Evidence-Based Communication Assessment and

Intervention

ISSN: 1748-9539 (Print) 1748-9547 (Online) Journal homepage: http://www.tandfonline.com/loi/tebc20

Music has positive effects for individuals with

neurological speech and language disorders but
questions remain regarding type, timing, and
fidelity of treatment

David J. Hajjar & John W. McCarthy (Commentary authors)

To cite this article: David J. Hajjar & John W. McCarthy (Commentary authors) (2014) Music has
positive effects for individuals with neurological speech and language disorders but questions
remain regarding type, timing, and fidelity of treatment, Evidence-Based Communication
Assessment and Intervention, 8:3, 116-123, DOI: 10.1080/17489539.2014.1001548

To link to this article: http://dx.doi.org/10.1080/17489539.2014.1001548

Published online: 28 Jan 2015.

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 Evidence-Based Communication Assessment and Intervention, 2014
Vol. 8, No. 3, 116–123, http://dx.doi.org/10.1080/17489539.2014.1001548
Review–Treatment

Music has positive effects for individuals with

neurological speech and language disorders but
questions remain regarding type, timing, and fidelity of
treatment
David J. Hajjar & John W. McCarthy (Commentary authors)
Communication Sciences and Disorders, Ohio University, Athens, OH, USA
.................................................................................................................................................
Q (1) individuals
What is the effect of treatments that incorporate components of music
who present with neurological language and speech disorders?
with

(2) Post hoc question: What are the mechanisms of recovery to explain the positive
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effects observed when using musical components as an intervention technique?

METHODS
disorder>), (3)<music>and (#1
or #2).
Design: Systematic Review.
Study selection and assess-
ment: Main inclusion criterion was
Data sources: Electronic dat-
articles published in a peer-reviewed
abases. PubMed, CINAHL, PsycINFO
journal prior to 2009. Other inclu-
and EMBASE. The list of search terms
sion criteria included: listing pre–post
used was as follows:<language dis-
measurement of effect, intervention
orders>,<speech disorders>,<com-
containing musical elements, and
munication disorders>,<aphasia>,
adults with deficits in “any linguistic
<articulation disorders>,<apraxia>,
modality” secondary to acquired
<speech>,<language>,<verbal>,
neurological impairments. Lastly, arti-
<oral>,<communication>,<motor
cles were written in English, French,
speech disorder>and <music>. The
German, or Dutch. Studies were
terms were linked using the combina-
excluded if participants included indi-
tions of: (1)<language disorders>
viduals with amusia, language acqui-
or <speech disorders>or <communi-
sition disorders, stuttering, psychiatric
cation disorders>or <aphasia>
diseases, dementia, hearing disor-
or<articulation disorders>, (2)
ders (including word deafness), voice
<apraxia>and (<speech>or<lan-
disorders, epilepsy, autism or individ-
guage>or <verbal> or <oral>or
uals without any disability. Music was
<communication>or <motor speech
defined as vocal or instrumental con-
taining at least one of the following
elements: rhythm, melody, or accent.
Speech and language disorders
included both expressive and recep-
tive impairment in “speech, reading,
Abstracted from: Hurkmans, J., de Brujin Boonstra, A. M., writing, and auditory language com-
Jonkers, R., Bastiaanse, R., Arendzen, H., & Reinders-Messelink, H. A.
prehension” (p. 3). The first and sec-
(2012). Music in the treatment of neurological language and speech
disorders: A systematic review. Aphasiology, 26, 1–19. ond authors reviewed all abstracts of
Source of funding and declaration of interests: Not reported. yielded articles independently for
For correspondence: E-mail: dh214513@ohio.edu

