Melodic Intonation Therapy in Chronic Aphasia: Evidence from a Pilot Randomized Controlled Trial

Transcranial direct stimulation over left inferior frontal gyrus improves language production and comprehension in post-stroke aphasia: A double-blind randomized controlled study

Transcranial direct current stimulation (tDCS) targeting Broca's area has shown promise for augmenting language production in post-stroke aphasia (PSA). However, previous research has been limited by small sample sizes and inconsistent outcomes. This study employed a double-blind, parallel, randomized, controlled design to evaluate the efficacy of anodal Broca's tDCS, paired with 20-minute speech and language therapy (SLT) focused primarily on expressive language, across 5 daily sessions in 45 chronic PSA patients. Utilizing the Western Aphasia Battery-Revised, which assesses a spectrum of linguistic abilities, we measured changes in both expressive and receptive language skills before and after intervention. The tDCS group demonstrated significant improvements over sham in aphasia quotient, auditory verbal comprehension, and spontaneous speech. Notably, tDCS improved both expressive and receptive domains, whereas sham only benefited expression. These results underscore the broader linguistic benefits of Broca's area stimulation and support the integration of tDCS with SLT to advance aphasia rehabilitation.

A targeted review of prosodic production in agrammatic aphasia

It is unclear whether individuals with agrammatic aphasia have particularly disrupted prosody, or in fact have relatively preserved prosody they can use in a compensatory way. A targeted literature review was undertaken to examine the evidence regarding the capacity of speakers with agrammatic aphasia to produce prosody. The aim was to answer the question, how much prosody can a speaker "do" with limited syntax? The literature was systematically searched for articles examining the production of grammatical prosody in people with agrammatism, and yielded 16 studies that were ultimately included in this review. Participant inclusion criteria, spoken language tasks, and analysis procedures vary widely across studies. The evidence indicates that timing aspects of prosody are disrupted in people with agrammatic aphasia, while the use of pitch and amplitude cues is more likely to be preserved in this population. Some, but not all, of these timing differences may be attributable to motor speech programming deficits (AOS) rather than aphasia, as these conditions frequently co-occur. Many of the included studies do not address AOS and its possible role in any observed effects. Finally, the available evidence indicates that even speakers with severe aphasia show a degree of preserved prosody in functional communication.

Efficacy of different rehabilitation therapies on post-stroke aphasia patients: A network meta-analysis

BACKGROUND

Although several rehabilitation interventions are effective in post-stroke aphasia (PSA), the efficacy of different rehabilitation interventions compared to each other remains controversial. Here, we aimed to compare the effectiveness of varying rehabilitation interventions in PSA.

METHODS

Randomized controlled trials on 8 kinds of rehabilitation interventions to improve speech function in patients with PSA were searched by computer from 10 databases, including PubMed, Web of Science, Cochrane, OVID, CINAHL, Embase, CNKI, WanFang, CBM, and VIP. The search scope was from the establishment of the database to August 2023. The literature screening, extraction of basic information, and quality assessment of the literature were conducted independently by 2 researchers. Network meta-analysis (NMA) was performed using Stata 17.0 software.

RESULTS

Fifty-four studies involving 2688 patients with PSA were included. The results of NMA showed that: ① in terms of improving the severity of aphasia, the therapeutic effects of repetitive transcranial magnetic stimulation were the most significant; ② motor imagery therapy was the most effective in improving spontaneous speech, repetition, and naming ability; ③ in terms of improving listening comprehension ability, the therapeutic effects of mirror neuron therapy was the most significant.

CONCLUSION

The 8 rehabilitation interventions have different focuses in improving the speech function of PSA patients, and the clinical therapists can select the optimal rehabilitation interventions in a targeted manner according to the results of this NMA and the patients' conditions and other relevant factors.

Neurologic music therapy for non-fluent aphasia: a systematic review and meta-analysis of randomized controlled trials

Introduction

The efficacy of neurologic music therapy (NMT) techniques for the treatment of non-fluent aphasia has been widely accepted by the rehabilitation medical community. However, consensus on which dimensions of speech function can be improved by NMT techniques and standardized intervention dosage remains elusive. This study aimed to provide evidence regarding the efficacy of NMT in improving speech function and explore the optimal intervention dose. A systematic review and meta-analysis were conducted to search for randomized clinical trials and open-label trials that evaluated speech functions after NMT.

Methods

We searched all papers and reviews published from database inception to July 2023, including PubMed, Cochrane Library, Web of Science, Embase, and CNKI. Statistical analyses were mainly carried out on RevManV5.4.1 and pooled using a random-effects model. The primary outcome was the standardized mean difference (SMD) in speech functions, determined by calculating the change in speech functions score from baseline to the primary endpoint in the NMT group versus the control arm.

