Neurological Processing in Fluency Disorders.pdf / KUNNAMPALLIL GEJO

7/27/2019 Neurological Processing in Fluency Disorders.pdf / KUNNAMPALLIL GEJO

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1KUNNAMPALLIL GEJO JOHN,MASLP


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Recent brain scan research has found

abnormalities in the brains of stutterers and

promises new treatments for stutteringusing drugs and computerized devices.

No differences between stutterers and non-

stutterers have been found during silent or

rest (Ingham, 1996).

During fluent speech, stutterers brains looksimilar to non-stutterers brains.

KUNNAMPALLIL GEJO JOHN,MASLP


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But during stuttering, cerebral activity changes

dramatically.

Left hemisphere areas active during normal

speech becomes less active, and

Areas in the right hemisphere not normallyactive during speech become active ,

(Braum,1997;Ingham,1997).



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Brain scans can show relative activity indifferent areas of the brain, but cant show

what the person is thinking or what each area

is doing

Researches often hypothesize on the functionof various brain areas



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something wrong with stutterers left brainspeech areas and so right brain areas not

developed for speech take over.

This seems unlikely, given that most stutterers

are capable of normal ,fluent speech in someconditions.

Fears and anxieties that stutterers experience,

generated by the limbic and paralimbic

structures.But these areas dont seem to beabnormally active during stuttering.



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Decreased central auditory processing duringstuttering seen in allstudies(Wu,1995;Fox,1996;Inghram,1997).

one study also found decreased activity in theareas that integrates auditory and somatic(body) sensation(Braun,1997).these all are rear

brain areas.

The researchers hypothesized that stutteringreduces this rear-brain sensory processing, and

reduces the left-brain communication of thissensory information to frontal speech andlanguage areas.



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The abnormal right brain activity may be analternative pathway for rear-brain sensory

information to travel to the front of the brain.

Another team of researchers believes that thekey to stuttering lies in the different functions

of the lateral and medial system (Goldberg,1985; Maguire, 1997).

the lateral system is the part of the cortex,

where our consciousness is, and we haveconscious awareness and control of lateralfunctions.



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This area produces and understands

language (wernikes area), form words

(Brocas area), and form muscle

movements (supplementary motor areas).

These areas can produce speech under

closed loop motor control, but high

attention demands and abnormally slow

speech(shea,1993) make this anundesirable way to talk.



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Different studies have found different results

because a variety of technologies were used(EEG Vs SPECT Vs PET, H2150 Vs FDG).

Most studies were small usually a half dozen

stutterers. The subjects were usually righthanded men-women and left handed men may

have different cerebral activity.



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Braun(1997) -language processing shifted to theright hemisphere, including the dorsolateral

prefrontal cortices,middle temporal gyrus, andanterior cingulated cortex.

motor functions shifts to the right hemisphere,including the anterior forebrain regions and

associated arch cortical para limbic areas.

visual processing is also appeared to shift to the

right hemisphere.



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Decreased sensory perception,including post

rolandic sensory areas and related

paritocortical para limbic regions.

Increased somatosensoryprocessing,including the dorsal region of the

angular gyrus,adjacent to the superior

parietal lobule,as well as somatosensory

association cortices in the medial ParietalLobe .



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De Neil, 1995: During silent reading there isincreased activation in the left angular

cingulated cortex, interpreted as a

reflection of cover anticipation of

stuttering.

Ingham, 1997:Diffuse over activitythroughout the cerebral and cerebellar motor

systems Deactivation of a verbal production

circuit between left frontal (BA47) andtemporal (BA22) cortex that has been

previously identified in normal speakers.



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Kalinowski, 1997: Some stutterers showed

the greatest reduction in the temporal-parietal area, and others showing greatest

reductions in the right hemisphere

posterior sites.

Kroll, 1997: After fluency shapingstuttering therapy there is increased left-

hemisphere activity, although large areasof activation in the right hemisphere

remain.



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Watson, 1994: Found the abnormal right-hemisphere activity only in stutterers who

also had language deficits.



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The central nervous system characteristics of

stuttered all examined in terms of informationprocessing strategies of the cerebral hemispheres

CNS characteristics all well gender stood by theobservation of behavioral events and relating

them to known or theorized .

CNS functions stuttering is an outcome ofmanipulable process rather than a static disorder,

resulting from CNS dysfunction which can be

compensated but not remediated.



