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Voices: A World Forum for Music Therapy, Vol 16, No 1 (2016)

[Research]

Music and Stroke Rehabilitation: A Narrative

Synthesis of the Music-Based Treatments
used to Rehabilitate Disorders of Speech and
Language following Left-Hemispheric Stroke
By Kevin Draper

Abstract
Stroke is a leading cause of long-term disability. A stroke can damage areas of the brain
associated with communication, resulting in speech and language disorders. Such
disorders are frequently acquired impairments from left-hemispheric stroke. Music-based
treatments have been implemented, and researched in practice, for the past thirty years;
however, the number of published reports reviewing these treatments is limited. This
paper uses the four elements of the narrative synthesis framework to investigate,
scrutinise and synthesise music-based treatments used in the rehabilitation of patients
with speech and language disorders. A systematic review revealed that fifteen studies
meet the inclusion criteria set out. It was found that the music-based treatments utilised
included: Melodic Intonation Therapy (MIT), Modified Melodic Intonation Therapy (MMIT),
adapted forms of MIT, the Singing Intonation, Prosody, breathing (German: Atmung),
Rhythm and Improvisation (SIPARI) method and a variety of methods using singing and
songs. From a synthesis of the data, three themes emerged which were key elements of
the interventions; they were: (a) singing songs and vocal exercises, (b) stimulating the
right hemisphere and (c) use of speech prosody. These themes are discussed and
implications for newly-qualified practitioners are explored.

Keywords: left-hemispheric stroke; speech and language disorders; music therapy; music
and stroke; aphasia.

Introduction
Every year around 10,000 people in Ireland have a stroke, with approximately 2000
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resulting in death. It is estimated that 30,000 people in Ireland are living with disabilities
caused by a stroke or a series of strokes (Irish Heart Foundation, n.d., para. 1). The most
common are varying severities of left- and right-sided hemiparesis and acquired speech
and language disorders such as aphasia, apraxia of speech, and dysarthria.
Consequently, professional therapeutic services are continuously required in
rehabilitation programmes designed for stroke survivors. There is an ever-growing body
of literature investigating the use of music-based methods in rehabilitation following
stroke in the areas of speech and language disorders, physical rehabilitation, emotional
and social support, and memory loss. For many years, research has been undertaken to
examine the efficacy and validity of these treatments in the rehabilitation process.
However, the methods and interventions adopted need to be assessed in a transparent
manner and arranged systematically. This paper seeks to investigate, review and
synthesise the music-based treatments used to rehabilitate left-hemispheric stroke
survivors with speech and language disorders.

Positioning of the Researcher: A Case Study

My interest in the area of speech and language rehabilitation following stroke began in
2013 during college work-experience placement at a rehabilitation hospital in the east of
Ireland. During this time, a patient was referred to me by a speech and language
therapist. John [pseudonym] was a fifty-five-year-old man who had recently suffered a
left-hemispheric cerebral vascular accident (CVA). He was diagnosed with global aphasia
and apraxia of speech. Post stroke he was now a wheelchair user and had mild paresis
in his upper limbs, but his prognosis for physical abilities was optimistic. His most
concerning post stroke impairment involved his verbal communication skills.

John attended a total of three with me. As a student, with limited experience working with
people with speech and language disorders, I had little prior knowledge of the potential
benefits which music-based treatments could offer him. However, basic patient
information gathered during the referral process informed me that he enjoyed singing
along to the radio but could not articulate the words of the songs. While adopting a client-
led approach, the music-therapy sessions usually involved song singing where I would
play a song on the guitar and sing, and John would vocalise along with me. He did not
have the ability to pronounce the lyrics but vocalised the melodies using the vowel
sounds a and ou, and also a mi sound. A particularly interesting moment in the
second session occurred when John spontaneously began to vocalise the melody of a
song without me accompanying him. He sang two verses of an Irish folk song; then he
stopped, smiled and nodded to me. I felt that this moment of spontaneity was especially
striking because he sang the melody in his own way and in such a manner that I was
able to accurately identify the song. Articulating this melody to an extent where it was
recognisable required rhythm, intonation, prosody, pitch, and oral muscle control.

Due to his injuries John had lost the ability to form a two-word intelligible phrase.
Nonetheless, in music-therapy sessions he demonstrated an ability to vocalise melodies
to an extent where the specific songs were clearly recognisable. However brief my time
with John, the experience left me feeling very curious with many questions. Most
importantly, I wanted to know how he was able to vocalise melodies which required
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various vocal and oral skills and abilities while simultaneously having a significantly
impaired ability to communicate using speech. I wanted to know what was happening
neurologically in the relationship between music and language, and between singing and
speaking. I wondered if a long-term music-based treatment could have benefitted his
rehabilitation. I considered how musical methods could be used when working with John,
and also I speculated if I, as a student, would have had the skills and time to implement
them.