Results

A total of 11 studies with 329 patients were included. NMT had a positive effect on repetition ability (SMD = 0.37, 95%CI [0.12, 0.62], p  < 0.05), but did not lead to significant differences in naming, comprehension, spontaneous speech, or communication. When the intervention time was >20 h, NMT exhibited a significant advantage at improving repetition ability (SMD = 0.43, 95%CI [0.06, 0.79], p  < 0.05).

Discussion

This study provides evidence supporting the NMT enhancement of repetition ability in patients with non-fluent aphasia. Future large-sample studies are required to determine the optimal intervention dose of music therapy for different subtypes of non-fluent aphasia.

Systematic review registration

PROSPERO, identifier CRD42023470313.

Effects of Music Therapy on Aphasia and Cognition of Patients with Post-stroke: A Systematic Review and Meta-analysis

PURPOSE

This investigation sought to systematically assess music therapy's impact on aphasia and cognition in patients with post-stroke.

METHODS

Comprehensive searches were performed across major databases, including PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, and Vip Chinese sci-tech periodicals (VIP), covering publications up to December 2023. After screening and extracting data from the retrieved literature, its quality was appraised, which was followed by a meta-analysis using RevMan software (version 5.4, Cochrane Collaboration, Oxford, UK).

RESULTS

Nine articles, which were published from 2008 to 2022, were covered in this investigation, comprising 309 stroke patients in total. Meta-analysis results from these variations were found to be not statistically significant in the degree of functional communication improvement between the experimental group and the control group (standardized mean difference [SMD] = 0.23, 95% confidence interval [CI] (-0.19; 0.77), P > 0.05). These variations were found to be not statistically significant in the improvement of understanding ability in the experimental group compared with that in the control group (SMD = 0.21, 95% CI [-0.66; 1.09], P > 0.05). The degree of improvement in repetitive ability of the experimental group was considerably greater than that of the control group (SMD = 0.37, 95% CI [0.01; 0.76], P < 0.05). These variations were found to be not statistically significant in the improvement of naming ability in the experimental group compared with that in the control group (SMD = 0.30, 95% CI [-0.19; 0.80], P > 0.05). The cognitive score of the experimental group was considerably greater than that of the control group (SMD = 0.75, 95% CI [0.44; 1.06], P < 0.05).

CONCLUSION

Music therapy can effectively ameliorate the repetition ability of patients with aphasia after stroke. It can also improve the cognitive ability of patients. Thus, music therapy could be further applied to treat this type of patients.

Melodic intonation therapy for non-fluent aphasia after stroke: A clinical pilot study on behavioral and DTI findings

Music-based melodic intonation therapy (MIT) has shown promise as a treatment for non-fluent aphasia after stroke. This trial compared the efficacy of music-based MIT and speech therapy (ST) in aphasia, focusing on arcuate fasciculus connectivity in brain structural and language ability scores. A total of 62 patients were enrolled, of whom 40 completed the trial. The experimental group received MIT for 30 min/d, five days per week for four weeks, while the control group received ST with the same dose. The BDAE and fMRI-DTI were performed at T0 and T1. The music-based MIT group demonstrated better language levels. DTI showed that FA, FN, and path length of the MIT group in the right hemisphere were significantly increased. Music-based MIT had positive effects on reorganization and activation of arcuate fasciculus in aphasia after stroke. This research is funded by NSFC No. T2341003 and No.2020CZ-10. Clinical Trials ChiCTR2000037871. Ethics approval number: 2020-013-1.

Clinical study of melodic intonation therapy combined with transcranial direct current stimulation for post-stroke aphasia: a single-blind, randomized controlled trial

Background

Globally, more than 10 million new stroke cases occur annually, of which aphasia accounts for about one-third. Aphasia has become an independent predictor of functional dependence and death for the stroke population. The closed-loop rehabilitation of combining behavioral therapy with central nerve stimulation seems to be the research trend of post-stroke aphasia (PSA) due to its advantages in improving linguistic deficits.

Objective

To verify the clinical efficacy of a closed-loop rehabilitation program combining melodic intonation therapy (MIT) with transcranial direct current stimulation (tDCS) for PSA.

Methods

This was a single-center, assessor-blinded, randomized controlled clinical trial, which screened 179 patients and included 39 PSA subjects, with the registration number ChiCTR2200056393 in China. Demographic and clinical data were documented. The primary outcome was the Western Aphasia Battery (WAB) used to assess language function, and the secondary outcomes included Montreal Cognitive Assessment (MoCA), Fugl-Meyer Assessment (FMA), and Barthel Index (BI) for evaluating cognition, motor, and activities of daily living, respectively. With the computer-generated randomization sequence, subjects were randomly divided into the conventional group (CG), MIT combined with sham stimulation group (SG), and MIT combined with tDCS group (TG). After the three-week intervention, the functional changes in each group were analyzed by the paired sample T-test, and the functional difference between the three groups was analyzed by ANOVA.

