Kim & Tomaino (2008)


Treatment Groups 

Note: Scroll about one-half of the way down the page to read the summary of the procedure(s).


C = Clinician

EBP = evidence-based practice

f = female

m = male

MT = music therapy

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist



SOURCE: Kim, M., & Tomaino, C. M. (2008.) Protocol evaluation for effective therapy for persons with nonfluent aphasia. Topics in Stroke Rehabilitation, 15, 555- 569.




DATE: January 26, 2018


ASSIGNED GRADE FOR OVERALL QUALITY: C- (The highest possible grade based on the type of evidence is C. The Assigned Grade for Overall Quality is not a judgment regarding the quality of the intervention, it merely evaluates the type of research design and implementation.)


TAKE AWAY: Investigators reviewed music therapy (MT) describing the effectiveness of 7 MT techniques for improving articulation, fluency, prosody, and breath support for patients (Ps) with nonfluent aphasia.



  1. What type of evidence was identified?
  • What was the type of evidence? Qualitative Research involving Multiple Participants


  • What was the level of support associated with the type of evidence? Level = C



  1. Group membership determination:


  • If there was more than one group, were participants (Ps) randomly assigned to groups? Not Applicable (NA), there was only one group.



  1. Was administration of intervention status concealed?
  • from participants? No
  • from clinicians? No
  • from analyzers? No



  1. Were the Ps adequately described? Yes

How many Ps were involved in the study?

  • total # of Ps: 7
  • # of groups: 1
  • List names of groups and the # of participants in each group:



  • Diagnosis: Nonfluent Aphasia



  • age: early 50s to early 70s
  • gender: 2m; 5f
  • cognitive skills:
  • 6 of the 7 Ps displayed intact cognitive skils;
  • 1 P had difficulty attending due to drowsiness associated with medications
  • motor skills: 6 of the 7 Ps were right hemiplegic
  • etiology: All Ps had experienced single or multiple strokes in the left hemisphere
  • post onset: 21 months to 21 years
  • social-emotional Status: the mood of the Ps was described as varied
  • comorbid medical issues:
  • chronic bronchitis 1
  • depression 1  
  • hypertension, high blood pressure 5  
  • diabetes 2
  • anemia 2  
  • coronary heart disease 1
  • renal artery stenosis 1  
  • congestive heart failure 1  
  • mild dementia 1


– Were the groups similar before intervention began? NA, there was only one group.


– Were the communication problems adequately described? Yes

  • disorder type:
  • All Ps diagnosed with nonfluent aphasia.
  • In addition.

∞ 3 Ps were diagnosed with apraxia

∞ 1 P was diagnosed with dysarthria

∞ 2 Ps were diagnosed with dysphagia

∞ 2 Ps were diagnosed with fluent aphasia

∞ 1 P was diagnosed with receptive aphasia


  • functional level: severity ranged from mild/moderate to severe



  1. Was membership in groups maintained throughout the study?
  • Did the group maintain at least 80% of its original members? Yes


  • Were data from outliers removed from the study? No



  1. Were the groups controlled acceptably? NA, there was only one group



  1. Were the outcomes measure appropriate and meaningful? Yes



  • OUTCOME #1: Articulation skills (accuracy rating)


  • OUTCOME #2: Fluency (words per utterance)


  • OUTCOME #3: Prosody (rating of rhythm and intonation)


  • OUTCOME #4: Breath support (number of syllables produced in sustained breath)


ALL the outcome measures were subjective.


– NONE of the outcome measures that were objective.



  1. Were reliability measures provided?
  • Interobserver for analyzers? No. However, the 66 videotapes were reviewed, described, and analyzed by 3 investigators. The data from these reviews were synthesized.


  • Intraobserver for analyzers?   No


  • Treatment fidelity for clinicians? NA _x__, the methodology involved a description and evaluation of treatment techniques used in music therapy with Ps with nonfluent aphasia. The purpose was not to investigate the effectiveness of a single program.