Left-Hemispheric Stroke
Baker and Tamplin (2006) explained that a cerebral vascular accident or CVA occurs
when a part of the brain is deprived of blood flow and subsequently dies. Neurological
damage can occur as a result of two types of CVA. Ischaemic stroke, which is the most
frequently diagnosed type, occurs when there is a blockage in an artery supplying blood
to the brain (Safranek, 2011). Haemorrhagic stroke occurs when sudden high blood
pressure causes arteries within the brain to rupture (Wong, 2004). The resulting effects of
stroke vary by its type and location in the brain. Following a left- or right-sided CVA, there
will often be residual damage to one of the main hemispheres in the brain. Discussing
left-sided CVAs specifically, Baker and Tamplin (2006) and Safranek (2011) described
how it affects the right side of the body causing hemiplegia or hemiparesis and
sensorimotor difficulties such as poor balance, gait and decreased speed of movement.
Difficulties can also materialise in memory problems, as well as behavioural and
personality changes. In the context of the current study it is important to note that left-
sided CVAs can result in speech and language disorders including aphasia, dysarthria
and apraxia of speech.

Speech and Language Disorders

Left-sided CVAs commonly cause three types of speech and language disorders; these
are dysarthria and apraxia of speech, and aphasia. This section is dedicated to briefly
discussing these three disorders.

Aphasia is defined as an acquired language disorder caused by some form of damage to

the brain, the most frequent being stroke (Hallowell & Chapey, 2008). Wong (2004)
described aphasia as damage to the part of the brain that controls language. It is
characterised by an impairment of the language modalities of speaking, listening,
reading, and writing. Aphasia is the most frequently diagnosed communication disorder
following a left-hemispheric stroke (Baker & Tamplin, 2006). According to the National
Stroke Association of America, there are 800,000 diagnosed strokes each year in the
USA with 2535% causing some form of aphasia (as cited in Conklyn, Novak, Boissy,
Bethoux, & Chemali, 2012). Schlaug, Norton, Marchina, Zipse, & Wan, (2010) and
Conklyn et al. (2012) reported corresponding statistics for the USA regarding the
development of aphasia following stroke. Similarly from a European perspective, Jungblut
(2005) stated that 30% of stroke survivors in Germany acquire aphasia.

There are several different types of aphasia which cause impairment ranging from mild to
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severe. These include fluent aphasia, non-fluent aphasia, anomic aphasia, global
aphasia and primary progressive aphasia. The literature sourced for the current synthesis
revealed that 96% of the left-hemispheric stroke survivors who participated in the studies
had non-fluent aphasia (see Appendix A and Appendix B); this is also known as Brocas
or expressive aphasia. It is characterised primarily by a deficiency in language
formulation and production (Hallowell & Chapey, 2008). Speech can be slow with long
pauses between words; the individual may have difficulty in naming objects and may
demonstrate poor sentence construction and disturbed prosody (Baker & Tamplin, 2006).
However, auditory and reading comprehension can remain intact.

Dysarthria defined as a disorder of movement or movement control of oral

communication is a motor speech disorder which can occur following a stroke. It refers
to the weakness of muscles responsible for oral, laryngeal and respiratory control (Duffy,
1995). Baker and Tamplin (2006) described dysarthria as poor articulation and vocal
control, while Wong (2004) stated that tongue control may be impaired affecting a
persons ability to speak clearly, chew food and clear food from the mouth, as well as
affecting voice consistency. Two common types of dysarthria include flaccid dysarthria
where the oral muscles become weak and tend to droop, and spastic dysarthria where
the oral muscles become tight and vocal sounds have to be forced and tense (Wong,
2004).

Duffy (1995) defined apraxia of speech as a neurological speech disorder which is

distinguished by an impaired ability to plan or programme conscious speech commands
into oral motor movements which are necessary for speech production. It can also be
diagnosed as oral apraxia, but in all cases it presents as a difficulty or inability to
coordinate movements of the tongue, lips or vocal cords (Wong, 2004).

Methodology
Narrative Synthesis
Narrative synthesis is a widely-used, systematic reviewing method (McDermott, Crellin,
Ridder & Orrell, 2013). Popay, Roberts, Sowden, Petticrew, Arai, Rodgers, Britten, Roen,
& Duffy, (2006) devised a narrative synthesis guide in order to make the approach more
systematic and to minimise bias. It defined narrative synthesis as an approach to
systematic reviews and the collection of findings that primarily relies on the use of words
and text in summarising and describing the findings. Findings can also be presented
using visual representations such as graphs, statistics, tabulations, conceptual maps, etc.
McDermott et al. (2013) demonstrated that the key to successful narrative synthesis is to
review what worked but also to investigate how and why an intervention might have
worked. It is suggested that this research method is particularly suited to music-therapy
literature (ibid.).