Results

There was no statistical difference on the baseline. After the intervention, the WAB's aphasia quotient (WAB-AQ), MoCA, FMA, and BI were statistically different in SG and TG, including all the sub-items in WAB and FMA, while only listening comprehension, FMA, and BI were statistically different in CG. The differences of WAB-AQ, MoCA, and FMA were statistically different among the three groups, but BI was not. The post hoc test results revealed that the changes of WAB-AQ and MoCA in TG were more significant than the others.

Conclusion

MIT combined with tDCS can augment the positive effect on language and cognitive recovery in PSA.

The effect of musicality on language recovery after awake glioma surgery

Introduction

Awake craniotomy is increasingly used to resect intrinsic brain tumors while preserving language. The level of musical training might affect the speed and extend of postoperative language recovery, as increased white matter connectivity in the corpus callosum is described in musicians compared to non-musicians.

Methods

In this cohort study, we included adult patients undergoing treatment for glioma with an awake resection procedure at two neurosurgical centers and assessed language preoperatively (T1) and postoperatively at three months (T2) and one year (T3) with the Diagnostic Instrument for Mild Aphasia (DIMA), transferred to z-scores. Moreover, patients' musicality was divided into three groups based on the Musical Expertise Criterion (MEC) and automated volumetric measures of the corpus callosum were conducted.

Results

We enrolled forty-six patients, between June 2015 and September 2021, and divided in: group A (non-musicians, n = 19, 41.3%), group B (amateur musicians, n = 17, 36.9%) and group C (trained musicians, n = 10, 21.7%). No significant differences on postoperative language course between the three musicality groups were observed in the main analyses. However, a trend towards less deterioration of language (mean/SD z-scores) was observed within the first three months on the phonological domain (A: -0.425/0.951 vs. B: -0.00100/1.14 vs. C: 0.0289/0.566, p-value = 0.19) with a significant effect between non-musicians vs. instrumentalists (A: -0.425/0.951 vs. B + C: 0.201/0.699, p = 0.04). Moreover, a non-significant trend towards a larger volume (mean/SD cm³) of the corpus callosum was observed between the three musicality groups (A: 6.67/1.35 vs. B: 7.09/1.07 vs. C: 8.30/2.30, p = 0.13), with the largest difference of size in the anterior corpus callosum in non-musicians compared to trained musicians (A: 3.28/0.621 vs. C: 4.90/1.41, p = 0.02).

Conclusion

With first study on this topic, we support that musicality contributes to language recovery after awake glioma surgery, possibly attributed to a higher white matter connectivity at the anterior part of the corpus callosum. Our conclusion should be handled with caution and interpreted as hypothesis generating only, as most of our results were not significant. Future studies with larger sample sizes are needed to confirm our hypothesis.

Melodic Intonation Therapy for aphasia: A multi-level meta-analysis of randomized controlled trials and individual participant data

Melodic Intonation Therapy (MIT) is a prominent rehabilitation program for individuals with post-stroke aphasia. Our meta-analysis investigated the efficacy of MIT while considering quality of outcomes, experimental design, influence of spontaneous recovery, MIT protocol variant, and level of generalization. Extensive literature search identified 606 studies in major databases and trial registers; of those, 22 studies-overall 129 participants-met all eligibility criteria. Multi-level mixed- and random-effects models served to separately meta-analyze randomized controlled trial (RCT) and non-RCT data. RCT evidence on validated outcomes revealed a small-to-moderate standardized effect in noncommunicative language expression for MIT-with substantial uncertainty. Unvalidated outcomes attenuated MIT's effect size compared to validated tests. MIT's effect size was 5.7 times larger for non-RCT data compared to RCT data (g̅case report = 2.01 vs. g̅RCT = 0.35 for validated Non-Communicative Language Expression measures). Effect size for non-RCT data decreased with number of months post-stroke, suggesting confound through spontaneous recovery. Deviation from the original MIT protocol did not systematically alter benefit from treatment. Progress on validated tests arose mainly from gains in repetition tasks rather than other domains of verbal expression, such as everyday communication ability. Our results confirm the promising role of MIT in improving trained and untrained performance on unvalidated outcomes, alongside validated repetition tasks, and highlight possible limitations in promoting everyday communication ability.

The scope and potential of music therapy in stroke rehabilitation

There is a growing interest in the use of music therapy in neurological rehabilitation. Of all the major neurological illnesses, stroke rehabilitation has been observed to have some of the strongest potential for music therapy's beneficial effect. The current burden of stroke has raised the need to embrace novel, cost-effective, rehabilitation designs that will enhance the existing physical, occupation, and speech therapies. Music therapy addresses a broad spectrum of motor, speech, and cognitive deficits, as well as behavioral and emotional issues. Several music therapy designs have focused on gait, cognitive, and speech rehabilitation, but most of the existing randomized controlled trials based on these interventions have a high risk of bias and are statistically insignificant. More randomized controlled trials with greater number of participants are required to strengthen the current data. Fostering an open and informed dialogue between patients, healthcare providers, and music therapists may help increase quality of life, dispel fallacies, and guide patients to specific musical interventions.

