the nondominant right hemisphere, which had been suppressed by the dominant left hemisphere, even though the dominant hemisphere was damaged.

Whether the preservation of the singing ability of aphasic patients can be confidently employed as a therapeutic method either by itself or in combination with other techniques remains to be determined. It should

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be acknowledged that our patient might have improved to a similar extent had conventional therapy been continued or no therapy instituted at all.

REFERENCES Albert, M. L., Sparks, R. W., & Helm, N. A. 1973. Melodic intonation therapy for aphasia. Archives of Neurology, 29, 130-13 l. Benton, A. L., & Joynt, R. J. 1960. Early descriptions of aphasia. Archives of Neurology, 3, 205-222. Brain, L. 1965. Speech Disorders: Aphasia, Apraxia and Agnosia. 2nd ed. Washington, D.C.: Butterworth & Co. Butler, S. R., & NorrseU, U. 1968. Vocalization possibly initiated by the minor hemisphere. Nature (London), 220, 793-794. Eisenson, J. 1971. The left brain is for talking. Acta Symbolica, 2, 33-36. Gazzaniga, M. S., & HiUyard, S. A. 1971. Language and speech capacity of the right hemisphere. Neuropsychologia, 9, 273-280. Goldstein, K. 1948. Language and Language Disturbances: Aphasic Symptom Complexes and Their Significance for Medicine and Theory of Language. New York: Grune & Stratton. Head, H. 1963. Aphasia and Kindred Disorders of Speech. Vol. 1. New York: Harrier. Keith, R. L. 1972. Speech and Language Rehabilitation: A Workbook for the Neurologically Impaired. Danville, IL: Interstate Printers and Publishers. Kimura, D. 1967. Functional asymmetry of the brain in clichotic listening. Cortex, 3, 163-178. Loebell, H. 1940. Cited by Luchsinger, R., and Arnold, G. E. 1965. Voice-SpeechLanguage Clinical Communicology: Its Physiology and Pathology. (G. E. Arnold and E. R. Finkbeiner, trans.) Belmont, CA: Wadsworth. Pp. 523-524; 625. Trevarthen, C. B. 1969. Cerebral midline relations reflected in split-brain studies of the higher integrative functions. Paper presented at XIX International Congress of Psychology, London, England (1969). Ustvedt, H. J. 1937a. The method of examination in amusia. Acta Psychiatrica et Neurologica (Kbh.), 12, 447-455. Ustvedt, H. J. 1937b. Ueber die Untersuchung der musikalischen Funktionen bei Patienten mit Gehirnleiden, besonders bei Patienten mit Aphasie. Acta Medica Scandinavia (Suppl.), 86, 1-737.

Singing as therapy for apraxia of speech and aphasia: report of a case.

BRAIN AND LANGUAGE 2, 483-488 (1975) Singing as Therapy for Apraxia of Speech and Aphasia: Report of a Case ROBERT L. K E I T H 1 AND A R N O L D E ...
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