Narrative synthesis involves four stages: (a) theory development, (b) preliminary
synthesis of findings, (c) exploration of relationships between studies, and (d) assessing
the robustness of the synthesis. The current study proposes to utilise these four
interactive elements in order to investigate, scrutinise, and synthesise the existing music-
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based methods used to rehabilitate individuals with disorders of speech and language.

Narrative Synthesis Stage One: Theory Development

The first stage of the narrative synthesis approach involved gathering background
information in order to understand the theory behind the specific area of research. After
the relevant information had been identified it enabled me to theorise how and why
certain interventions work. By working through this process, I was able to determine the
direction I was coming from as a researcher and acknowledge my own beliefs; in turn it
enabled me to recognise my own biases. Formulating a personal theory allows a
researcher to identify questions and themes that are important to their own research, as
well as possible implications for practice. My theory development involved considering
the link between music and language from birth, and also how this may impact or
influence a person with communication impairments following stroke.

Link between music and language.

The link between music and language has been established in previous research and is
widely accepted (Hartley, Turry, & Raghaven, 2010; Hurkmans, de Bruijn, Boonstra,
Jonkers, Bastiaanse, Arendxen, & Reinders-Messelink, 2012). Infants are born with an
innate ability to imitate, respond to, match, and vocalise maternal singing and speech
(Briggs, 1991; Hargreaves, 1996). Chen-Hafteck (1997) provided evidence on the link
between music and language in early child development. Crystal (1987) stated that at
around 820 months an infant displays the first signs of gross oral activities required for
speech development (as citied in Chen-Hafteck, 1997). As the infant grows older, their
vocalisations described as cooing are continually becoming more coordinated. This is
indicative of their growing vocal control, which is essentially a musical ability. The authors
proposed that these learned abilities by infants are prelinguistic or premusical, which
reinforces the close relationship between music and language. At this point, it must be
considered that musical ability is possibly ingrained in human nature from birth.

There is also a strong link between music and language in people with speech and
language impairments. Disorders such as aphasia occur because of damage to the areas
of the brain necessary for communication. However, Brust (1980; 2001) outlined that for
more than 200 years, it has been reported that patients who have severely-impaired
speech abilities retain the ability to produce well-articulated and accurate words when
singing (as cited in Wilson, Parsons, & Reutens, 2006).

The infant and the stroke patient.

As discussed above, the literature provides strong evidence for the link between music
and language in infancy and a relationship between singing and speaking following brain
injury. It has been suggested that infants have musical abilities (Briggs, 1991; Chen-
Hafteck, 1997; Hargreaves, 1996), but they do not have the linguistic skills necessary for
verbal communication until 1 or 2-years old. They rely on body language and preverbal
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methods to communicate their needs. Thus, in many ways, people with acquired speech
and language disorders communicate on the same level as an infant. They may have lost
several communication abilities and may also rely on non-verbal communication.
Therefore, with this evidence in mind, the capabilities of a person with a speech or
language disorder resulting from a stroke are, somewhat, comparable to the musical and
communication abilities of an infant.

Musical ability following stroke.

In relation to musical abilities, it has been observed that some stroke patients with
aphasia have intact musical skills, in particular their unimpaired ability to sing. This
observation led to the development of melodic intonation therapy or MIT (Albert et al.,
1973). Evidence suggests that music-based treatments hold specific benefits for the
recovery of speech and language following stroke. In more recent years, other musical
methods have been developed, such as modified melodic intonation therapy or MMIT
(Baker, 2000) and the SIPARI method: Singing, Intonation, Prosody, Atmung (breathing),
Rhythm, Improvisation (Jungblut and Aldridge, 2004). It is very much an expanding body
of literature and research because the musical protocols being devised are still being
evaluated and their effectiveness, in the rehabilitation of stroke patients, is being
continually evaluated. Despite the existing wealth of literature on the topic there are few
studies to date which provide in-depth analysis, exploration and synthesis of these
musical intervention techniques.

Data Search
Search strategy.
For this synthesis, the literature search was greatly influenced by search methods utilised
by Woodward (2012). The current search used a step-wise approach that involved the
following elements: searching databases, scrolling through citations, deep journal
searching, and researching outside sources. A table was developed in order to organise
and guide the search strategy (see Table 1). Electronic searches were conducted
primarily on AMED, MEDLINE, PsycINFO, CINAHL, Cochrane Library, SAGE, Science
Direct, and Google Scholar. Relevant journals were identified and searched; these
included Journal of Music Therapy, Nordic Journal of Music Therapy, and Music and
Medicine. Three key subject areas formed the scope of the search: music, speech and
language disorders, and stroke. Within these areas, subcategories of keywords were
created to identify relevant studies. To ensure that all relevant areas were covered,
search terms were used in combination and these included the keywords within the
subcategories. When conducting the search, it was also necessary to develop a list of
inclusion and exclusion criteria (see below) which could be used to determine which
studies were relevant to this particular synthesis.

