Stahl et al. (2011)


Comparison Research


SOURCE: Stahl, B., Kotz, S. A., Henseler, I., Turner,R., & Geyer, S. (2011). Rhythm in disguise: Why singing may not hold the key to recovery from aphasia.  Brain: A Journal of Music, 134, 3083-3093. doi:10.1093/brain/awr240



DATE:   March 8, 2014




TAKE AWAY:  This is a comparison study, not an intervention study. It is included to provide evidence supporting the inclusion of music-based intervention in evidence-based practice analyses and summaries of prosodic therapies. The investigators determined that nonfluent German-speaking participants with larger basal ganglia lesions were likely to benefit from rhythmic interventions and they recommended that emphasizing rhythm interventions (including rhythmic hand tapping) could benefit articulatory accuracy.  There also were findings relevant to the type of lyrics but they are not the focus of this review.



1.  What type of evidence was identified?

a.  What was the type of evidence?  Comparison Research 

b.  What was the focus of the research?  Clinically Related

c.  What was the level of support associated with the type of evidence?  Level = B


2.  Group membership determination:

a.  If there were groups, were participants randomly assigned to groups?  N/A

b.  If there were groups and participants were not randomly assigned to groups, were members of groups carefully matched?  N/A

3.  Were experimental conditions concealed?

a.  from participants? No

b.  from administrators of experimental conditions?  No

c.  from analyzers/judges?  No 



4.  Were the groups adequately described?  Yes

a.  How many participants were involved in the study?

•  total # of participant: 17

•  # of groups:   1


b.  The following variables were  described                                         

•  age:  27-80 years, mean 56 years

•  gender:   9f, 8m  

•  cognitive skills: no Ps suffered from dementia

•  expressive language: naming task—light to severe disability

•  receptive language:  ranged from no disability to severe disability

•  token task:  light to middle disability

•  repetition:  no to severe disability

•  etiology:  most ischemia in middle cerebral artery, other left hemisphere damage included hemorrhages in left putamen, basal ganglia, pons, and medulla; overall only 2 Ps did not have left basal ganglia lesions; 3 Ps also had right hemisphere  lesions

•  premorbid neurology:  none of the Ps had a history of neurological problems

•  time since onset:  with the exception of one P, at least 3 months

•  Emotional state:  none of the Ps had a history of psychiatric problems


c.   Were the groups similar before intervention began?  Not Applicable

d.  Were the communication problems adequately described?  Yes

•  disorder type:  all nonfluent aphasia (Broca’s or global aphasia)

•  other:  see Repetition, Token Task, Expressive Language; Receptive Language in 4b.


5.  What were the different conditions for this research?

a.  Subject (Classification) Groups?  No 

b.  Experimental Conditions? 

•  modalities (melodic intoning, rhythmic speech, spoken arrhythmic control)

•  lyrics (original, formulaic, nonformulaic)

c.  Criterion/Descriptive Conditions?  Yes

•  frequency variation – used only for correlational analysis with articulatory quality

•  pitch accuracy– used only for correlational analysis with articulatory quality


6.   Were the groups controlled acceptably?  Not Applicable. This was a single group, within-subjects experimental design.



7.  Were dependent measures appropriate and meaningful?  Yes

a.  Dependent measures:

•  OUTCOME #1:  Articulatory quality (percentage of correctly produced syllables in each condition)—inferential statistical analysis

•  OUTCOME #2:  Pitch accuracy –correlational analysis

  OUTCOME #3:  Frequency variability—correlational analysis

b.  The dependent measures that are subjective:

•  OUTCOME #1:  Articulatory quality (percentage of correctly produced syllables in each condition)—inferential statistical analysis

•  OUTCOME #2:  Pitch accuracy –correlational analysis


c.  The dependent measure that is objective:

  OUTCOME #3:  Frequency variability  (using Praat to analyze frequency—correlational analysis



8.  Were reliability measures provided?


a.  Interobserver for analyzers?  Yes. Overall inter-rater reliability for  combined Outcomes  #1 and #2 (see below for descriptions of outcomes) is 0.98; for each P ranged from 0.93 to 1.00.


•  OUTCOME #1:  Articulatory quality (percentage of correctly produced syllables in each condition)—inferential statistical analysis for lyrics and modalities

•  OUTCOME #2:  Pitch accuracy –inferential analysis for lyrics only; correlational analysis


b.  Intraobserver for analyzers?  No


c.  Treatment fidelity for investigators? No 


9.  Description of design: 

•  repeated measure ANOVA for articulatory quality for both modality and lyrics with age and basal ganglia scale as covariates.

•  repeated measure ANOVA for pitch accuracy for lyrics

•  correlation between

–  articulatory quality and pitch accuracy

–  articulatory quality and frequency variation


10.  What were the results of the statistical (inferential) testing?

a.  Comparisons that are significant  (p ≤ 0.05).

•  OUTCOME #1:  Articulatory quality (percentage of correctly produced syllables in each condition) –lyrics and modalities

•  OUTCOME #2:  Pitch accuracy–lyrics

b.  The statistical tests used to determine significance were ANOVA with covariance other, not named, post hoc analyses. Correlations also were executed.

c.  Were effect sizes provided?  Yes.

–  There were partial eta squared measures for some OUTCOME #1  (Articulatory quality) cd comparisons:

  •  0.49 (large effect for interaction of age with formulaic and original lyrics)

  •  0.55 (large effect for the interaction of basal ganglia lesion with rhythmic speech intervention compared to arrhythmic control.)

d.  Were confidence interval (CI) provided?  Yes


e. The reported confidence intervals were

•  95% CI:  for   OUTCOME #1:  Articulatory quality


11.  Brief summary of clinically relevant results: 

•  This investigation did not identify a positive effect for singing on articulatory accuracy. Moreover, pitch accuracy and frequency variation were not related to articulatory accuracy.

•  This lack of a positive effect for singing was constant for the 3 types of lyrics, including well-known lyrics.

•  The rhythmic speech condition was significantly better than the arrhythmic condition.  In particular, Ps with larger lesions of the basal ganglia were more likely to perform better in the rhythmic condition than in the arrhythmic condition while those with small lesions tended not to show a positive effect for the rhythmic condition.







PURPOSE:  To investigate the contribution of melody (pitch, frequency variation), rhythm, lyric memory, and motor automaticity to improve speech production of Ps with non-fluent aphasia

POPULATION:  nonfluent aphasia; adult







DOSAGE:  two 1-hour session




•  Each session was divided into 2 sections and there was a pause between sections.

•  The first session consisted of the following interventions:  sung, spoken rhythmic, arrhythmic, a pause, arrhythmic, spoken rhythmic, sung.

•  In the second session, the order of interventions was reversed:  arrhythmic, spoken rhythmic, sung, a pause, arrhythmic, spoken rhythmic, and sung.

•  Each of the modalities was presented with 3 types of lyrics:

–  original (well-known German nursery rhymes or folk songs)

–  formulaic (common, every day sayings such as “How are you?)

–  nonformulaic (grammatically correct but unlikely sentences such as ‘thin like oak’ (p. 3088)

•  P sang (sung condition) or spoke (rhythm, arrhythmic conditions) in time with pre-recorded model.

•  Ps sat in front of loudspeakers that played the auditory stimuli.

•  P’s task was to repeat the auditory stimuli.  Motor cues such as rhythmic hand tapping were not permitted.

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