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This
article describes rehabilitative language therapy
in a case of aphasia with damage to oral and
written production as a consequence of a stroke.
This work has been done fundamentally joining music
and words, developing aspects such as: •
phonological, lexical, syntactic and prosodic levels
of language;
•
articulation;
• body perception;
• inhibition ability and choice of acoustic stimuli;
• perception and expression of feelings and emotions;
F rom a strategic point of view, the central nucleus
of the work was based on the automatic rehabilitation
of language through music and on the
search for transformation from automatism to
consciousness.
Introduction
The experience that I will describe refers to a rehabilitative
intervention aimed at a client suffering from
aphasia. This intervention has an experimental
and empirical nature and it was planned
for a client who I will call R.P.
Description of the case
R.P. is a doctor who, in November 1998, suffered an
apoplectic fit caused by an obstruction of the inner
left carotid artery due to a presumed dissection.
A dominant aphasic
impairment was immediately
detected with prevalent compromise of
expression.
Once the oedematous phase had been passed the exams
confirmed the existence of two hypodense cortical-
sub cortical areas without mass effect, at the
temporal - f rontal- parietal area, which can be attributed
to ischemic damage at the critical stage.
Two months after the pathological event, in January
1999, R.P. underwent a neuropsychological exam to evaluate the
status of his linguistic and
non-linguistic cognitive
functions. As far
as linguistic functions were
concerned, at
a lexical and a sub-lexical level
the most conspicuous impairments showed
themselves to be at the expense of the transcodification
mechanisms (in particular oral-written conversion)
and of the output lexicons (especially
orthographic) where a conservation of nouns
rather than verbs emerged. The phonological and
orthographical input lexicons (lexical decision
within the norm) did not seem to be affected,
even if the tests concerning the latter were
made difficult on some occasions because of
the presence of bilateral otosclerosis which did not
always permit an easy evaluation of the exact levels
of comprehension. At a morphosyntactic level,
although partly hidden by the lexical deficits, a
non-grammatical framework with vague immediate
memory impairments emerged (especially of
spoken material).
Before the pathological event R.P. had a high and
extensive cultural level. His restless, curious and
open personality had also driven him to study
and carry out research both in areas related to
his professional sphere and in other very different
areas.
R.P. had a great correctness and richness of language and
he remembered the laws that govern it
from a grammatical, morphological, syntactic and
orthographic point of view perfectly. From a musical
point of view R.P. did not have any particular training
or knowledge. His musical education had
consisted of lots of "light" music that had
accompanied him throughout his life. In his adolescence
and early youth R.P. would join his group
of friends to sing, accompanying themselves with
every kind of household object that could
act as a percussion instrument. They sang the songs of songwriters in
their original form
and, in addition, they
manipulated and remade
them by improvising on
them. "Pure" improvisations
or creations of
new songs or texts also formed part of the
activities practiced by the group. R.P. himself reported
to have learnt to play some chords on the
guitar, thus using it to accompany the songs.
In November 1997, R.P. joined the polyphonic choir
that I myself conduct. He had never sung in a
choir and his knowledge of "classical" music was
limited. At that time his intention to take part
in a choir was not motivated by a mainly musical
interest but rather by a need for expression, release
and to seek well being. Before his apoplectic
stroke R.P. had time to sing in the choir
for six months.
Initial observations and considerations
Eight days after having suffered the ischemic fit and
while he was still hospitalised, R.P. only articulated the
syllables /ta/ and /pa/, which replaced every
part of speech and were always accompanied by
the same gesture of the right arm in a stereotyped
way.
At the same time R.P. managed to sing some of the
choir’s pieces at least partially. He couldn’t start
them by himself but given the initial input he
continued to sing, re p roducing the piece’s melodic
pattern precisely and with reasonable pronunciation
and articulation of the text, showing small
difficulties with certain phonemes or
phonemic groups but never so much so as to make
the words pronounced incomprehensible.
He showed a little difficulty in the reproduction of
the rhythmic aspect which was however fairly
well conserved and became perfectly recognizable.