Potential Benefits of Music Therapy on Stroke Rehabilitation

Stroke is associated with a high rate of disability and mortality, and survivors are usually accompanied with dysphagia, aphasia, motor dysfunction, cognitive impairment, depression, and other complications. In the past decades, many studies have been conducted to reveal the pathogenesis and pathological mechanisms of stroke. Furthermore, treatment methods have been developed that contribute to the elevated survival rate of stroke patients. Early rehabilitation poststroke is starting to be recognized as important and has been receiving increasing attention in order to further improve the quality of life of the patients. As an emerging method of poststroke rehabilitation, music therapy can help attenuate dysphagia and aphasia, improve cognition and motor function, alleviate negative moods, and accelerate neurological recovery in stroke patients. This review helps summarize the recent progress that has been made using music therapy in stroke rehabilitation and is aimed at providing clinical evidence for the treatment of stroke patients.

The relationship between entrainment dynamics and reading fluency assessed by sensorimotor perturbation

A consistent relationship has been found between rhythmic processing and reading skills. Impairment of the ability to entrain movements to an auditory rhythm in clinical populations with language-related deficits, such as children with developmental dyslexia, has been found in both behavioral and neural studies. In this study, we explored the relationship between rhythmic entrainment, behavioral synchronization, reading fluency, and reading comprehension in neurotypical English- and Mandarin-speaking adults. First, we examined entrainment stability by asking participants to coordinate taps with an auditory metronome in which unpredictable perturbations were introduced to disrupt entrainment. Next, we assessed behavioral synchronization by asking participants to coordinate taps with the syllables they produced while reading sentences as naturally as possible (tap to syllable task). Finally, we measured reading fluency and reading comprehension for native English and native Mandarin speakers. Stability of entrainment correlated strongly with tap to syllable task performance and with reading fluency, and both findings generalized across English and Mandarin speakers.

Functional neurological disorder: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder

BACKGROUND: The term “functional neurological disorder,” or “FND,” applies to disorders whose occurrence of neurological symptoms fluctuate with the patient’s attention to them. However, many other disorders that are not called “FND” nonetheless can also follow this pattern. Consequently, guidelines are unclear for diagnosing “FND.” OBJECTIVE: To review the neurological conditions that follow this pattern, but which have not so far been termed “FND,” to understand their overlap with conditions that have been termed “FND,” and to discuss the rationale for why FND has not been diagnosed for them. METHOD: A systematic review of the PubMed literature registry using the terms “fluctuation,” “inconsistency,” or “attention” did not yield much in the way of these candidate disorders. Consequently, this review instead relied on the author’s personal library of peer-reviewed studies of disorders that have resembled FND but which were not termed this way, due to his longstanding interest in this problem. Consequently, this approach was not systematic and was subjective regarding disease inclusion. RESULTS: This review identified numerous, diverse conditions that generally involve fluctuating neurological symptoms that can vary with the person’s attention to them, but which have not been called “FND.” The literature was unclear for reasons for not referring to “FND” in these instances. CONCLUSION: Most likely because of historical biases, the use of the term “FND” has been unnecessarily restricted. Because at its core FND is an attentionally-influenced disorder that can respond well to behavioral treatments, the field of neurological rehabilitation could benefit by extending the range of conditions that could be considered as “FND” and referred for similar behavioral treatments. Because the term “FND” has been viewed unfavorably by some patients and clinical practitioners and whose treatment is not implied, the alternative term attentionally-modifiable disorder is proposed.

Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A Systematic Review-Based, Individual Participant Data Network Meta-Analysis

BACKGROUND AND PURPOSE

Optimizing speech and language therapy (SLT) regimens for maximal aphasia recovery is a clinical research priority. We examined associations between SLT intensity (hours/week), dosage (total hours), frequency (days/week), duration (weeks), delivery (face to face, computer supported, individual tailoring, and home practice), content, and language outcomes for people with aphasia.

METHODS

Databases including MEDLINE and Embase were searched (inception to September 2015). Published, unpublished, and emerging trials including SLT and ≥10 individual participant data on aphasia, language outcomes, and time post-onset were selected. Patient-level data on stroke, language, SLT, and trial risk of bias were independently extracted. Outcome measurement scores were standardized. A statistical inferencing, one-stage, random effects, network meta-analysis approach filtered individual participant data into an optimal model examining SLT regimen for overall language, auditory comprehension, naming, and functional communication pre-post intervention gains, adjusting for a priori-defined covariates (age, sex, time poststroke, and baseline aphasia severity), reporting estimates of mean change scores (95% CI).