© 2015 Taylor & Francis


inclusion decisions. The seventh
author’s vote was used to resolve
disagreements. In total, 15 studies
were selected for review, 94% (1175)
of the 1250 yielded having been
excluded due to lack of “therapy
study” and/or participant groups
other than those secondary to
acquired neurological impairments.
Of the remaining 75, 50 were
excluded due to lack of pre-post
measures; 7 studies were then
excluded for unspecified reasons,
with 3 additional ones rejected based
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on full text review and conferral with
the seventh author. No reliability
information was included.
Outcomes: Outcome variables dis-
cussed in the synthesis included three
broad categories: patient characteris-
tics, intervention/outcome variables,
and methodological quality. Patient
characteristics included number in
study, age, gender, etiology, speech-
language diagnosis, time post onset,
and severity of speech-language
impairment. Intervention and out-
come variables included objective(s),
International Classification of Func-
tioning (ICF), treatment program,
condition, schedule, linguistic level,
and musical parameters. Points were
allocated to studies based on meth-
odological quality indicators inspired
by the American Speech-Language-
Hearing Association (ASHA) levels-of-
evidence framework (study design,
blinding, sampling, group compara-
bility, treatment fidelity, outcomes,
significance, precision, intention-to-
treat). One point was awarded for
attaining the “highest level of quality”
for each marker. Although agree-
ment between authors 1 and 2 was
listed as “high,” no specific informa-
tion about reliability of point alloca-
tion or coding was provided.
Education, hemispheric dominance,
REVIEW–TREATMENT 117
and musical background were
included in a preliminary set of
patient variables; they did not meet
the a priori decision for > 50% of
the studies to report the variable,
and thus were not included. The
authors summarized patient charac-
teristics, intervention, and outcome
variables as well as methodological
quality in three separate tables,
labeled 2, 3, and 4, respectively.
Outcomes were considered on a
study-by-study basis. A positive out-
come was one in which the authors
reported improvement or positive
change based on the measures used.
For example, changes in the number
of words produced or higher scores
on a standardized test were taken as
evidence of positive outcomes. Statis-
tical testing was not always used in
tracking such changes. No effect
sizes were independently calculated
by the authors based on data that
were reported across studies.
MAIN RESULTS
The results of 583 patients were repre-
sented in the 15 studies selected, 82%
(480) of whom were in a single study
(Popovici, 1995). Five studies had one or
two patients, one study had four, six stud-
ies had seven or eight patients, with the
remaining two studies having 15 and 32,
respectively. The range of reported ages
was 18 to 84 years. Studies reporting gen-
der had relatively equal numbers of males
and females, with the exception of the
77% of males in the Popovici study. There
was significant variation in etiology and
specific speech-language diagnosis for all
subjects across the 15 selected studies.
Patient characteristics included individuals
 118 REVIEW–TREATMENT
with acquired neurological disorders, such
as Traumatic Brain Injury (TBI) and Cere-
bral Vascular Accident (CVA), as well as
progressive disorders, such as Parkinsons
Disease (PD) and Multiple Sclerosis (MS).
In regard to SLP diagnosis, individuals pre-
sented primarily with nonfluent aphasia,
with some studies also including those
with dysarthria and apraxia of speech. The
Popovici study included individuals with
fluent aphasia.
Nine quality indicators were used, based
on the guidelines from the ASHA levels-of-
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evidence scheme (2001). The authors
assigned points, either 1 or 0, to each of the
nine indicators in order to determine meth-
odological quality for each study. The high-
est level of methodological quality any
study received was 4 (2 studies). Four stud-
ies received a 3, three studies 2, one with 1,
five with (0). The maximum possible was 9.
Ninety percent of the research partici-
pants were involved in group study
designs. The remaining subjects were stud-
ied with case series or case study design.
The frequency of service delivery varied
widely among the studies.
With regard to types of intervention
reviewed in the studies, nine of the studies
used Melodic Intonation Therapy (MIT),
with one study using a combination of
MIT and “semantic training.” Among the
nine studies that specifically used MIT, the
frequency of service ranged from 2 to 10
sessions each week over a period ranging
from 1 to 108 months. For studies using a
modified MIT or informal approach, ther-
apy frequencies ranged from 1 to 3 times a
week for 30 to 60 min over a period of
between 3 weeks and 12 months. Most
studies employed individual intervention
sessions. In almost half of the studies a
Music Therapist delivered the intervention
with a Speech-Language Pathologist deliv-
ering the other half (2 studies did not
report). Six studies used either Singen
Intonation Prosodic Atmung Rhytmusueb-
ungen Improvationen (SIPARI) or a more
informal approach to music therapy, such
as vocal exercises or group singing. SIPARI
is described as music therapy variation
based on MIT principles.
Hurkmans et al. noted that MIT
prescribes a schedule of twice-a-day,
30–45-min sessions, 5 times a week. Upon
reviewing the schedules of treatment, the
authors noted that in most instances less
therapy than recommended was provided
in the studies evaluating the effectiveness
of MIT. Table 3 indicates that wide varia-
tions in minutes each session as well as in
sessions each week were noted.
None of the studies involved randomized
controlled trials or mention of blinding.
Seven of the studies reported outcomes
based on standardized assessment mea-
sures. The remaining studies were missing
information on validity and reliability as
related to outcome measures. None of the
studies reported treatment fidelity.
The authors report that treatment
approaches using musical elements
resulted in measurable improvement
across all 15 studies. This improvement
was taken as evidence of positive outcomes
for each study and contributes to the
authors’ conclusions about positive out-
comes across studies. All studies included
multiple outcome measures without defin-
ing the primary outcome. For example,
Baker (2000) described an increase in the
number of words produced by patients. On
the other hand, Belin et al. (1996)
described improvement on specific items of
the Boston Diagnostic Aphasia Examina-
tion as well as explanations from MRI and
PET in order to provide mechanisms of
recovery to explain findings. Some exam-
ples of outcome measures include aspects
of voice and articulation, repetition, nam-
ing, auditory comprehension and scores on
formal measures.