Music Speech and Language Disorders Stroke

Music therapy Aphasia Left-hemispheric stroke

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Musical methods Dysarthria
Music interventions Apraxia
Speech disorder
Language disorder
Table 1. Knowledge categories and search terms

Inclusion criteria:

Studies in the English language published in peer-reviewed journals or book

chapters between 2003 and 2013;
Studies exploring the use of music-based treatments as interventions;
Studies focusing on the rehabilitation of patients with speech and language
disorders;
Studies that included left-hemispheric stroke patients;
Studies that explored the use of music as a key method in addressing speech and
language disorders.

Exclusion criteria:

Studies that were published pre2003;

Studies that included right-hemispheric stroke patients.

An issue that arose during the data search was the difficulty in sourcing relevant literature
pertaining to the key subject areas of this study. A search for music and stroke
identified an abundance of articles across the databases. Furthermore, specific searches
for music therapy, stroke and aphasia revealed over 100 studies across databases,
however, many were not relevant to this synthesis. When the combined keywords were
searched, and when the inclusion and exclusion criteria were subsequently applied, a
significant number of studies had to be excluded revealing a relatively small number of
applicable studies (see below). The difficulty in sourcing literature was probably due to
the very specific focus of the current synthesis.

Results
Narrative Synthesis Stage Two: Developing a Preliminary Synthesis
Description of search results and data.
The data search revealed over 20 relevant studies that were then scrutinised under the
inclusion and exclusion criteria. The participant information sections indicated that
several of these studies focused on right-hemispheric stroke patients and, therefore,
were excluded. Other studies were conducted prior to the year 2003 and were excluded
on this basis. Some of the studies did not focus on the rehabilitation of individuals with
speech and language disorders, but were instead concerned with the link between
emotional difficulties and communication impairment following stroke; these studies were
also excluded. A total of 15 studies met the inclusion criteria. Fourteen of these were
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sourced from peer-reviewed journals and one study formed a chapter in a book.

The synthesis process.

The synthesis process was broken into two steps. The first step was a preliminary
synthesis which involved the creation of a literature matrix (see Appendix A). The
purpose of the matrix was to organise and summarise each of the 15 studies, and
combine all of them together in one table. The matrix made the, somewhat,
overwhelming task of extracting relevant information from each study more manageable.
The matrix was made up of several columns of basic information including methodology,
number of participants, focus of the study, and musical interventions. It also presented a
brief narrative summary of each study that was influenced by a methodology developed
by Lucas, Baird, Law, & Roberts, (2007) that provided guidance on textual study
commentaries for narrative synthesis reviews. The summaries conveniently supply the
principal points of each study making it unnecessary for the reader to read, or scroll
through, each article in entirety. The literature matrix was also a starting point which
would facilitate further synthesis of the data during the course of this research.

Following the narrative synthesis approach, the second step of the synthesis process
involved the creation of an extensive and in-depth table in which all 15 studies were
synthesised (see Appendix B). The purpose of this table was to provide more
comprehensive details of each study than the literature matrix (Appendix A) had
produced, and to begin to identify specific information, characteristics and patterns
across the studies which were deemed potentially important to the current study.

Overview of the Literature

By using both the literature matrix (Appendix A) and the detailed synthesis table
(Appendix B) a full overview of the studies was obtained. Firstly, several characteristics
were identified as particularly important starting points when analysing the data. The
following sub-sections outline the preliminary stages of data analysis and also attempt to
answer some important research questions that arose during this process.

Study methodologies.
As stated above, in total there were 15 studies included in the synthesis. Of these 15, 12
studies utilised quantitative research methods while the other three utilised qualitative
descriptions and evaluations of interventions and outcomes. Further breaking down the
methodologies used in each of the 15 studies, we see that five studies used a
randomised controlled trial (RCT) approach (Conklyn et al., 2012; Jungblut, 2005;
Jungblut, Suchanek, & Gerhard, 2009; Lim, Kim, Lee, Yoo, Hwang, Kim, & Kim, 2012;
Straube, Schulz, Geipel, Mentzel, & Miltner, 2008). Three of the RCTs involved between
17 and 30 participants, while of the remaining two RCTs one involved five participants
and the other only two. Of the 10 studies that did not use RCTs, four studies used a
multiple-participant case study design each involving between six and eight participants
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(Kim & Tomaino, 2008; Racette, Bard, & Peretz, 2006; Schlaug, Marchina, & Norton,
2009; Vines, Norton, & Schlaug, 2011). The remaining six studies were conducted as
single-participant case studies.