RESULTS

Data from 959 individual participant data (25 trials) were included. Greatest gains in overall language and comprehension were associated with >20 to 50 hours SLT dosage (18.37 [10.58-26.16] Western Aphasia Battery-Aphasia Quotient; 5.23 [1.51-8.95] Aachen Aphasia Test-Token Test). Greatest clinical overall language, functional communication, and comprehension gains were associated with 2 to 4 and 9+ SLT hours/week. Greatest clinical gains were associated with frequent SLT for overall language, functional communication (3-5+ days/week), and comprehension (4-5 days/week). Evidence of comprehension gains was absent for SLT ≤20 hours, <3 hours/week, and ≤3 days/week. Mixed receptive-expressive therapy, functionally tailored, with prescribed home practice was associated with the greatest overall gains. Relative variance was <30%. Risk of trial bias was low to moderate; low for meta-biases.

CONCLUSIONS

Greatest language recovery was associated with frequent, functionally tailored, receptive-expressive SLT, with prescribed home practice at a greater intensity and duration than reports of usual clinical services internationally. These exploratory findings suggest critical therapeutic ranges, informing hypothesis-testing trials and tailoring of clinical services. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018110947.

Behavioral interventions for poststroke aphasia

There is a long history of behavioral interventions for poststroke aphasia with hundreds of studies supporting the benefits of aphasia treatment. However, interventions for aphasia are complex with many interacting components, and no one treatment is appropriate for all persons with aphasia. We present a novel, simple framework for classifying aphasia interventions. The framework is incorporated within the overarching International Classification of Functioning, Disability, and Health (ICF) model and is consistent with the commonly-held definition that aphasia is a multimodality disorder that impairs, in varying degrees, the understanding and expression of both oral and written language modalities. Furthermore, within the language impairment level, it distinguishes between the linguistic areas of phonology, semantics, and syntax that may be impaired individually or in combination. We define the terminology of the proposed framework and then categorize some common examples of behavioral interventions for post-stroke aphasia. We describe some of these interventions in greater detail to illustrate the extensive toolbox of evidence-based treatments for aphasia. We address some key issues that clinicians, usually speech-language pathologists, consider when selecting interventions for their specific patients with aphasia, including dose. Finally, we address various models of service delivery for persons with aphasia such as Intensive Comprehensive Aphasia Programs (ICAPs) and Aphasia Centers.

Melodic Intonation Therapy on Non-fluent Aphasia After Stroke: A Systematic Review and Analysis on Clinical Trials

Melodic intonation therapy (MIT) is a melodic musical training method that could be combined with language rehabilitation. However, some of the existing literature focuses on theoretical mechanism research, while others only focus on clinical behavioral evidence. Few clinical experimental studies can combine the two for behavioral and mechanism analysis. This review aimed at systematizing recent results from studies that have delved explicitly into the MIT effect on non-fluent aphasia by their study design properties, summarizing the findings, and identifying knowledge gaps for future work. MIT clinical trials and case studies were retrieved and teased out the results to explore the validity and relevance of these results. These studies focused on MIT intervention for patients with non-fluent aphasia in stroke recovery period. After retrieving 128 MIT-related articles, 39 valid RCT studies and case reports were provided for analysis. Our summary shows that behavioral measurements at MIT are excessive and provide insufficient evidence of MRI imaging structure. This proves that MIT still needs many MRI studies to determine its clinical evidence and intervention targets. The strengthening of large-scale clinical evidence of imaging observations will result in the clear neural circuit prompts and prediction models proposed for the MIT treatment and its prognosis.

DUbbing Language-therapy CINEma-based in Aphasia post-Stroke (DULCINEA): study protocol for a randomized crossover pilot trial

BACKGROUND

Communication is one of the most important predictors of social reintegration after stroke. Approximately 15-42% of stroke survivors experience post-stroke aphasia. Helping people recover from aphasia is one of the research priorities after a stroke. Our aim is to develop and validate a new therapy integrating dubbing techniques to improve functional communication.

METHODS

The research project is structured as three work packages (WP). WP1: development of the dubbed language cinema-based therapy: Two research assistants (a speech therapist and a dubbing actor) will select the clips, mute specific words/sentences in progressive speech difficulty, and guide patients to dub them across sessions. Words to be dubbed will be those considered to be functionally meaningful by a representative sample of aphasic patients and relatives through an online survey. WP2: a randomized, crossover, interventional pilot study with the inclusion of 54 patients with post-stroke non-fluent aphasia. Patients will be treated individually in 40-min sessions twice per week for 8 weeks. Primary outcomes will be significant pre/post differences in scores in the Communicative Activity Log (CAL) questionnaire and Boston Diagnostic Aphasia Examination (BDAE) administered by a psychologist blinded to the patients' clinical characteristics.

SECONDARY OUTCOMES

General Health Questionnaire (GHQ)-12, Stroke Aphasia Quality of Life Scale (SAQOL-39), Western Aphasia Battery Revised (WAB-R), and the Stroke Aphasic Depression Questionnaire (SADQ10). WP3: educational activities and dissemination of results. WP3 includes educational activities to improve public knowledge of aphasia and dissemination of the results, with the participation of the Spanish patients' association Afasia Activa.