In answer to the post hoc question
related to neural mechanisms involved in
recovery, instrumental assessment (i.e.
PET, CT, and fMRI) was used in three of
the 15 studies. These three studies identi-
fied neural correlates using MIT as the pri-
mary treatment intervention. Although
two reported suggestive evidence of right-
hemisphere importance or added right-
hemisphere recruitment, one implicated
recovery within the left hemisphere.
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AUTHORS’ CONCLUSIONS
The authors were satisfied with the
descriptions of intervention programs
reviewed given that most used MIT or
described their adaptation or alternative
program. The authors also noted that the
outcomes reported were all positive. As
seen in Table 5 of the review, measured
improvements were seen across all studies.
However, the exact number of patients
who improved was difficult to determine
due to diverse patient characteristics and
an extensive variety of outcomes mea-
sured. The authors extracted outcome
information from each of the studies and
reported positive results only.
Patient characteristic gaps that the
authors identified as important for future
research included more patients in the
sub-acute phase, as well as an analysis of
the effects of education, cognitive func-
tioning, hemispheric dominance, and
musical background. The standards set for
the number of studies required to report
on these variables precluded their discus-
sion in the review. The authors indicate
that they personally felt that these vari-
ables were important for understanding
the effects of music.
The interventions were limited in the
context by two factors. First, the authors
noted that individuals with aphasia
REVIEW–TREATMENT 119
frequently receive multiple therapies,
either concurrently or in sequence. Order
and multiple treatment effects, therefore,
make definitive conclusions about the
effect of any single therapy problematic.
Second, the limitation of studies to study-
ing the impairment level of functioning
limited the scope of effectiveness conclu-
sions.
The authors contextualize their discus-
sion of methodological quality by noting
that a blind randomized controlled trial
with individuals with aphasia and music
would be extremely difficult on many lev-
els and that experimental group designs
need not be emphasized. Specifically, the
authors support the use of case series
designs but call for better methodological
descriptions and the use of statistics. The
authors note that Popovici (1995) had a
large number of subjects but did not
perform any statistical analyses.
In summary, the authors recommend
research guidelines that would improve
and standardize the reporting of specific
characteristics, interventions, and quality
indicators. They suggest models currently
used in rehabilitation, such as the ICF/
WHO model. In their concluding remarks,
the authors ultimately say that because of
quality concerns, “no conclusions can be
drawn with regard to the effect of the use
of musical elements in the treatment of
individuals with acquired neurological dis-
orders” (p. 16). Additionally, the authors
describe the findings of their three
reviewed neural mechanism studies as
“contradictory” and requiring further
study.
COMMENTARY
T
his review highlights some of the
limitations involving research in the
area of using music with patients
 120 REVIEW–TREATMENT
who experience neurological communica-
tion disorders. The art of music thrives on
free expression. This type of expression
can produce positive results across the
vocal and instrumental media, and thus
music can be a motivating and meaning-
ful intervention in therapy. With that in
mind, attempting to apply principles of
evidence-based practice and empirically
supported treatments to the intervention of
music is challenging, but not an excuse
not to be as rigorous as possible. The
authors of the systematic review took on
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this challenge by highlighting 15 studies
that use some type of musical focus in
treating adults with speech and/or lan-
guage communication disorders. The
authors found studies that used either an
established program such as MIT or a
more general treatment approach using
musical parameters such as melody,
rhythm or singing. In the current review
the answer to the question about the
effect is that the studies all report positive
findings, but quality indicators do not offer
a satisfactory level of certainty. A stronger
endorsement of “positive findings” could
be obtained by the authors performing
their own statistical analyses based on the
data. The authors’ struggle in coming to a
singular conclusion also highlights the
inherent difficulties in using music in a
way that supports individual clients’ pref-
erences while simultaneously meeting the
rigorous demands of the scientific
method. Beyond the challenges in captur-
ing the essential contributions of music,
there are some other points to consider in
capturing or qualifying the effects of
music.
It is noteworthy that the initial yield of
studies was 1250. The authors review arti-
cles in four languages, including, English,
French, German, and Dutch. The effort to
include articles in other languages is to
be commended and distinguishes this sys-
tematic review from many other efforts.
However, when multilingual inclusion is
part of a review, it is important to ensure
that the key databases from the home
countries of each additional language are
adequately sampled. Ultimately, the inclu-
sion of only 15 studies emphasizes the
challenge researchers and clinicians face
when making decisions about interven-
tions involving music.
By initiating this review, the authors
have started an important conversation
related to synthesis in this area, and they
suggest some important gap-related future
directions. They note that music interven-
tions have been developed from clinical
practice and that many positive outcomes
have been experienced in these settings.
Furthermore, the authors realize that evi-
dence of the effectiveness of treatment is
essentially unknown. They have set the
stage for research involving other types of
music interventions, such as the Speech-
Music Therapy for Aphasia (SMTA)
program. The SMTA, developed from clin-
ical practice by two of the authors of
the review, combines speech-language
pathology and music therapy. The authors
report that it has some components of
MIT but expands on musical elements like
dynamics, tempo, and meter.
As a result of conducting the systematic
review, the authors have gathered impor-
tant information that can be applied to
future research in this area. By measuring
specific outcomes, defining patient char-
acteristics, improving methodological
quality and ensuring treatment fidelity, it
can be possible to measure the effective-
ness of these interventions. This review
may serve as a catalyst to encourage
future research in this promising area.

