Shots - Health Blog
11:01 pm
Sun December 25, 2011

Singing Therapy Helps Stroke Patients Speak Again

Originally published on Tue December 27, 2011 9:39 am

Debra Meyerson was hiking near Lake Tahoe 15 months ago when a stroke destroyed part of the left side of her brain, leaving her literally speechless. It happens to more than 150,000 Americans a year.

But now Meyerson is learning to talk again through an approach that trains the undamaged right side of her brain to "speak." Specifically, it's a region that controls singing.

For more than 100 years, it's been known that people who can't speak after injury to the speech centers on the left side of the brain can sing.

In the 1970s, Boston researchers started to use a sort of "singing therapy" to help stroke survivors speak again.

However, it never caught on much – perhaps because a lot of therapists, not to mention patients, weren't comfortable singing what they wanted to say. And back then, the science wasn't advanced enough to show the actual changes in the brain that result from the therapy.

That's changing fast.

Congresswoman Gabrielle Giffords, who has had a version of "singing therapy," astounded everyone by her ability to speak again – albeit so far in single words and short phrases. Nearly a year ago, a would-be assassin's bullet tore through the speech center in Giffords' left brain.

Singing Sessions

Less visibly, an NIH-funded study at the Beth Israel Deaconess Medical Center in Boston may be the first rigorous trial of singing therapy. They call it melodic intonation therapy. Post-stroke patients are assigned to a form of conventional speech therapy or to singing therapy. They undergo 90 minutes of treatment a day for 15 weeks.

Debra Meyerson, 54, is a volunteer in that study. Her aphasia is a cruel twist of fate. Meyerson is an expert in gender and race relations who was a dynamic and popular speaker before her stroke. After a year of conventional speech therapy, she couldn't speak more than a word or two.

When NPR sat in on one of her therapy sessions recently, Meyerson still struggled to speak even the simplest phrases. But she's beginning to talk again.

"If you go to a restaurant and the server asks if you'd like something before your main dish, you might choose something like this," therapist Andrea Norton says, showing Meyerson a picture of a salad. Then Norton sings the word "salad," intoning the syllables on a minor third – the tune every child knows from the taunt "nyah-nyah! nyah-nyah!"

Norton slows everything down. That's critical because the right side of Meyerson's brain – the singing part that's being retrained to "speak" – is good at melody and pitch, but it's not as fast as the left-sided language center, called Broca's area.

It's also not as good at the rhythmic components of speech. That's why Norton taps Meyerson's left hand (controlled by the right brain). The tapping entrains the rhythms of speech and engages the motor nerves needed to produce speech in Meyerson's mouth and throat.

Then she shifts to a different phase – bridging the gap between singing and speaking. First Norton has Meyerson sing the phrase "Would you pour me a glass, please?" Next the therapist says it with exaggerated diction that's in between singing and normal speech.

Then, gratifyingly, Norton speaks the sentence. "Would you pour me a glass, please?" she says. "Nice!" Norton says.

Watching this laborious process, you might not appreciate the remarkable thing that's going on inside the brains of patients like Meyerson. The Harvard team has evidence that melodic intonation therapy actually remolds the brain.

Growing Nerves

One of the clearest examples is Laurel Fontaine, a 16-year-old sophomore at North Attleborough High School in southeastern Massachusetts. A little more than four years ago, when Laurel was 11, she suffered a devastating stroke – unusual in a child, but not as rare as you might think.

Laurel's stroke destroyed 80 percent of the left side of her brain. One of her doctors says it's the biggest stroke he's ever seen.

"My doctor told me I'm not going to talk, I'm not going to walk, I'm not going to, like, do anything...press buttons...ever," she says.

After a year of conventional speech therapy, Laurel could speak only a word or two at a time. Then her mother persuaded the Beth Israel Deaconess researchers to let Laurel enroll in their research project.

The singing therapy lasted only about four months, but it's had permanent effects. Though Laurel still struggles sometimes to find the words she wants, she doesn't have to sing them out loud.

"I'm singing in my head and talking out loud without singing," she says between classes. "I do it, like, really quick."

Laurel offered the researchers a big bonus – an identical twin sister named Heather. So the researchers could use MRI scans to compare the girls' brains. They focused on a structure on the right side that's important for singing.

Before Laurel began melodic intonation therapy, that structure was smaller in her brain compared to Heather's. That's probably because she hadn't been doing anything with her voice for a whole year.

But during therapy, scans showed that nerve fibers in Laurel's right-sided singing center actually grew – they clearly multiplied and thickened. With therapy, those nerve bundled got bigger than the corresponding region in Heather's brain.