Musical interventions.
The initial and most basic question that this research sought to answer involved
identifying the musical interventions utilised in the 15 studies. It was found that a variety
of musical interventions were utilised and explored. Of the 15 studies:

five studies investigated the efficacy of MIT;

five studies incorporated a variety of methods using songs and singing;
two studies used adapted versions of MIT;
two studies explored the SIPARI method;
and one study investigated MMIT.

Speech and language disorders.

During the early stages of this synthesis, it was also important to identify, within each of
the 15 studies, the types of speech and language disorders concerned. This would
determine the focus of the literature and who could benefit from these music-based
treatments. In total there were 108 study-subjects involved across all 15 studies. Ninety-
nine of these subjects had suffered various types of left-hemispheric strokes. Five other
participants had damage of the right cerebral hemisphere and four more participants
were healthy adults recruited as control subjects in one study (Straube, Schulz, Geipel,
Mentzel, & Miltner, 2008).

Of the 99 diagnosed with left-hemispheric stroke, 96 of those were diagnosed with non-
fluent Brocas-type aphasia. Three participants were diagnosed with global aphasia. The
99 left-hemispheric stroke participants also displayed signs of other speech and language
disorders. Six participants had non-fluent aphasia, dysarthria and apraxia; four
participants had aphasia and apraxia of speech; and two participants had non-fluent
aphasia and dysarthria

Discussion
Narrative Synthesis Stage Three: Exploring the Relationship Among
Studies
Purpose of this stage.
When conducting stage three of the narrative synthesis the relationships within, and
among, the 15 studies were explored; the synthesis table (Appendix B) proved a useful
aid in this process. This stage also considered the overall purpose of the current study.
Based on my position, at that particular time in my career, it was acknowledged that the
information collected should have relevant implications for newly-qualified practitioners.
Therefore, during detailed examinations of the 15 studies the need to extract clear,
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practical, and easily understandable information was recognised. When on placement I

worked with a stroke patient with global aphasia and during the synthesis process
important information was also gleaned; both of these factors informed me of the types of
music-based treatments available when working with this client population, as well as
providing indications of the types of disorders and clients which may benefit from such
treatments.

It was also necessary to explore both the treatments and the studies in more detail in
order to determine how and why the treatments did, or did not, produce an effect. In
addition, during this process it was necessary to identify themes which revealed
information of particular relevance to newly-trained music therapists. This information
was obtained by exploring and identifying patterns and common factors among the
music-based treatments and the studies.

Characteristics of studies: Focus, analysis, and outcomes

The relationships among the studies were explored in terms of their focus, data collection
and analysis, and their measures and outcomes.

Focus of the studies.

Seven studies had a specific focus on investigating the efficacy, benefits and potentials of
music-based treatments (Conklyn et al., 2012; Hough, 2010; Jungblut, 2005; Jungblut et
al., 2009; Kim & Tomaino, 2008; Wilson, Parsons, & Reutens, 2006; Zipse, Norton,
Marchina, & Schlaug, 2012). Of these seven, Jungblut (2005) and Jungblut et al. (2009)
investigated the efficacy of the SIPARI method using participants with non-fluent aphasia.
Four of the seven studies investigated the effects of MIT and adapted forms of MIT, while
one study explored the potential of a unique musical treatment protocol.

A further four studies were similar to one another in that they each explored two
interventions or approaches simultaneously. Within these four studies, Racette, Bard, &
Peretz, (2006) and Straube et al. (2008) investigated singing and speaking with
participants. They aimed to identify the potentials of singing and to determine if the
effects of singing are solely responsible for improving the speech of aphasic patients.
Using an RCT design, Lim et al. (2012) investigated the effects of neurologic music
therapy (NMT) and speech language therapy. The NMT consisted of MIT and therapeutic
singing. Similarly, Schlaug et al. (2008) examined two interventions using participants
who were randomly assigned to attend MIT sessions and speech-repetition therapy.

Data collection and analysis.