The detailed tables in the review pro-
vide extensive information about patient
characteristics, measured improvements,
and schedules of treatment. However, the
efforts in summarizing the studies in tables
could have been followed by more
focused criticism of treatment fidelity,
exploration of different kinds of groupings
in making conclusions, and an outline of
means to capture the extensive literature
beyond the 15 studies reviewed.
According to Table 4, which reports
methodological quality, none of the 15
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studies reported treatment fidelity. There
are at least two important consequences.
The first relates to representing MIT as an
intervention and the uncertainty that
comes from not knowing whether the
intervention has been implemented as
planned. In other words, it becomes diffi-
cult to ascertain what level of fidelity
brought about the changes observed
(Schlosser, 2002). The second involves
the difficulty of replicating studies without
knowing the intervention’s fidelity results.
MIT outlines an intensive schedule of
twice-a-day, 30-min sessions, 5 times a
week. When looking at schedules of inter-
vention, just one of the nine studies that
used MIT (Schlaug, Marchina, & Norton,
2008) approximated the prescribed
amount of treatment each week. This
poses the question whether the selected
studies that focus on MIT are accurate
representations of this specific treatment
intervention. In order to compare out-
comes based on a specific intervention, it
is important that the treatments be deliv-
ered as consistently as possible with
regard to frequency and duration. Even
when a program is modified, it is critical
to report on faithful implementation of
any modification in order to ensure that
the conclusions drawn are based exactly
REVIEW–TREATMENT 121
on the modifications made and not on the
results of the clinicians implementing an
intervention.
A logical extension of modifications is
an exploration of why such modifications
are needed or implemented. Factors such
as time, schedules, individual patient
skills, and the skills and experience of the
therapist may be reasons to modify treat-
ment approaches. For example, Conklyn,
Novak, Boissy, Bethoux, and Chemalib
(2012) discuss the effects of modified
melodic intonation therapy in a pilot
study. They cite the limitations of tradi-
tional MIT and reasons why therapists
may need to make modifications to the
standard protocol. Norton, Zipse,
Marchina, and Schlaug (2009) discuss a
variety of interpretations of the original
program, including the types of individuals
who are administering MIT. They mention
that due to some of the complex interpre-
tations on the protocol, therapists with
limited musical background may be pre-
vented from using the treatment. It would
have been useful to note any descriptions
of the reasons why authors deviated from
the prescribed protocol for MIT or an
analysis of the deviations made according
to the populations and settings.
A key value in synthesis is in detecting
patterns. Given the heterogenous nature
of the literature reviewed, the authors’ ini-
tial efforts are commendable. We offer a
few post hoc suggestions of other avenues
that could be considered. As the authors
note, methodological quality was rated as
low for the 15 studies. With regard to
quality, although the studies were limited
to 0–4 points in quality indicators, it is not
the case that all studies were of equal
quality in terms of being “low”. It is possi-
ble to distinguish among studies as more
or less convincing even when the highest
 122 REVIEW–TREATMENT
levels of quality are not reached. It seems
possible that the “positive” message need
not be abandoned because of quality
indicators alone. Conversely, publication
bias can lead to an overall positive mes-
sage as well. A search of dissertations or
other unpublished research could poten-
tially reveal an even less conclusive
picture of effects.
With regard to specific speech-
language diagnosis, it might have been
more helpful for the authors to separate
diagnostic categories and focus specifi-