Dr. Gottfried Schlaug, who heads the study, says that's exactly what he was looking for.

"It is the perfect confirmation," he says. "Basically, the hardware of the system really changed to support this increased vocal output."

And Laurel continues to improve. It's possible, Schlaug says, that when Laurel is in her 20s, someone who didn't know any better would never suspect she ever had a massive stroke that left her unable to speak.

The Age Factor

But how much of her remarkable recovery is because Laurel was so young when her brain was injured? Schlaug says her youth was definitely a factor.

"However, we know that patients even in their 80s can show plastic changes to their brain, can show adaptations," he says. It just may take longer. And, as with learning a foreign language at a later age, an older brain may never get to the same level.

From his work with older patients Schlaug says a surprising amount of recovery is possible. He also reports good results working with autistic children and people with Parkinson's disease who have trouble speaking.

Schlaug thinks singing therapy can be enhanced by simultaneously stimulating the brain with painless, low-voltage electricity – and one day, possibly, by drugs.

For now, it takes an incredible amount of willpower. Meyerson can testify to that.

"Recovery is long and hard," Meyerson told Laurel Fontaine recently when therapist Andrea Norton brought them together.

"Well, it's hard at first," Laurel told the older woman. "But you can get used to it. I'm getting better all the time. Don't get frustrated."

"Yes...yes...thank you!" Meyerson replied, clearly moved by Laurel's example.

Clearly Laurel's a star and Deb Meyerson has a long way to go. But she's determined to get there. By next Labor Day — the second anniversary of her stroke — Meyerson wants to start public speaking again, this time as an advocate for better stroke care.

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

STEVE INSKEEP, HOST:

It's MORNING EDITION from NPR News. I'm Steve Inskeep.

LINDA WERTHEIMER, HOST:

And I'm Linda Wertheimer in for Renee Montagne.

One of the remarkable stories of this year is the recovery of Arizona Congresswoman Gabrielle Giffords. She was shot in the head in January. The bullet penetrated parts of her brain that control speech. Yet last month she surprised many people by speaking in public.

INSKEEP: One therapy she used is our subject in Your Health on this Monday morning. Giffords spoke again in part thanks to the power of music. Singing can help people with brain injuries, and that includes two patients who met NPR's Richard Knox.

RICHARD KNOX, BYLINE: Fifteen months ago, Debra Meyerson suffered a massive stroke that left her unable to speak.

DEBRA MEYERSON: My speech is - yes.

KNOX: It's a cruel twist of fate. Meyerson is a Stanford professor, an expert in gender and race relations. She was an accomplished and popular speaker. Here she is before her stroke, giving a lecture.

MEYERSON: Let me tell you the plan for today. We're going to talk for a few minutes about when and from where you can make a difference.

KNOX: I met Professor Meyerson at Beth Israel Deaconess Medical Center in Boston.

MEYERSON: Stroke is...

KNOX: Meyerson knows exactly what she wants to say. Her intelligence is intact. But she has trouble getting out even the simplest phrases.

MEYERSON: Uh...

KNOX: It's desperately frustrating. Doctors call it aphasia - the inability to speak. Every year more than 150,000 stroke victims suffer it. But Meyerson is beginning to talk again. It takes a lot of work - an hour and a half every day with therapist Andrea Norton, using a technique called Melodic Intonation Therapy. The therapist shows Meyerson a picture of a salad and says this is something she might want to order at the beginning of a meal.

ANDREA NORTON: So now I'm going to sing. You wait, and then sing after me. OK? (Singing) Salad...

MEYERSON: (Singing) Salad.

KNOX: Basically, Meyerson's learning to sing what she wants to say. For example, when she wants people to slow down.

MEYERSON: (Singing) Just a minute, I'm thinking.

NORTON: Good, again.

KNOX: With each syllable, the therapist taps Meyerson's hand. That helps engage the nerves in her right brain that control the muscles in her mouth and throat she needs to vocalize.

(SOUNDBITE OF HUMMING)

KNOX: She also tells her to hum a phrase to herself before she tries to sing it.

(SOUNDBITE OF HUMMING)

KNOX: Meyerson won't always have to do this. Singing is a bridge back to speech.

MEYERSON: (Singing) Would you pour me a glass, please?

KNOX: Then Norton has her do it in a way that's kind of in between singing and normal speech.

NORTON: Would you pour me a glass, please?

MEYERSON: Would you pour me a glass, please?

KNOX: Norton says for over 100 years it's been known that people who can't speak after injury to the left side of the brain can sing.