DISCUSSION

This pilot clinical trial will explore the efficacy of a new therapeutic tool based on dubbing techniques and computer technology to improve functional communication of patients suffering from post-stroke aphasia with the use of standardized test assessment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04289493 . Registered on 28 February 2020.

The effect of music therapy on language recovery in patients with aphasia after stroke: a systematic review and meta-analysis

OBJECTIVE

The aim of this meta-analysis was to evaluate the evidence on the effectiveness of music therapy in the recovery of language function in post-stroke aphasia, compared with conventional therapy or no therapy.

METHODS

We searched studies that explored the effect of music therapy on language function in post-stroke aphasia and published in PubMed, Embase, the Cochrane Library, Web of Science, CINAHL, ProQuest Digital Dissertations, and ClinicalTrials.gov from inception to March 2021. Six reviewers independently screened out eligible studies, extracted data, and evaluated the methodological quality. Results were pooled using mean difference (MD) with 95% confidence interval (CI). Heterogeneity was assessed by the chi-square test and I² statistic.

RESULTS

Six studies were included in this meta-analysis involving 115 patients. The methodological quality of these studies ranged from poor to excellent. There was significant mean difference in functional communication for post-stroke aphasia by 1.45 (95% CI: 0.24, 2.65; P = 0.02, from poor to excellent evidence), in repetition by 6.49 (95% CI: 0.97, 12.00; P = 0.02, from acceptable to excellent evidence), and in naming by 11.44 (95% CI: 1.63, 21.26; P = 0.02, from acceptable to excellent evidence). But there was no significant difference in comprehension for post-stroke aphasia by 7.21 (95% CI: - 10.88, 25.29; P = 0.43, from acceptable to excellent evidence).

CONCLUSIONS

Music therapy can improve functional communication, repetition, and naming in patients with post-stroke aphasia, but did not significantly improve comprehension.

TRIAL REGISTRATION

CRD42021251526.

Melodic Intonation Therapy for Post-stroke Non-fluent Aphasia: Systematic Review and Meta-Analysis

Introduction: Melodic intonation therapy (MIT) is one of the most studied speech and language therapy (SLT) approaches for patients with non-fluent aphasia, although the methodological quality of the studies has been rated as low in previous reviews. The aim of this study is to update current evidence on the possible efficacy of MIT for the treatment of non-fluent post-stroke aphasia.

Methods: A systematic review and meta-analysis. We selected randomized clinical trials (RCT) that included adult patients over 18 years of age with non-fluent post-stroke aphasia, whose intervention was MIT vs. no therapy or other therapy. We excluded non-RCT studies, mixed populations including patients with aphasia of non-stroke etiology, studies with no availability of post-stroke aphasia-specific data, and incomplete studies. Three sections of communicative ability were analyzed as outcomes: functional communication, expressive language (naming and repetition), and comprehension.

Results: We identified a total of four eligible RCTs involving 94 patients. Despite the heterogeneity in the psychometric tests employed among the trials, a significant effect of MIT on functional communication (evaluated by the Communication Activity Log) was found (SMD 1.47; 95% CI 0.39–2.56). In addition, a positive effect of MIT on expressive language (repetition) was found (SMD 0.45; 95% CI 0.01–0.90). No significant effects on comprehension measurements were found, despite a lack of significant statistical heterogeneity.

Conclusion: This systematic review and meta-analysis shows a significant effect of MIT on improving functional communication and on repetition tasks. Future larger RCT specifically addressing those outcomes should provide the definite evidence on the efficacy of MIT on post-stroke aphasia recovery.

Systematic Review Registration:PROSPERO-URL https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020144604.

Novel Advances to Post-Stroke Aphasia Pharmacology and Rehabilitation

Aphasia is one of the most common clinical features of functional impairment after a stroke. Approximately 21–40% of stroke patients sustain permanent aphasia, which progressively worsens one’s quality of life and rehabilitation outcomes. Post-stroke aphasia treatment strategies include speech language therapies, cognitive neurorehabilitation, telerehabilitation, computer-based management, experimental pharmacotherapy, and physical medicine. This review focuses on current evidence of the effectiveness of impairment-based aphasia therapies and communication-based therapies (as well as the timing and optimal treatment intensities for these interventions). Moreover, we present specific interventions, such as constraint-induced aphasia therapy (CIAT) and melodic intonation therapy (MIT). Accumulated data suggest that using transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) is safe and can be used to modulate cortical excitability. Therefore, we review clinical studies that present TMS and tDCS as (possible) promising therapies in speech and language recovery, stimulating neuroplasticity. Several drugs have been used in aphasia pharmacotherapy, but evidence from clinical studies suggest that only nootropic agents, donepezil and memantine, may improve the prognosis of aphasia. This article is an overview on the current state of knowledge related to post-stroke aphasia pharmacology, rehabilitation, and future trends.