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MORPHOLOGICAL ASYMMETRIES COGNITIVE/BEHAVIORAL ASYMMETRIES

The planum temporale-one third toseven times larges in the left

hemisphere for normal right handed

subjects (Geshwind and Levistsky

1968)

Left hemisphere better equipped toprocess brief sounds (


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Left and right pulvinar are shownto be involved in informationprocessing. They found that rightpulvinar was involved in

processing visual stimuli and leftpulvinar with processing verbalor auditory stimulus

Spatial stimuli under analytictask demands are processed by ithemisphere (weheatly ,Willis andMitchell 1979)

Trained musicians process musicmore left hemispherically than

non musician (Gates and Bradshaw

1977)

Speech is more lateralizedlinguistic function i.e. to left

hemisphere where as language is

least lateralized being present in

various degrees in both

hemisphereKUNNAMPALLIL GEJO JOHN,MASLP

Th i ht h i h


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The right hemisphere maycomprehend spoken words byperforming an acoustic patternmatch with stored examples, than

performing acoustic analysis likeleft hemisphere ,zaidel (1979)

The lexicon in the right hemisphere

is connotated associative and

imaginative where as that of leftare precise denotative and

phonologic (Bradshaw 1980)



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Authors Method Variable Results

Zaidel

(1979)

Dichotic /Tachistopic Phonological

component in

nonsense syllables

The greater the

phonological

component greater

the left

hemispheric

activation

Tallal and Newcomb

(1978)Responding sides ofvarying duration

Duration ofauditory stimuli

Left hemispheresdamaged subjects

were impaired in

their ability to

respond to sounds

of brief duration

Faber- Clark and

Moore (1983)

Alpha suppression Recall and recognition

and word listsCreator left

hemisphere

suppression with

recall greater right

hemisphere

suppression forrecognitionKUNNAMPALLIL GEJO JOHN,MASLP


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CNS investigations suggest that stutterers lack

cereberal dominance for speech (Orton 1927,Teavis 1931) Teavis (1931) hypothesized that

stuttering results from asynchronous arrival of

nerve impulses in bilaterally impaired jaw

muscles.

Some earlier studies suggested a lack of cerebral

dominance for stutterers (Lindley 1940

freestone 1942) other studies also demonstrate

right hemispheric dominance for language



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Douglass (1943) replicated by Knott and

Tjossen, 1943 found that stutterers as a

group have less percent time alpha in theirright occipital areas compared to their left

occipital areas during silence while non

stutterer evidenced the opposite.

EEG studies found neuronal dysfunction

rather than hemispheric differences (Fox

1960) deemphasized hemispheric asymmetry

difference between stutterers and nonstutterers during language processing.



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TACHESTOSCOPIC VISUAL METHODS

SCALP RECORDED AVERAGED EVOKED

RESPONSES

HEMISPHERIC ALPHA ASYMMETRIES

CORTICAL BLOOD FLOW (CBF)

TEMPORARY ANESTHETISATION OF CEREBRALHEMISPHERES



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Moore(1976) reported a significantly largerpropotion of stutterers had the left field

preference than did the non stutterers

Plakosh(1978) found no visual field difference

for stutterers and found out that stutterers

were more dependent on visuospacial aspects

of visually presented lingustic stimuli than

normals.



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Limitations:-

Information can be presented only for a short

duration

Only short stimulus arrays can be used.

Controlled luminous conditions are needed along

with Sophisticated equipment to present and time the

stimulus parameters



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ADVANTAGES:

Allows observation of a specific cortical

response over cortical areas, hence helps

to locus hemispheric function. Can be used to study relative activation

latencies of different cortical areas

(Brown, Marsh, Smith, 1973, 76 Neville

1980)



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Moore and Haynes, (1980) found out that

comprehension of connected verbal discourse

was unaffected in male stutterers who also

demonstrated reduced hemispheric alpha,

which would reflect right hemisphere

superiority in processing semantic aspects of

language.



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ADVANTAGES:-

It can be used to study hemispheric

processing over time using a variety ofstimuli, (;phrases, sentences etc)

LIMITATION:-Scalp electrodes are used. Hence results

reflect activity of many small zones of

cortical surface beneath the electrodes

(cooper, osserton and Shaw ,1974



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Woods,stumps,sheldon&proctor(1980)

2 stutterers were subjected to CBF measurements

while reading aloud.

Condition 1-under haloperidol-read aloud-

increased fluency.

Condition2-without medication-both stutterers

showed higher cerebral blood flow in brocas area

on the right compared to the left hemisphereduring stuttering.