The reproduction of rhythmic fragments had been
conserved even if a great effort could be observed
in its realization.
In hospital R.P. was almost immediately subjected to
a rehabilitative speech therapy intervention consisting
of the reproduction of vowels following the
therapist’s lip movements which drove him
to an exasperated articulation and repetition of
the names of people nearby and of certain objects,
as well as attempting to make him write his
name, surname, job, etc. R.P. couldn’t do what was
asked of him, or he managed it with great difficulty,
thus experiencing a sense of enormous frustration
and incapacity.
I proposed to R.P. a sung performance on a reciting note
of vowels in the order /u/, /o/, /a/, /e/, /i/ already
done in the choir and that he now performed with
ease at various pitches as the reciting note
was changed a semitone at a time.
These observations
together with R.P.’s emotional and
affective reactions, the enthusiasm and, I could
almost say, anxiety with which he awaited the
moment of my arrival to be able to sing, led me
to ask myself various questions and to the following
considerations:
1. A person who goes through an experience such
as that faced by R.P. cannot only be considered from
the point of view of their aphasic impairment
and language recovery. We can’t not
take into account the psychological situation that
this person is experiencing. We can’t not
take into account who he was, where he came
from and what his world and his life experience
were before the pathological event, and
not adapt the intervention immediately to the
personality and the needs of the person we have
in front of us.
2. We cannot avoid asking ourselves how his perception in
general has changed and in particular his
perception of himself. How his self-image has
changed, his own sense of identity.
3. We cannot forget the fear in the face of death, of
the repetition of the apoplectic fit and of his
own organic and mental state in general. The
confusion and fear in the face of the evolution of
the illness and its consequences, and reflection
in the face of his new life situation and
future. Why can’t we ignore the fact that there
is a "broken line" that separates what comes
before from what comes after?
4. If, as in this case, the client can sing easily and with
pleasure from the very first moment, why
not encourage it, allowing him to hear his
own voice and gain confidence in himself and
in his chances of recovery, at same time encouraging
the flow of his breathing and the physical-
articular exercise via the pronunciation of
the lyrics? Why not take into consideration from
the very beginning that pieces of music
that the client can recall, even automatically, belong to his history
nevertheless and might
re p resent a small bridge across which memories,
sensations, images, affection and emotions
can pass and thus represent a link between
what comes before and what comes after?
5. The language related to the lyrics of a vocal piece
undoubtedly belongs to the sphere of automatic
language. But if the main textbooks on
language rehabilitation in aphasia cases recommend
starting from and initially encouraging clients’
automatic language, why not take
this form of automatism into account which
moreover allows the global involvement of
the person with an extremely important emotional
component, acknowledged as being essential
in rehabilitation, re-education and learning
activities?
6. From an anatomical-functional point of view, some
of the main Neuropsychological and Neurolinguistic
works place the possibility of establishing
a compensatory gesture of the right
hemisphere for linguistic functions, as well
as the possibility of reorganising the areas nearest
to the injury, at the basis of the rehabilitation and re-education of an
aphasic client.
Furthermore, the need not only to use alternative
strategies but also to implement activities
that can involve extensive areas of the
brain via the involvement of various sensory and
perceptive procedures is recognized, as
well as the huge influence of emotional experience
on the efficiency of cognitive processes.
Despite being aware
that the sphere of neurosciences
is an extremely complex field reserved
for specialists and still partially shrouded
in mystery, even for them, I asked myself
why music could not contribute d
i rectly to the rehabilitation of language, given
the fact that it is a very complex neuropsychological activity
which, as such, involves multiple
cognitive processes and is capable, moreover,
of multiple sensory involvement.
It is also recognised that music, through some
of its components and is close relationship with
emotional processes, is closely linked to
the activities of the right hemisphere.