Effectiveness of Melodic Intonation Therapy in Chinese Mandarin on Non-fluent Aphasia in Patients After Stroke: A Randomized Control Trial

Melodic intonation therapy (MIT) positively impacts the speech function of patients suffering from aphasia and strokes. Fixed-pitch melodies and phrases formulated in MIT provide the key to the target language to open the language pathway. This randomized controlled trial compared the effects of music therapy-based MIT and speech therapy on patients with non-fluent aphasia. The former is more effective in the recovery of language function in patients with aphasia. Forty-two participants were enrolled in the study, and 40 patients were registered. The participants were randomly assigned to two groups: the intervention group (n = 20; 16 males, 4 females; 52.90 ± 9.08 years), which received MIT, and the control group (n = 20; 15 males, 5 females; 54.05 ± 10.81 years), which received speech therapy. The intervention group received MIT treatment for 30 min/day, five times a week for 8 weeks, and the control group received identical sessions of speech therapy for 30 min/day, five times a week for 8 weeks. Each participant of the group was assessed by a Boston Diagnostic Aphasia Examination (BDAE) at the baseline (t1, before the start of the experiment), and after 8 weeks (t2, the experiment was finished). The Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) were also measured on the time points. The best medical care of the two groups is the same. Two-way ANOVA analysis of variance was used only for data detection. In the spontaneous speech (information), the listening comprehension (right or wrong, word recognition, and sequential order) and repetitions of the intervention group were significantly higher than the control group in terms of the cumulative effect of time and the difference between groups after 8 weeks. The intervention group has a significant time effect in fluency, but the results after 8 weeks were not significantly different from those in the control group. In terms of naming, the intervention group was much better than the control group in spontaneous naming. Regarding object naming, reaction naming, and sentence completing, the intervention group showed a strong time accumulation effect. Still, the results after 8 weeks were not significantly different from those in the control group. These results indicate that, compared with speech therapy, MIT based on music therapy is a more effective musical activity and is effective and valuable for the recovery of speech function in patients with non-fluent aphasia. As a more professional non-traumatic treatment method, MIT conducted by qualified music therapists requires deeper cooperation between doctors and music therapists to improve rehabilitating patients with aphasia. The Ethics Committee of the China Rehabilitation Research Center approved this study (Approval No. 2020-013-1 on April 1, 2020) and was registered with the Chinese Clinical Trial Registry (Registration number: Clinical Trials ChiCTR2000037871) on September 3, 2020.

Neural plasticity: The substratum of music-based interventions in neurorehabilitation

BACKGROUND

The plastic nature of the human brain lends itself to experience and training-based structural changes leading to functional recovery. Music, with its multimodal activation of the brain, serves as a useful model for neurorehabilitation through neuroplastic changes in dysfunctional or impaired networks. Neurologic Music Therapy (NMT) contributes to the field of neurorehabilitation using this rationale.

OBJECTIVE

The purpose of this article is to present a discourse on the concept of neuroplasticity and music-based neuroplasticity through the techniques of NMT in the domain of neurological rehabilitation.

METHODS

The article draws on observations and findings made by researchers in the areas of neuroplasticity, music-based neuroplastic changes, NMT in neurological disorders and the implication of further research in this field.

RESULTS

A commentary on previous research reveal that interventions based on the NMT paradigm have been successfully used to train neural networks using music-based tasks and paradigms which have been explained to have cross-modal effects on sensorimotor, language and cognitive and affective functions.

CONCLUSIONS

Multimodal gains using music-based interventions highlight the brain plasticity inducing function of music. Individual differences do play a predictive role in neurological gains associated with such interventions. This area deserves further exploration and application-based studies.

Speech rehabilitation in post-stroke aphasia using visual illustration of speech articulators: A case report study

Recent studies on the remediation of speech disorders suggest that providing visual information of speech articulators may contribute to improve speech production. In this study, we evaluate the effectiveness of an illustration-based rehabilitation method on speech recovery of a patient with non-fluent chronic aphasia. The Ultraspeech-player software allowed visualization by the patient of reference tongue and lip movements recorded using ultrasound and video imaging. This method can improve the patient's awareness of their own lingual and labial movements, which can increase the ability to coordinate and combine articulatory gestures. The effects of this method were assessed by analyzing performance during speech tasks, the phonological processes identified in the errors made during the phoneme repetition task and the acoustic parameters derived from the speech signal. We also evaluated cognitive performance before and after rehabilitation. The integrity of visuospatial ability, short-term and working memory and some executive functions supports the effectiveness of the rehabilitation method. Our results showed that illustration-based rehabilitation technique had a beneficial effect on the patient's speech production, especially for stop and fricative consonants which are targeted (high visibility of speech articulator configurations) by the software, but also on reading abilities. Acoustic parameters indicated an improvement in the distinction between consonant categories: voiced and voiceless stops or alveolar, post-alveolar and labiodental fricatives. However, the patient showed little improvement for vowels. These results confirmed the advantage of using illustration-based rehabilitation technique and the necessity of detailed subjective and objective intra-speaker evaluation in speech production to fully evaluate speech abilities.