During fluent moments CBF was observed in left

hemisphere compared to right hemisphere.KUNNAMPALLIL GEJO JOHN,MASLP


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Anesthetization of cerebral hemisphere inanother method is determine hemispheric

lateralization for language Wada (1949)

suggested a general anesthetic to be injected

in to the left or right carotid artery.

Anesthetization lasts for 2-3 mins and in most

subjects temporary loss of language is evident

on injection to the left carotid artery.



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This procedure is used to infer hemispheric

language dominance, also could be used to

understand speech dominance. Most studies

have used speech motor tasks.

LIMITATION

Provides indication of gross interhemisphericactivation

Invasive and patient is at risk

Use restricted to medical personnel, neuro

surgeon and nuerologist



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Neuroimaging is a general term that refers to

radiologic and physiologic techniques that can

provide a visual representation of intact

functioning neurological systemsStructural -CT MRI

functional FMRI, MCBF, PET, SPECT ,EEG& Eps

RadiographicElectrical activity



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Watson and Freeman 1997 Obtained MRI data for 20 adultstutteres with developmentalstuttering and found no significancedifference in the scan of stutterers

compared to at all controls

Strunh Black and Nasser (1987) Reported a CT study of adults with

developmental stuttering their

findings indicated no focal lesion inboth subjects. Certain structural

anomalies well noted like enlargement

of interior horns of ventricle as well as

a focal anatomical asymmetrical right

under than left in the occipital lobe.


Fintzo Pool Freeman Devous They used quantitative electro


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Fintzo Pool Freeman Devousand Watson (1991)

They used quantitative electroencephalo graphic (EEG) technique in astudy of testing resting EEG and auditoryevoked potential (AEA) for 20 adults 50thdevelopmental stuttering.

MethodPlaced 20 electrode sites - the scalp andhad additional electrodes as extracortical monitories and linked earlobereferences.

Subjects revised binaural presentation of10 3dBSPL PT &tone bursts as stimuli

ResultsGlobal reduction of EEG amplitudes inthe better frequency region when

compared to a group of 12 adult nonstutterersAEP data indicated differences for theparticipants who stuttered implicatingtemporal cortex and angular cortexdysfunctions.


Watson, Pool Freeman and Finitizo Performed SPECT &CBF scans can to


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Watson, Pool Freeman and Finitizo(1992)

Performed SPECT &CBF scans can toadults males with developmentalstuttering and compared them tosubjects performance on laryngealreactions time.

ResultsStutterers demonstrated low rCBF forsuperior and middle temporal areas

Ingham for and Ingham (1994) PET or CBG data for 4 adults with

developmental stuttering and for normal

speakers during resting, solo reading and

choral reading condition.

This data indicated that adults who

stuttered showed increased blood, flow

to the supplementary motor area tosuperior lateral premotor cortex during

solo reading condition and

activation of these regions was

significantly reduced during the fluency

enhancing choral reading condition



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A Position Emission Tomography study of Silentand Oral Single Word Reading in Stuttering

and Non-stuttering Adults (JSHR, 2000)Kroll, R.M., DeNil, Kapur, S. & Houle S.



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To investigate the presence and extent of

difference between stuttering and non-stuttering speakers in the lateralization of

cortical and sub cortical language

processes during silent and oral reading

tasks.



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10 stuttering and 10 non-stuttering male

adults (Eng. Speakers)

20-45 years

Matched for education and handedness

Task Low imagery words

3 Tasks

-Non-linguistic (Baseline)

-Linguistic

Oral reading

Silent reading


Sil t di 25 d (bi ll bl )


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Silent reading-25 words (bisyllable)

oral reading-25 words

PET scans were done.

Findings- silent reading

Cortical and sub cortical regions of increased

neural activation associated specifically withsilent reading for the 2 groups

S & NS activation was evident in cerebellar and

lingual gyrus. Increased activation of left cingulated cortex

and frontal areas in stuttering speakers.



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Findings-Oral reading Increased cortical activation seen in left

hemisphere in non-stutterers and a bilateral

pattern in stutterers.

Cortical activation was observed in

homologous areas in the right hemisphere.



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Disconnection of Speech Relevant BrainAreas in Persistent DevelopmentalStuttering (The LANCET, Vol.360,2002)



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To determine if a disconnection between

speech-related cortical areas are the

structural basis of persistent developmental

stuttering by characterizing brain tissuestructure through diffusion tensor imaging

(DTI)



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Subjects

15 adults (5 women) with developmentalstuttering mean age 30.6 years.