  1. Summary of the description of the results:




  • OUTCOME #1: Articulation skills (accuracy rating)— across music therapy techniques the gains for individual Ps ranged from 5% to 40%


  • OUTCOME #2: Fluency (words per utterance) across music therapy techniques the gains for individual Ps ranged from 5% to 65%


  • OUTCOME #3: Prosody (rating of rhythm and intonation) across music therapy techniques the gains for individual Ps ranged from 10% to 50%


  • OUTCOME #4: Breath support (number of syllables produced in sustained breath) across music therapy techniques the gains for individual Ps ranged from 0 to 5 syllables


– What was the statistical test used to determine significance? NA, differences were described and not subjected to inferential statistical analysis.


– Were confidence interval (CI) provided? No



  1. What is the clinical significanceNA, evidence-based practice data were not provided.



  1. Were maintenance data reported? No



  1. Were generalization data reported? No



  1. Describe briefly the experimental design of the investigation.


  • This qualitative research involved Protocol Evaluation in which the investigators reviewed 66 videos of MT sessions from 7 Ps with nonfluent aphasia.


  • The investigators identified 7 MT techniques from the literature that were used with the Ps and noted their effectiveness as well as recommended guidelines for employing each of the techniques.


  • The 7 MT techniques were

– Singing Familiar Songs

– Breathing into Single Syllable Sounds

– Dynamically Cued Singing

– Musically Assisted Speech

– Rhythmic Speech Cuing

– Oral Motor Exercise

– Vocal Intonation









PURPOSE: To describe and evaluate techniques used in MT with Ps with nonfluent aphasia and to link the findings to existing research.


POPULATION: Nonfluent Aphasia; Adults






ELEMENTS OF PROSODY USED AS INTERVENTION: rhythm, intonation, loudness, rate, tempo, pause




DOSAGE: 8 to 12 individual sessions, 3 times a weeks, 4 weeks, about 30 minutes each session


ADMINISTRATOR: Music therapist.






  • The Clinician (C), a Music Therapist, administered the sessions in a quiet room.


  • The C administered 7 MT treatment techniques in each of the sessions:

– Singing Familiar Songs

– Breathing into Single Syllable Sounds

– Dynamically Cued Singing

– Musically Assisted Speech

– Rhythmic Speech Cuing

– Oral Motor Exercise

– Vocal Intonation


  • The 7 MT techniques had been derived from the existing literature and were included in the treatment of the speech and singing for Ps with nonfluent aphasia.


  • The sessions were recorded and then analyzed by a team of researchers who developed a description of each technique’s effectiveness and guidelines for application.


  • The investigators comments (summary, analyses, hints) for each of the seven techniques are listed below.




  • Description:

– C leads P in the singing of familiar songs.

– C directs P to select a favorite song.

– C and P focus on the most familiar parts of the song and repeatedly sing them.

– C assists P by modifying the tempo to match P’s skills.

– The investigators contend that modifications of tempo, loudness, and intonation can facilitate interactions between P and C.


  • Evidence: (see also Item #9 above)

– Six of the 7 Ps displayed improved articulation and rhythm while singing.

– Five of the Ps had “shallow” (p. 561) voice quality, this improved while singing familiar songs.

– Familiar songs and familiar portions of songs appear to increase motivation and performance.


  • sang 80% of words correctly in the first verse of a familiar song and
  • during the second, less familiar, verse she sang only 60% of the words correctly and her loudness decreased 50%.
  • with practice during therapy, her performance on the second verse improved but did not reach the level of the first verse.

– The rhythm of the songs appear to facilitate articulatory accuracy.


  • could not produce the words from a familiar song accurately in speech or even produce the rhythm even when cued by mouthing and/or tapping
  • in the context of singing the words P produced 80% of the words accurately and used the targeted rhythm


  • Hints:      

– Make sure the songs are familiar; do not improvise new songs.

– It is important to focus on the familiar portions of songs.

It is better to use songs that P knew premorbidly.

– To facilitate accurate production of rhythm and articulation while singing, C should modify the tempo to match P’s skills.

– C should provide cues (e.g., tapping, drum beating, up-down hand movement, mouthing, etc.) to facilitate P’s production.

– To improve the melody of a P’s singing, C should insure that when singing in unison with P, the C should not be too loud and at times let the Ps sing independently. Rather than rely solely on unison singing, P can model and then have C imitate singing.