Several methods of data collection were applied throughout the 15 studies. Five studies
presented pre and post treatment data collection and analysis (Conklyn et al. 2012;
Jungblut, 2005; Lim et al. 2012; Schlaug et al., 2009; Vines et al., 2011). Five other
studies were designed by establishing a baseline prior to treatment; this was followed by
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an analysis of outcomes at specified follow-up assessments (Hough, 2010; Jungblut et

al., 2009; Schlaug et al., 2008; Wilson et al., 2006; Zipse, Norton, Marchina, & Schlaug,
2012). For example, Schlaug et al. (2008) established a baseline assessment of speech
output and conducted follow-up assessments after 40 and 75 sessions of treatment.
Three studies used qualitative descriptive analysis of participant capabilities and
assessments at the beginning of treatment and reported the outcomes on an on-going
basis (Hartley et al., 2010; Kim and Tomaino, 2008; 2010). The final two studies
investigated the relationship between singing and speaking (Racette et al., 2006; Straube
et al., 2008); they collected their data when experimental conditions were created and
evaluated it post treatment.

Measures and outcomes.

Identifying the relationship between the measures taken in each study and the outcomes
of each study was important in order to determine which aspects of the participants
disorders were targeted and measured during each study. All 15 studies provided
outcomes and recommendations for future research. The participants in nine of the
quantitative studies showed significant improvements in their outcome measures. For
example, an RCT conducted by Conklyn et al. (2012), that used a control group and a
treatment group, demonstrated a significant difference in pre and post assessments in
the treatment group following a session of MMIT. Significant improvements in
assessment tests of expressive linguistic skills, speech output, phrase production and
fluency of speech were found in studies conducted by Hough (2005), Jungblut (2005),
Jungblut et al. (2009), Schlaug et al. (2009), Vines et al. (2011) and Zipse et al. (2012).
The outcomes of the qualitative study by Tomaino (2010) also revealed an improvement
in singing ability at 4 weeks into the study. After 4 months of treatment the lone
participant was singing more freely, had complete recall and flow of words, and had
improved speech production, speech fluency, and word retrieval.

Themes and Implications for Practice

Bearing in mind previous information identified and explored concerning the relationships
among, and characteristics of, the 15 studies, this section aims to outline the principal
themes that emerged during the synthesis process. These themes specifically relate to
why and how the interventions may work, as well as commonalities between approaches
and key elements of the interventions. During the exploration and synthesis of the 15
studies, three major themes emerged; these were:

the use of singing and vocal exercises;

stimulating the right hemisphere;
and the use of speech prosody in musical exercises.

Singing songs and vocal exercises.

A total of eight studies utilised various musical methods of singing and vocal exercises
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(Hartley et al., 2010; Jungblut, 2005; Jungblut et al., 2009; Kim and Tomaino, 2008; Lim
et al., 2012; Racette et al., 2006; Straube et al., 2008; Tomaino, 2010). When singing or
exploring songs, all eight studies used songs that were familiar to the participants or they
used prelearned songs. Singing familiar songs which forms a key component of the
SIPARI method was central to the treatment interventions used by Jungblut (2005) and
Jungblut et al. (2009). The six other studies also explored familiar song-singing as a
treatment protocol; in addition, they looked at the efficacy of singing and the relationship
between singing and speaking. Racette et al. (2006) and Straube et al. (2008) found that
speech improvements and superior performance during singing can not be explained
solely by the effect of singing. However, Racette et al. (2006) proposed that singing along
to an auditory model has greater potential to improve intelligibility than speaking alone.
The single participant in the study undertaken by Straube et al. (2008) was able to sing
phrases more accurately than speak the same phrases. It was suggested that this was
not due to the effect of singing but possibly due to a memory-based mechanism linking
melody to words.

Vocal or oral exercises, in the form of musically-assisted breathing exercises, featured

within four of the eight studies (Jungblut, 2005; Jungblut et al., 2009; Lim et al., 2012;
Kim and Tomaino, 2008). In each of these four studies participants were encouraged to
focus on breathing while being supported and assisted by therapists. For example, Kim
and Tomaino (2008) conducted an exercise which encouraged breathing into single-
syllable sounds; the participants were instructed to focus on breathing and to gently
accompany an exhale with a vocal sound. These sounds were then developed into
pitched syllables and, in turn, into vowel sounds. Similar exercises were executed in the
two studies investigating the SIPARI method where participants were encouraged to
focus on respiration, and to support and regulate articulation and respiration (Jungblut,
2005; Jungblut et al., 2009).

Stimulating the right hemisphere.

It is suggested that MIT works on the basis of engaging language-capable right-
hemispheric regions of the brain to compensate for the damaged left hemisphere (Albert
et al., 1973). In 11 of the 15 studies, an integral part of various musical interventions with
stroke survivors involved an attempt to stimulate and engage their undamaged right
hemispheres (Conklyn et al., 2012; Jungblut, 2005; Jungblut et al., 2009; Kim and
Tomaino, 2008; Lim et al., 2012; Schlaug et al., 2008; Schlaug et al., 2009; Tomaino,
2010; Vines et al., 2011; Wilson et al., 2006; Zipse et al., 2012). Tentative evidence
suggests that improvements resulting from MIT are linked with increased right-
hemispheric activity (Hough , 2010; Schlaug et al., 2009; Zipse et al., 2012;). Vines et al.
(2011) tested a hypothesis based on this evidence where direct current brain stimulation
was used to increase excitability of the right hemisphere during MIT treatment. In turn,
current was also applied to reduce excitability of the right hemisphere. Results showed
significant improvements in fluency of speech when areas of the right hemisphere were
stimulated, thus providing support strongly in favour of the authors hypothesis.