7. From the point of
view of their components, spoken
language and musical language (despite
being a matter of two different and quite
distinct languages) share parameters such
as intensity, pitch, duration, rhythm, timbre, tempo- density which play
a fundamental role
in modulating the quantity and quality of the
information in both. From the point of view
of the phonic-phonetic material of which
the two languages are composed and the
structures it gives rise to, the close relationship existing
in both between signifier and
signified is clear. From a formal- syntactic point
of view the constituent elements in the two
languages are not organised by chance but
follow well-defined grammatical rules which
vary according to the era and the culture. Through these considerations
I adopted Dogana’s
views which consider the bi-directional synergism
created by the encounter between spoken language and musical language
which, through their
isomorphisms, allows
the optimisation of their onomatopoeic capacities
and their synaesthetic and structural
worth. The two languages also allow
continual references through the phenomena of
phonetic symbolism which encourages both
objectification of the musical perceptive datum
and the translation and musical perception
of the linguistic objective datum.
This rich encounter between the two languages
seemed to be able to facilitate a language
rehabilitation intervention.
Description of the intervention
Following the abovementioned considerations, the
intervention was carried out on various fronts,
which can be summarized as follows:
• Support and
encouragement work, with special attention
to the preservation of self-confidence and
confidence in the chances of recovery.
• Work on body perception.
• Work on articulation and on the motor aspects of
language, from the point of view of plan-ning and
execution.
• Work on the recovery of short-term phonological memory.
• Work on the
three levels of language (phonological, syntactic,
semantic) through the rehabilitation of
the expressive and emotional meaning
of phonemes, words and phrases.
• Work on rhythm and the fluency of language.
• Work on prosody
through the interpretation of the
emotional-affective meaning of text.
• Work on the
recovery of space-time concepts through
the articulation of movement with musical
parameters.
• Work on
inhibition ability and choice of acoustic stimuli.
•
Emotional-affective resonance.
Each of these intervention areas was tackled both individually
and in relation to other people. The
start and the focal point of the intervention was
encouraging the automatic recovery of pieces of
music from R.P.’s history, in order to then look
for the transition from automatism to intentional action.
This activity was assisted and accompanied
by didactic activities aimed at developing
sensitivity towards the musical parameters of
intensity, pitch, timbre, duration and rhythm.
Starting off with pieces sung in the choir and thus
belonging to R.P.’s "recent past", then going back
through his history we encountered pieces from
his youth, to then come back to the here and
now by learning new pieces. Thus,
the work consisted of:
1. Reconstruction of the whole piece from both a musical
and a textual point of view.
2. Reconstruction of the semantic and emotional meaning
of the text.
3. Performance of the piece as follows: a) singing by
imitation in the form of an echo, b) singing together
simultaneously, c) singing together but
not simultaneously, following an interplay alternating
words or phrases.
4. Search for and appropriation of a pulse which did
not limit free expression but which gave it a
container to signify order, continuity and fluency.
A pulse which matched R.P.’s "tempo".
5. Performance of
the piece marking time with movement
in space and by hand clapping.
6. Division of the
piece into half-phrases or phrases and
performance of these in isolation.
7. Extraction of the
rhythmic organisation of each
of these fragments which was performed by
hand clapping or on a percussion instrument, with
the following combinations: a) sung
voice-percussion, b) sung voice- percussion- movement in space
reproducing the pulse,
c) sung voice-movement in space reproducing the
rhythmic structure, d) percussion only.
The pieces used, at least in the beginning, were
chosen from those with a syllabic organization so
we were able to focus attention on the differences in duration of the
syllable- sounds and thus on the syllabic structure of each word in the
text.
8. Search for the stress accent in each word, and execution of this in percussive form together with the sung voice.
9. Search for the stress accent in each phrase and pre p a ration and execution of this through
movement.
10. Relating the climax of the phrase to the expressive and significative intentionality of the text and the music.
11.Transformation of the piece into rhyme and its performance: a) respecting the original
melodic outline but giving equal weight to each syllable, b) taking away the melodic outline and reciting it as a real
rhyme.
12. Recitation of the text following its expressive- emotional
contents.
In carrying out this work the phonemes or
phoneme groups and the parts of speech with which
R.P. showed greatest difficulty were highlighted.
Thus, short vocalization exercises emerged from
the same pieces of music. Initially created as an
extension of the
melodic- rhythmic features of a particular fragment, these exercises were used
to increase our awareness of the difficulties
found and, through their isolation, to overcome
them.