– In severe cases, C may consider withholding the Musically Assisted Speech technique until P is successful with the Singing Familiar Songs technique.






  • Description:

– P breathed single syllable sounds. This was achieved by having P exhale and gently vocalize speech sounds using the following hierarchy:

  • producing natural vocal sounds (e.g., yawning, throat clearing, sighing, etc.)
  • sighing vowels
  • producing vowels
  • producing bilabial consonants
  • producing alveolar consonants
  • producing velar consonants


  • Evidence: (see also Item #9 above)

– Articulatory accuracy increased when Cs introduced pauses between syllables.

– The addition of melody to this technique had equivocal results. EXAMPLE:

  • For one P the addition of a melody to the technique resulted in P humming rather than singing the targets.
  • Other Ps seemed to perform better when C intoned targeted syllables in unison with the P and then alternated between modeling and imitation.
  • Melody added to the stimuli was associated with more improved articulation accuracy when the singing involved tones that were disconnected (staccato) from one another rather than when they were sung with smooth transitions from one syllable to the next (in legato.) EXAMPLE:

– TWINKLE TWINKLE LITTLE STAR was associated with better articulation accuracy than AMAZING GRACE.


  • Hints:

— The hierarchy of targets speech sound to vocalize is a guideline. Cs should adapt the hierarchy to the articulatory skills of their P and the hierarchy can be modified during the treatment to reflect Ps’ skills.

— Modeling by the C appears to be an effective strategy.

— When targeting and modeling yawning, throat clearing, sighing, C should mimic P’s natural breathing patterns.

— The sighing of vowels is most successful when it begins with C modeling production on a slow and long exhalation.

— To assist Ps in the initiation and/or the sustaining of sounds, the investigators recommend using visual cues (e.g., hand movement) or sustaining tremolos using a guitar.

— Repetition paired with “attention and motivation” (p 561) increased the accuracy of imitation.

— The investigators note that adding a melody to the vocalizations when using this technique has equivocal effects. That is, it facilitated progress in some Ps and impeded progress with other Ps.






  • Description: In the singing of songs, C pauses to cue P to produce the targeted word/words.


  • Evidence: (see also Item #9 above)

– Rhythm appeared to profit more from this technique than intonation.

– This technique seemed effective in encouraging attention as indicated by

  • increased eye contact of more than 50% in all Ps
  • limited increased rate in 6 of the 7 Ps.

– Cueing can be helpful to those who are struggling with this technique. EXAMPLE:

  • A P who perseverated a nonsense syllable was able to produce the target word when the C provided facial cues (mouthing or facial expressions.)


  • Hints:

– Cs should monitor the frequency of use of this technique as too frequent use could be associated with distraction or loss of interest.

– It is best to use familiar songs with this technique. Improvised songs are not as successful.

– Also Cs should avoid using phrases that tap the Ps’ internal states as they appear to be a distraction.






  • Description: C identifies common phrases that are used in activities of daily living and in conversation and pairs them with familiar melodies. The phrases are taught in isolation and in role-playing of daily activities.


  • Evidence: (see also Item #9 above)

– Gains associated with articulation and fluency were observed with this technique.

  • Ps with articulation problems improved 10% to 30% in intelligibility
  • Ps with fluency problems rate of speech improved up to 15%.

– Ps performed better when a familiar song was reviewed first and then the daily living/conversational phrase was inserted into the melody of the familiar song. EXAMPLE:

  • Ps’ articulatory accuracy and prosody were better when Cs first introduced the targeted familiar song with its original/familiar lyrics and then used the same melody inserting the targeted daily activity/conversational phrase compared to initially targeting the daily/activity/conversational phrases paired with the familiar melody.
  • When Cs’ initially targeted the daily/activity/conversational phrases paired with the familiar melody, Ps seemed confused 80% of the time.
  • Six of the 7 Ps performances improved when Cs enhanced the rhythm of the songs by rhythmically cuing beats and accents using rhythmic cues such as drum beating or finger tapping.
  • Ps with dysarthria generally responded better to staccato (word by word or even syllable by syllable) and slow beats.
  • Ps with fluency (i.e., number or words in a phrase) problems in the absence of articulation problems generally responded better to focusing on short phrases instead of single words/syllables.
  • Ps have individual differences regarding how much setting up of the context is appropriate during the role-playing portion of this technique.