To further increase phrase production during MIT, right-hemispheric networks are

stimulated by tapping the left hand. Seven studies which utilised MIT, MMIT, and adapted
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forms of MIT engaged the right hemisphere by tapping the participants left hand or by
the participant moving their left hand rhythmically or using their left hand to tap on a
drum. The two studies exploring the SIPARI method engaged the right hemisphere using
rhythmic exercises and improvisations involving instruments and the voice (Jungblut,
2005; Jungblut et al., 2009). Kim and Tomaino (2008) also used rhythmic speech cueing
to stimulate the right hemisphere. Participants were guided in clapping or tapping on a
drum along with the speech rhythm of the target phrase which was being exercised
vocally. In contrast, the study undertaken by Hough (2010) which investigated an
adapted form of MIT did not use the left-hand tapping method. Houghs results were in
disagreement with the need for left-hand tapping; the participant in his study showed
significant improvements in standardised tests without engaging in left-hand tapping.
Hough therefore suggested that it is not a critical component of MIT. Despite this
conclusion, further research is necessary in order to establish the validity of these
findings.

The practice of stimulating the right hemisphere was common throughout the literature.
Each musical intervention adopts a slightly different approach but essentially they all
share a common aim, i.e. to increase right-hemispheric activity in order to augment
speech production.

Use of speech prosody.

In 11 studies vocal and oral musical exercises were used in conjunction with each other
as part of treatment interventions (Conklyn et al., 2012; Hough, 2010; Jungblut, 2005;
Jungblut et al., 2009; Kim and Tomaino, 2008; Lim et al., 2012; Schlaug et al., 2008;
Schlaug et al., 2009; Vines et al., 2011; Wilson et al., 2006; Zipse et al., 2012). Of these
11 studies, eight of them explored various forms of MIT; they focused in particular on the
use of phrases and sentences that are intoned. These intoned phrases were examined
on the basis of three elements of spoken prosody: variation in pitch, tempo and rhythm of
the utterance, and stress points (Baker, 2000). While several types of MIT were revealed
in this research, these core exercises appeared consistently throughout the studies. Their
use was also evident in three further studies which did not use MIT. When investigating
the SIPARI method, intonation, prosody, and rhythmic speech exercises also formed key
elements in the approaches taken by Jungblut (2005) and Jungblut et al. (2009). Kim and
Tomaino (2008) also incorporated vocal intonation and musical dynamics into treatment
protocols.

Implications for newly qualified practitioners.

When exploring the commonalities between the 15 music-based treatment studies, the
main themes that emerged included: singing songs and vocal exercises, increasing
activity of the right hemisphere, and the use of speech prosody exercises (discussed
above). Based on the evidence and knowledge gained from the literature, this paper
proposes that it is essential that newly-qualified practitioners are made aware of these
three themes when conducting music-based interventions with post stroke patients
displaying speech and language disorders. Table 2 provides essential information for any
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practitioner. This table would have proved beneficial to my own experience as a student
when working with post stroke aphasic patients.

Themes/
Essential Elements Benefits for Client
Interventions
Songs familiar to Uses existing vocal abilities to
Singing and client modified to improve speech production
Vocal clients ability Encourages vocal utterance
Exercises Breathing and processes
vocal exercises

Tapping of the Stimulates the undamaged right

Stimulating left hand by hemisphere in order to increase
the Right client or therapist phrase production
Hemisphere Tapping a drum
with the left hand

Intoned phrase Develops linguistic skills

exercises Improves phrase production
Use of Rhythmic singing
Speech and speaking
Prosody
Vocal tempo
exercises

Table 2. Information for practitioners

Limitations
Narrative Synthesis Stage Four: Assessing the Robustness of the
Synthesis
As far as I am aware, this is the first narrative synthesis review that looks at music-based
treatments used to rehabilitate left-hemispheric stroke patients displaying disorders of
speech and language. It was intended from the outset that the review would be
transparent; it adopted a defined search strategy and clearly specified inclusion and
exclusion criteria. The process has aimed to be systematic in the analysis and
exploration of the resulting data. However, it is acknowledged that certain factors may
draw the robustness of the synthesis and the strength of its findings into question.