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cally on studies that use music to improve
patients’ speech disorders, as against
studies that use music to improve patients’
language disorders. This separation of
diagnostic criteria might have lead to
improved methodological quality in
regard to variables such as patient char-
acteristics and intervention and outcome
measures. As a result of separating diag-
nostic criteria, the potential impact for
clinical application of specific interventions
using musical components may be stron-
ger. Similarly, patients included in the
selected research studies presented with
neurological language and speech disor-
ders of a heterogeneous nature, with a
variety of single and mixed etiologies. By
patients with mixed etiologies (i.e. TBI and
CVA) having been grouped together,
questions remain about the effectiveness
and appropriateness of using specific
musical techniques in treatment. The
inclusion of individuals with fluent aphasia
was particularly curious and perhaps
worthy of highlighting.
There is always a balance to strike in
reviews about what studies to include and
exclude. Certainly the research questions
drive the scope, but too fine a point can
lead to narrow conclusions with a limited
impact, while too broad a net can lead to
diluted answers. We wondered if elements
of the story about music, its uses and
non-uses, were lost in the large number of
studies excluded in this review. The nature
of results might possibly lie in the clini-
cians themselves. As noted above, studies
related to the reasons and circumstances
under which MIT is modified are important
pieces of the therapeutic puzzle. Further, it
could be critically important to understand
why some individuals use music at all in
sessions. It is possible that music may pri-
marily be used by therapists who have
musical backgrounds, who have had past
success using music in clinical practice, or
who are willing to try an approach that
may push them out of their “comfort
zones”. The definition of “music” will likely
always present some kind of challenge. In
MIT, the areas of melody and rhythm are
the essential musical components. This
systematic review did not focus on other
components of music, such as tempo, tim-
bre, harmony, or dynamics, in either vocal
or instrumental forms.
The exploration of neural mechanisms
for recovery was a somewhat curious
addition to the current review. It is unfor-
tunate that question was asked post hoc
and not in the context of the search strat-
egy used by the authors. We are not cer-
tain that the idea of “contradictory
findings” could be applied to the results
of neural mechanisms, given the nature of
evidence available in the review. Rather,
the possibilities for exploring neural mech-
anisms in a systematic way in a future
study are far more intriguing. The growing
literature related to neurologic music ther-
apy aimed more at a restorative than a
compensatory approach (Baker & Roth,
2004) certainly reinforces the need, and
perhaps helps partially to explain the
authors’ interest.

As stated in previous commentaries
(McCarthy, 2013; McCarthy, Cooley, &
Benigno, 2010), the idea that music has
value does not appear to be in question in
people’s minds. The question of how and
why it has benefits is still among the more
provocative. We appreciate the authors’
efforts in contributing to the evidence base
related to music and intervention. Still,
when searches have such high rates of
exclusion and when conclusions must be
so tempered, we wonder if the pursuit of
how and why is of more pressing concern.
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We would also offer as a final call to all
with an interest in this area that modern
technologies offer the opportunities to
share the audio and video treatments and
results of music related interventions so
that the challenge of capturing and sum-
marizing the effect of musical interventions
can be open to a wider audience.
Declaration of interests: The commentary
authors report no conflicts of interests and are
solely responsible for the content of this struc-
tured abstract.
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