  • Hints:

– First present the familiar song with its standard lyrics and then insert the targeted phrases into the familiar melody.

— As a preparatory cue, Cs should use rhythmic cues (e.g., guitar strumming, finger tapping) at the beginning of each target phrase.

– Consistently pair a targeted phrase with the same familiar song.

– If a P is having trouble with a targeted phrase, consider changing the familiar song that has been paired with that phrase.

– Cs should remember to adjust the tempo of the familiar melody to optimize Ps’ production. Usually the adjustment is slowing the tempo but the tempo can be too slow or staccato for some Ps or contexts.

– Although Cs should provide some imaginary context for the role-playing portion of this task, too much attention to setting up the context is distracting.






  • Description: P motorically claps or taps a drum to the rhythm of a target phrase. The targets can be song lyrics, daily activity phrases, or conversational phrases.


  • Evidence: (see also Item #9 above)

– Five of the Ps spontaneously added melody to the targeted phrases.

– Targets that had been used in the Musically Assisted Speech technique were increasingly successful.

– Ps had trouble separating rhythm and melody for the speech targets. That is some Ps sang rather than spoke speech targets using the targeted rhythm.

– A P with hemiplegia, apraxia, and rhythm problems responded well to (1) rhythm targets when the task was adapted to her physical limitations and (2) the targets initially targeted 2 syllable words and gradually moved to 3 word phrases.

– Ps with rhythm problems but not apraxia or with mild apraxia responded best to whole phrase targets.

– The investigators reported that for 6 of the 7 Ps, improved rhythm in speech and singing was “correlated with assertiveness of vocal quality” (p. 565.)


  • Hints:

– Cues include:

  • Beats that are “slow and steady” (p. 558) and adapted to the P’s skill level.
  • For song lyrics, the rhythm of the song is a good cue
  • For speech phrases, the rhythm of natural prosodic speaking patterns is the preferred cue.

– Using song melodies tend to be more effective than speech.

– When targeting speech, Cs should monitor Ps’ addition of melody to the target.

– Inclusion of multimodality cues and temporal cues can help P in imitating the C.






  • Description: The purpose of this technique is to improve “oral motor formations” (p. 558.) This is accomplished by C directing P to observe him/her carefully and then modeling a small part of a familiar song using exaggerated mouth and tongue movements.


  • Evidence: (see also Item #9 above)

– The investigators noted that this technique was associated with considerable progress in articulatory accuracy and vocal quality. One P did not respond well to this technique but that P was drowsy and inattentive during sessions.


  • Hints:

– C should correct P’s errors and repeat the same target multiple times.

– C’s feedback should be sensitive to P’s skill level, attention skills, motivation, and progress.

– Cs should be careful to give clear instructions and feedback and to monitor P’s performance carefully.

– This technique often is not successful with Ps with eye contact and/or attention problems. Dynamically Cued Singing or Vocal Intonation are recommended in such cases.

– Cs should be sure to allow sufficient time for Ps to process what has been modeled and to perform the target. It is best to establish a clear rhythm of modeling-waiting-responding.






  • Description: C model exaggerated intonation patterns for speech phrases associated with different meanings. Cs provide visual cues (e.g., hand or head motions) representing changes in intonation/pitch as needed to achieve a positive outcome.


  • Evidence: (see also Item #9 above)

– The investigators noted that Ps progressed in the ability to modulate their pitch, intonation, and loudness.

– Progress was reported to have generalized out of the clinic into the nursing home context for 2Ps.

– As the result of this technique, Ps appeared more spontaneous and natural.

– Tempos that were too slow or excessively exaggerated interfered with progress.


  • Hints:

– The use of visual cues (e.g., hand movements representing changes in intonation) facilitated progress.

– The use of role-playing helped Ps generate intonation patterns that were appropriate to the context.

– The ideal tempo appears to be slow and clear but within normal limits for tempo and intonation.



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