The data analysis found that in 13 studies there were significant improvements reported
in the outcomes following the various treatments. Due to a number of factors, the
potential for generalisation of these results within this synthesis must be considered. It
must be noted that the number of participants involved in each of the 15 studies was
small. The RCT by Conklyn et al. (2012), with 30 participants overall in both the control
and treatment groups, involved the largest number of participants across all of the
studies. Of the multiple-participant case studies, Racette et al. (2006) with eight
participants had the most participants. All other studies were single-participant case
studies.
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It must also be noted that the number of sessions, as well as the duration of treatment,
varied greatly across the 15 studies. For example, Conklyn et al. (2012) conducted just a
single session investigating the effects of MMIT. In comparison, Schlaug et al. (2008)
carried out 75 MIT sessions. Few studies were carried out over similar time frames.
Hartley et al. (2010) reported on 9 years of music-therapy treatment with a single
participant; their research provided qualitative analysis of improved linguistic skills.
Jungblut et al. (2009), who also reported significant improvements, conducted 3 years of
treatment that included 360 SIPARI sessions with a single participant. On the other hand,
several studies, while also reporting improved linguistic skills, conducted their various
treatments over a relatively short period of time comprising a number of weeks (Hough,
2010; Jungblut, 2005; Kim and Tomaino, 2008; Lim et al., 2012).

Three studies investigated the potentials of unique treatment protocols. Hough (2010)
and Zipse et al. (2012) proposed adapted forms of MIT that revealed improvements in
phrase production for each of their single participants. Kim and Tomaino (2008) also
investigated the efficacy of an innovative treatment protocol and provided qualitative
descriptions of guidelines for practitioners. Although the three studies reported improved
outcomes, each study represents early research into newly-developed musical
interventions. These interventions, therefore, require further research before their efficacy
can be established and included in future reviews of this nature.

Bearing these points in mind, the robustness of this review is, somewhat, weakened.
Thus, it proved difficult to consolidate the three themes (discussed above) which
appeared relevant to newly-qualified practitioners because these themes had emerged
from evidence which was, at times, tentative. While I proposed that these themes are
essential elements in music-based work with patients suffering from speech and
language disorders, due to a lack of consistency in approaches, I cannot suggest a
duration or frequency of treatment. It is anticipated that this uncertainty may be damaging
to the compilation of music-therapy programmes by newly-qualified practitioners because
the amount of treatment required to achieve positive results cannot be estimated.

This synthesis was also subjected to my own biases because I had previous experience
working with a patient with aphasia. Prior to conducting this research, my preconceived
aspirations anticipated confirmation from the literature that these musical treatments
produced positive effects. Therefore, it was difficult to maintain a neutral perspective
when analysing the outcomes of the studies. For example, when considering the
conclusions made by Racette et al. (2006) and Straube et al. (2008) which argued that
music-based interventions were not responsible for improvements in speech, these
findings were, somewhat, rejected in favour of the evidence provided in the majority of
studies which directly linked improvements in speech with music-based interventions.

Conclusions
The current paper provides a narrative synthesis review of music-based treatments used
to rehabilitate individuals with disorders of speech and language following left-
hemispheric stroke. Although there is a wealth of literature pertaining to the relationship

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between music and stroke, a systematic search for recent literature specifically focusing
on speech and language disorders revealed only 15 studies; this indicates that up-to-date
literature in this area is limited. This review is in agreement with a similar review
undertaken by Hurkmans et al. (2012) that found that all 15 studies reported positive
treatment outcomes.

After conducting an in-depth synthesis, five types of music-based treatments were

revealed; these were: (a) MIT, (b) songs and singing, (c) adapted forms of MIT, (d)
SIPARI method, and (e) MMIT. Through further exploration and analysis of the
interventions and studies, three major themes emerged; these were: (a) singing songs
and vocal exercises, (b) stimulating the right hemisphere, and (c) use of speech prosody.
By being familiar with these three themes, it is proposed that a newly-qualified
practitioner will have an adequate starting point when working with left-hemispheric
stroke clients displaying speech and language disorders. However, it does not
necessarily follow that these themes should form a pioneering treatment protocol. It is
also hoped that practitioners working in the field of neurological rehabilitation can use this
synthesis, and these themes (Table 2), as a source of preliminary information to explore
the musical interventions that exist, as well as their core elements. It is also
recommended that newly-qualified practitioners conduct comprehensive research of all
music-based treatments which they intend to implement and that they do not rely, solely,
on this review. If this is done, consistency and a systematic approach in the
implementation of interventions may be achieved.

Appendices
Appendix A: Literature Matrix (pdf)

Appendix B: Preliminary Synthesis of Studies (pdf)

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