5-year course of therapy-induced recovery in chronic non-fluent aphasia - Three single cases

Over a period of five years, three severely impaired chronic non-fluent aphasia patients with concomitant apraxia of speech (AOS) received annual treatment periods of specific rhythmic-melodic voice training SIPARI. This therapy concept focusses on improving planning, programming, and sequencing of speech movements emphasizing specifically the training of cognitive capabilities such as executive functions. Behavioral and neural data were assessed at the start of the therapy and continuously after each treatment period. As previously reported, a first major finding was that after the first treatment period, significant improvements in language and speech motor performance were measured going hand in hand with significant additional peri-lesional activation in all patients particularly in the posterior part of the left superior temporal gyrus. This activation pattern was continuously confirmed by each subsequent scan. However, assessments after the third treatment period yielded additional significant activations in dorsolateral prefrontal cortex regions, namely in the left middle and superior frontal gyri, and anterior cingulate gyrus resulting in a further statistically significant increase in speech profile level, an overall and clinically relevant measure of the severity of aphasia. On the basis of our results, we assume that even in long-term rehabilitation of severely impaired non-fluent aphasia patients the applied treatment may support coactivation with dorsolateral prefrontal regions, suggested to be particularly involved in cognitive processing. This left-lateralized dorsolateral prefrontal-parietal network is supposed to be engaged in domain-general aspects of active phonological memory. To the best of our knowledge, no comparable studies are available as yet. Therefore, we hope that our study may serve to attract more attention for the late stages of long-term rehabilitation, not at least as a challenge for therapists and researchers alike.

Melodic intonation therapy in post-stroke nonfluent aphasia: a randomized pilot trial

Objective:

To collect data to estimate the sample size of a definitive randomized controlled trial to evaluate the effects of Melodic Intonation Therapy in post-stroke nonfluent aphasia.

Design:

A randomized, crossover, interventional pilot trial.

Setting:

Departments of Neurology and Rehabilitation from a university general hospital.

Participants:

Stroke survivors with post-stroke nonfluent aphasia.

Interventions:

Patients randomized to group 1 had treatment with Melodic Intonation Therapy first (12 sessions over six weeks) followed by no treatment; the patients in group 2 started active treatment between three and six months after their inclusion in the study, serving as waiting list controls for the first phase.

Main measures:

The Communicative Activity Log (CAL) questionnaire and the Boston Diagnostic Aphasia Examination (BDAE) were evaluated at baseline, and at six and 12 weeks.

Results:

Twenty patients were included. Four of the patients allocated to group 2 crossed over to group 1, receiving the treatment at first. Intention-to-treat analysis: after adjustment for baseline scores, the mean difference in the CAL evaluation from baseline in the treated group was 8.5 points (95% confidence interval (CI), 0.11–17.0; P = .043), with no significant change in any of the BDAE sections. Per-protocol analysis showed similar results with a clear treatment effect ( P = .043) on the CAL.

Conclusion:

Melodic Intonation Therapy might have a positive effect on the communication skills of stroke survivors with nonfluent aphasia as measured by the CAL questionnaire. A full-scale trial with at least 27 patients per group is necessary to confirm these results.

Changes in Resting-State Connectivity following Melody-Based Therapy in a Patient with Aphasia

Melody-based treatments for patients with aphasia rely on the notion of preserved musical abilities in the RH, following left hemisphere damage. However, despite evidence for their effectiveness, the role of the RH is still an open question. We measured changes in resting-state functional connectivity following melody-based intervention, to identify lateralization of treatment-related changes. A patient with aphasia due to left frontal and temporal hemorrhages following traumatic brain injuries (TBI) more than three years earlier received 48 sessions of melody-based intervention. Behavioral measures improved and were maintained at the 8-week posttreatment follow-up. Resting-state fMRI data collected before and after treatment showed an increase in connectivity between motor speech control areas (bilateral supplementary motor areas and insulae) and RH language areas (inferior frontal gyrus pars triangularis and pars opercularis). This change, which was specific for the RH, was greater than changes in a baseline interval measured before treatment. No changes in RH connectivity were found in a matched control TBI patient scanned at the same intervals. These results are compatible with a compensatory role for RH language areas following melody-based intervention. They further suggest that this therapy intervenes at the level of the interface between language areas and speech motor control areas necessary for language production.

The role of music therapy in rehabilitation: improving aphasia and beyond

Music is part of the human nature, and it is also philogenically relevant to language evolution. Language and music are bound together in the enhancement of important social functions, such as communication, cooperation and social cohesion. In the last few years, there has been growing evidence that music and music therapy may improve communication skills (but not only) in different neurological disorders. One of the plausible reasons concerning the rational use of sound and music in neurorehabilitation is the possibility to stimulate brain areas involved in emotional processing and motor control, such as the fronto-parietal network. In this narrative review, we are going to describe the role of music therapy in improving aphasia and other neurological disorders, underlying the reasons why this tool could be effective in rehabilitative settings, especially in individuals affected by stroke.