NORTON: We ask people to speak the words to happy birthday and mostly they can't do it. And if you ask them to sing, they usually can sing the song and you wouldn't know that they had a stroke.

KNOX: She says it's because the brain processes music on both sides.

NORTON: And so even though the left side speech area has been affected by the stroke, there's this preserved singing ability which is happening in the right hemisphere.

KNOX: Turns out the right hemisphere is good at melody and pitch, while the left hemisphere speech center specializes in rhythm. It's also faster. So while the right hemisphere can speak, it has to be trained to do it.

Several decades ago, other Boston researchers started to use singing therapy to help stroke survivors speak again. But it never caught on very much, maybe because a lot of therapists and patients weren't comfortable singing. And back then the science wasn't advanced enough to show actual changes in the brain that result from the therapy. That's changing fast, thanks to patients like Laurel Fontaine.

Where are we going?

LAUREL FONTAINE: To the elevator.

KNOX: I met her at North Attleboro High School in Massachusetts, where she's a sophomore.

A little more than four years ago, when Laurel was 11, she suffered a devastating stroke. Yes, it does happen in children. It destroyed almost the entire right side of her brain. One of her doctors says it's the biggest stroke he's ever seen. [POST-BROADCAST CORRECTION: It destroyed almost the entire LEFT side of her brain.]

FONTAINE: My doctor told me I'm not going to talk. I'm not going to walk. I'm not going to, like, do anything. Press buttons.

KNOX: Ever?

FONTAINE: Ever.

KNOX: Oh, gosh.

FONTAINE: Yeah.

KNOX: After a year of conventional speech therapy, she could speak only a word or two at a time. Laurel still struggles sometimes to find the words she wants. But she doesn't have to sing them out loud.

FONTAINE: I'm singing in my head and talking out loud without singing. I do it like really quick.

KNOX: The singing therapy lasted only about four months, but it's had permanent effects. In fact, researchers can actually see the changes that therapy had on the undamaged right side of her brain.

Laurel has an identical twin, so the researchers could use MRI scans to compare the girls' brains. They focused on a structure on the right side that's important for singing. Before Laurel began therapy, it was smaller in her brain.

DR. GOTTFRIED SCHLAUG: It was actually somewhat underdeveloped on the right side of her brain compared to her sister.

KNOX: That's Dr. Gottfried Schlaug. He heads the Harvard research program studying melodic intonation therapy. Schlaug says that singing region was probably smaller in Laurel's brain because she hadn't been doing anything with her voice for a whole year. But over the 15 weeks of therapy, scans showed that nerve fibers in Laurel's right-sided singing center grew - they clearly multiplied and thickened. With singing therapy, that region in Laurel actually got bigger than in her sister Heather's brain.

Think about that for a second. Singing therapy actually remolded the right side of Laurel's brain in a matter of months. Schlaug says it's exactly what they were looking for.

SCHLAUG: It is the perfect confirmation. Basically, the hardware of the system really changed to support this increased vocal output.

KNOX: And Laurel continues to improve.

SCHLAUG: Every time that she comes in, we see that she can do things that she couldn't do before.

KNOX: He says it's possible that when Laurel is in her 20s, somebody who didn't know any better would never suspect she ever had a massive stroke that left her unable to speak.

But how much of her success is because Laurel was so young when her brain was injured? Schlaug says her youth was a factor.

SCHLAUG: However, we know that patients even in their 80s can show plastic changes to their brain, can show adaptations.

KNOX: It just may take longer. And, as with learning a foreign language at a later age, an older brain may never get to the same level. But from his work with older patients, Schlaug says a surprising amount of recovery is possible. Schlaug thinks singing therapy can be enhanced by simultaneously stimulating the brain with painless, low-voltage electricity, and one day, possibly, by drugs.

For now, it takes an incredible amount of willpower.

MEYERSON: Let's check the (unintelligible).

(SOUNDBITE OF LAUGHTER)

KNOX: But Meyerson was inspired to keep at it by Laurel Fontaine. Therapist Andrea Norton got them together recently. We got a recording of that meeting. Meyerson talks about how long and hard her recovery is. Laurel has some words of encouragement.

FONTAINE: It's hard at first, but you can get used to it. I'm getting better all the time. Don't get frustrated.

MEYERSON: Yes. Thank you.

FONTAINE: You're welcome.

MEYERSON: Yes.

KNOX: Clearly, Laurel's a star and Deb Meyerson has a long way to go. But she's determined to get there. By next Labor Day - the second anniversary of her stroke - Meyerson wants to start public speaking again, this time as an advocate for better stroke care.

Richard Knox, NPR News, Boston. Transcript provided by NPR, Copyright NPR.