Aphasia is a language impairment that affects the production or comprehension of speech and the ability to read or write. Among its main characteristics, it is found that the etiology is always due to a brain injury; typically, these lesions occur in the dominant hemisphere of language, bringing specific symptoms such as anomia or inability to name any object and poor fluency of oral expression; in turn, all these directly affect the communicative abilities in aphasic patients presenting alterations in mood, behavior, and interpersonal relationships ¹. In this sense, there are different diagnoses and stages of aphasia; Broca's aphasia is a language diagnosis resulting from a neurological disorder characterized by a lack of oral fluency, phonemic paraphasias, verbal and written agrammatism, and repetition difficulties. Likewise, the symptom of agrammatism in this type of aphasia is characterized by the production of content words, which have a descriptive meaning (nouns, adjectives, verbs) or short sentences in which functional words are omitted, which have a syntactic function within the word or sentence: articles, prepositions, personal pronouns, and verbal inflections, thus configuring a simplified language, where certain conventional elements of grammar disappear ². However, comprehension skills are preserved and configured as a nonfluent aphasia.

One of the tools used by speech therapists to rehabilitate nonfluent aphasias is Melodic Intonation Therapy (TEM) since it has positive results in rehabilitating patients with verbal fluency difficulties. TEM has different phases in its application and consists of maintaining the rhythm of oral statements, where the patient tries to reproduce such statements while keeping the intonation and rhythm. As the therapy progresses, the therapist decreases the stimulation, and the patient must reproduce the item independently and with his usual prosody ³. The clinical case aims to test the effectiveness of melodic intonation therapy in the symptom of agrammatism (nominal syntagm), which is composed of an element (noun), which can be accompanied by different determiners (articles), which agree in gender and number. Thus, in his immediate context, the patient increases his oral production and decreases his agrammatical speech, mainly using functional words.

The subject is 55 years old, has previously acquired language, is male, married, a watchman, has a high school education, is right-handed, and has no relevant family history. As the first symptoms presented, the patient reported headaches and loss of consciousness at home. He was seen in the emergency department for presenting inability to move, dyspnea, and fatigue. The symptoms had started five days earlier with the sudden onset of severe headache, confusional state, and slurred speech in the early hours of the morning.

The neurological examination on admission showed temporospatial disorientation, Glasgow scale 11, and motor aphasia. CT of the brain without contrast showed no evidence of old lesions. An acute ischemic cerebrovascular accident (CVA) in evolution was diagnosed.

Currently, she presented Broca's aphasia, not associated with the discrimination of points of articulation, nor with the identification of the meaning of words, as well as severe deficits in alternating and divided attention and difficulty in encoding and storing information. At the sensorimotor level, she presented right hemiparesis with motor impairment of the hand but with independent walking ability.

Finally, this dependent person needed constant support and supervision to perform basic and instrumental activities of daily living. He used a wheelchair to move around. The family reported that the patient presented emotional instability and discouragement that made it impossible for him to participate in family activities. For the participation in this case analysis, the history of brain damage suffered by the patient, the aphasic symptoms presented, and the fact that at the time of the intervention, he did not report a history of previous treatment for his oral language difficulties were considered.

During the application of TEM, it was possible to identify that in most of the short metrical and high-frequency syntagms, he did not present difficulties in any of the stages of the therapy levels, and even spontaneously and independently without requiring support. It is important to point out that, during the therapeutic process, the patient showed interest and motivation, and his receptivity provided him with new communicative skills even though the therapy was based on the constant repetition of stimuli, facilitating the achievement of the proposed objectives. In the last four sessions, the patient presented a significant and permanent increase in the score, configuring an important improvement in the symptom of agrammatism.

The patient was re-evaluated when were completed the twelve intervention sessions, finding improvement in fluency, reduction of pauses during the speech, increase in the length of words composed of determiner + noun (nominal syntagm), achieving an improvement in length from one to two words. In turn, she presented a grammatical form with two-word utterances, limited to enunciative and stereotyped, using definite determiners + common and concrete nouns, with an increase in the use of grammatical categories (nominal syntagm) (Table 2).

Table 2

Item	Score obtained	Expected score
Expressive language	44	60
Comprehensive language	44	44
Writing	21	99
Reading	21	30
Written calculation	6	12
Visual	15	15
Copy of a figure	2	5
Pantomime	24	24
Communication profile	5	6
TOTAL	182	231

As the sessions went on and after the introduction of the determiner + noun, the patient was able to progressively comply with the stages and levels of therapy with less difficulty.

In response to the objective of the research, items related to the symptoms of agrammatism contemplated in the initial and final evaluation are retaken. Therefore, conversational speech, descriptive speech, oral fluency, content, and grammatical form are considered expressive language. The score obtained in sentence length is maintained as established in the evaluation protocol; however, it is important to point out that the patient manages to increase the number of words from one to two. Regarding the score obtained for conversational and descriptive speech, there is evidence of an increase in the number of words according to the test scale.

Melodic intonation therapy is a tool that allows speech-language pathologists to address language impairment in nonfluent aphasic patients because of brain injury.

According to Haro-Martínez et al. ³, melodic intonation therapy has proven to be feasible and beneficial in earlier stages, within the first months after brain injury; they also report that it has a positive effect on communication skills in patients with nonfluent aphasia. In this case, where there is evidence of communication disorders, specifically in oral production (fluency, sentence length, anomias, agrammatism) and characteristics of expressive language disorders, by sharing the communicative characteristics and the time elapsed after the lesion, we can be said that greater benefits can be evidenced in terms of oral production in the use of grammatical categories, sentence structuring according to the conversational topic, expanding the possibilities of the effectiveness of the therapy.

Because the therapy focuses on expressive language skills, results have been particularly positive when applied to selected groups of patients ⁵, specifically those with production limitations, including decreased verbal agility, relatively preserved comprehension, and poor repetition. These characteristics partially coincide because the patient presented decreased oral fluency, sentence length and information content, and auditory comprehension; they increase the factors that predict positive language outcomes.

On the other hand, the study of Melodic Intonation therapy by Van Der Meulen et al. ⁶, mentions that intensive training in a short period produces an improvement. Thus, the therapy application period in this case was developed in 12 sessions for one month, in agreement with the authors above, who state that the greater the intensity and periodicity, the greater the probability of desertion.

Mattioli ⁷ indicated that intensive training in the acute stage, in a short period, has significant results in the rehabilitation processes, so the intervention in the patient of study is performed in the initial phase of his brain injury, showing substantial progress in expressive language, mainly in the symptom of agrammatism.