Each piece, as I have already said several times, was chosen from the repertoire of pieces from
R. P.’s musical history, always choosing the one
most suited to each stage of rehabilitation in
terms of structure, technical linguistic content
and expressive-
emotional content.
I attached fundamental importance to the latter because I considered it important that the
textual content of a piece could offer R.P.
the possibility to express feelings, needs and emotions
that could not otherwise have been expressed
verbally, also
leading him to an awareness of his situation,
his pain and his anger in a gradual and safe
way.
We worked on sub-lexical mechanisms and on the
recovery of short-term phonological memory (already
confronted via the vocalization exercises) through
the selection of new pieces in foreign
languages (Lappish, Finnish, Croatian, various
African languages), of rhymes in dialect and
nonsense rhymes. The compositions, anchored to
strong rhythmic or rhythmic- melodic and, in
any case, formal structures enabled us to work on
the phonic-phonological aspects of language, also
allowing us to translate them into bodily or sound-
instrumental movement, creating a playful, pleasurable
and thus stimulating atmosphere.
Next we looked for the phonic- phonological contents
of some words and their relationship to its
meaning, discovering an intriguing world made
of: a) congruence between sound- meaning; b)
expressive-emotional contents made up of
the quality of the sound itself and its physicality - corporeality.
Apart from lexical and phonological rehabilitation,
I used this activity to further awareness
of the quality of articulation and proprioception
not only limited to the phonatory apparatus.
As soon as it was possible, R.P. and I sang easy two-part
songs and, later, polyphonic or isorhythmic
pieces, in which each person had to keep
his own part. A privilege we were able to enjoy
was the participation of a small group from the
choir that joined us for some meetings, helping us
to reinforce work on the simultaneous meeting
of several voices, in which each person has
to be able to find and assert himself within a whole
made up of different voices whom we encounter
and confront, but always creating a common
whole created by differences.
Furthermore, with this activity R.P. was able to test
his ability to listen to, choose and inhibit simultaneous
stimuli. The meeting with the choir for R.P. also represented the start
of his opening up
towards the outside, having to face and meet with
others through an activity in which he also had
to play a precise role. R.P. did not feel up to this
task. He was nevertheless able to verify, in a safe
environment, that his place was still there and
that he was capable of taking it.
Conclusions
Lack of experience and of information in this type
of intervention did not allow me to start off with
a highly structured programme including an objective
method of initial and final evaluation. In
actual fact, the evaluation of the results of the intervention
was carried out via the periodic control reports
that R.P. took on and from the direct observation
on my part of the gradual recovery of
his communicative abilities and his professional and
relational social reintegration. In fact, R.P. resumed
his working life, continued his family life,
returned to the choir in which he participated with
absolute normality, adapting himself to the
pace of learning of the other choir members, and
resumed his social life. His language still shows
a deficit in the speed of locating lexicons which
causes small interruptions in his speech and
the need to speak slowly, but he manages to correctly
cope with any topic, obviously showing greater
ease and fluency in relation to daily or practical
ones. For me, this is the real conclusion of
the experience.
From a more objective and scientific point of view
my conclusions become no more than questions for
which I have not been able to find answers:
how much of R.P.’s recovery was spontaneous?
How much is owed to the speech therapy
interventions which, although fragmented
and short, nevertheless took place?
How much is due to the music
therapy?
There is an aspect which I have not directly talked about
but which was of great importance in my intervention,
the relational aspect. I always considered the relationship between R.P.
and myself to be fundamental, a
relationship which was formed by
continuously listening to his needs and, as
a result, adapting to them. Not only technical needs,
for the recovery of language, but to a great
extent also emotional needs.
I will therefore conclude with a final
question: to what extent did this
relational- communicative aspect
affect R.P.’s recovery and reintegration? |
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This experience refers
to a rehabilitative
intervention
aimed at a client
suffering from
aphasia.
Before his
apoplectic stroke
R.P. had time to
sing in the choir for
six months
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