No neurological or medical disorder.

All subjects were right handed except one. Severity was assessed before DTI.

Task

To read aloud news paper article (141 words)and spontaneous speech sample



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Fractional Anisotropy (FA) is a measure of

coherence of the orientation of fibers within

each voxel. (volume of cell).

It was significantly lesser in the stutterer

group than controls in the rolandic operculum

of only the left HS immediately above the

sylvian fissure.



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This region encompasses the white matter

immediately below the sensori-motor

representation of the oropharynx at the end

of central sulcus.

Variation in gyral anatomy reported in

persistent developmental stuttering



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Evidence in Bimanual Finger-Taping of anAttentional Component to Stuttering.

Williams G.Webster (1990)

Behavioral Brain Research



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To analyze the 2:1 tapping performance of

right and left handed male and female

stutterers and non-stutterers. (Tapping a keytwice with one hand for each single tap by

the other hand)



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8 subjects in each 8 groups formed bycombining 3 independent variables i.e.

handedness (R/L)

group (S & NS)

sex (Male/Female)

Finger tap apparatus

IV- group, sex, handedness, lead hand and

block and trial

DV tapping rate

No. of attempts required for successful

tapping



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Right handers tapping rates were faster

under R2/L1 than under L2/R1 condition. Performance under two lead hand conditions

was similar for left handers.

Number of attempts needed parallels the

speed data.

No significant difference between males and

females.

Performance of stutters was significantly

lower than non-stutterers under both had

hand condition.



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Preliminary results of a functional MRI studyof brain activation patterns in stutteringand non-stuttering speakers during a

lexical access task.Blomgren, Nagarajan .S, Lee N.J.(2003)

Journal of Fluency Disorders.



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To present preliminary fMRI data relating to

activation areas involved in lexical access ina group of stuttering and non-stuttering

speakers



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Subjects

7 stutterers and 9 normally fluent speakers. Stutterers 19-39 years

Normals -20-40 years

SSI was administered (17-31) mild-severe

Task:

Box car design.

Four sets 30s rest block

Four 30s active block Active block task word description

(auditory) (28 word description) .

fMRI was done.



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The stuttering speakers displayed significant

group activation patterns in left hemisphere

speech and language areas as well as right

hemisphere homologue areas.

Activation sites include right and left posterior

supervisor temporal gyrus. Substantial right

temporal gyrus, left and right temporal gyrus

right and left inferior frontal gyrus bilateralactivation of the superior precentral gyrus and

association cortex.



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Over activation was seen in right auditory

association area and right lateral pre central

gyrus.

Non-stutterers activated primarily left

hemisphere cortical speech and language

areas.



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Brain correlates of stuttering and syllableproduction, A PET performance correlationanalysis.

Fox and Ingham et.al. Brain (2000)



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To distinguish neural system of those of

speech from that of stuttering using PET

scans.

To perform a correlation analysis using both

stuttering rate score and a speech rate score

in stutterers and non-stutterers.



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10 right handed men stutterers and 10

controls.

90 PET images were obtained.

Mean age 32 years.

Oral reading task used ie; solo readings and

choral reading and rest condition (Eyes closed)



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Stutter rate varied with fluency inducing

conditions like choral reading.

Stutter rate correlates were more lateralized

to the right cerebral and left cerebellar

hemispheres.

Syllable correlates were bilateral which

lateralized to a greater extent to left cerebral

and right cerebellar hemisphere.

Cerebellar syllable correlates were more

extensive in stutterers than controls.KUNNAMPALLIL GEJO JOHN,MASLP


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Neural Mechanisms underlyingStuttering: Evidences from BimanualHandwriting Performance.

Williams, G.Webster.

Brain and Language (1983)



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To explore more on the ungated

interhemispheric communication instutterers through bimanual co-ordination

paradigm



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8 subjects in each 8 groups.

An apparatus consisting of paired vertical

writing boards (3 different position)

24 trials of testing four 1-syllable word were read out. Client

had to repeat it orally and write the first

letter of the words.

96 words.



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Stutterers made more mirror reversals with

non-dominant hand than disfleunt speakers.

Stutters had poor quality of letter formationthan did fluent speakers.

Stutterers were slower to complete their

writing then nonstutterers



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SMA plays a significant role in mediation ofstuttering.

Damage to the SMA would result in binaural

co-ordination difficulties in human and non-human primates.

Callosum in stutterers plays an ungated

function for the flow of information from onehemisphere to other hence bilateral

activation.



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Alpha hemispheric asymmetry andstuttering: some support for asegmentation dysfunction hypothesis.

W.H. Moore and William O HaynesJournal of Speech and Hearing Research (1980)



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The study was designated to analyze the

hemispheric asymmetries and non stuttering

subject



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Subjects:

80 subjects ( non stutterers (M and F) and

male stutterers) with mean age range of

(21.5, 20.5, 23.3) right handed subject .

Stimuli:

Audio recorded verbal and non verbal stimuli

( reading passage and pure tones)

EEG was used to obtain the data



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The stuttering male subjects had less or

hemisphere asymmetry on Right hemisphere

for verbal and non verbal stimulus

Performance of male stutterers indicatedthat they were processing both information

in their motor program function and

perceptual function and peripheral function

appear to be in right HS

Females used more LHS for linguistic



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Females used more LHS for linguistic

processing and Right hemisphere for non

linguistic processing.

Male subjects had equal participation of both

hemispheres



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Hemispheric Asymmetry of Alpha WaveSuppression in Stutterers and NonStutterers

Fitch J and Batson E

Journal of Fluency Disorders (1989)



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To compare hemispheric alpha wave

impression in stutterers and non stutterers in

auditory verbal and nonverbal ,

visual verbal and non verbal.



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Right handed stuttering males 10-15 years

Assessed during SSI (mod -8, serv-3 , 1-very

severe)

12 male right handed non stutterers

Stimulus

Auditory-

Audio taped 75 monosyllabic nouns and verbs 15 sounds pure tones and NBN



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Visual

75 monosyllabic nouns (pictures)

75 cards of geometric figure.

EEG activity recorded in control (Relational

and experimental condition)



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On comparison of mean 2% statistically

significant difference was found in right

cerebral hemisphere for stuttering group.

Stuttering group exhibited Smaller

percentage of right /it alpha percentage

ratio in all condition.



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Stuttering and the basal ganglia circuits:a critical review of possible relations

Per A. Alm

Journal of Communication Disorders37(2004) 325-369

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It is proposed that the basal ganglia-

thalamocortical motor circuits through the

putamen are likely to plays a key role instuttering.

The core dysfunction in stuttering is

suggested to be impaired ability of the basal

ganglia to produce timing cues for the

initiation of the next motor segment inspeech.



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Cunnington et al. (1996) suggested that theSMA is especially involved in self-

initiated,well-learned, complex, and

sequential movements.

Functions of the SMA are more closely related

to the timing of movements than to the spatial

programming.



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These types of function suggest an importantrole for the SMA in speech.

Cunnington et al. proposed that the basal

ganglia, via the SMA, provide internal timing

cues to facilitate the initiation of the sub

movements in a well-learned motor sequence



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Mechanisms of cerebral control of singingdiffer from the control of speech has been

shown by Jeffries, Fritz, and Braun (2003).

Using PET brain imaging these authors

compared the pattern of activation during

speech with the pattern during song with

words.



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Speech resulted mainly in left hemisphere

activation, while singing was accompanied by

widespread right hemisphere activation.

An interesting finding was that speech

resulted in increased activity in the left dorsal

putamen (the basal ganglia motor circuit)

while singing did not result in such activation

of either left or right putamen



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This result is well in line with the suggestion

discussed above, that normal speech requirestiming cues from (the left) basal ganglia

system, while singing is based on a different

strategy for timing of syllables, mainly

involving right hemisphere structures.

Foundas et al. (2001) used MRI to investigate

cerebral morphology in 16 adults with

persistent developmental stuttering and 16matched controls.



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There was no reported history of brain injury,

dyslexia, specific language impairment, ADHD,

or other neuropsychiatric disorders.

The mean level of education was high, 16.5

years. Half of the stuttering group had a family

history of stuttering. Two main findings of thestudy were:

(a) increased total size of the planum temporale

(PT), and

(b) increased number of gyri in speech related

areas in the stuttering group.



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Positron Emission Tomography Study

of Short- and Long-term TreatmentEffects on Functional BrainActivation in Adults who Stutter

De Nil L.F.; Kroll R.M.; Lafaille S.J.; Houle S., 28, (2003 ), 357-380

Journal of Fluency Disorders.



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Previous studies have shown that fluency-inducing techniques, such as choral speech,

result in changes in neural activation as

measured by functional neuroimaging.

In the present study, positron emission

tomography was used to investigate the

effects of intensive behavioral treatment,

followed by a 1-year maintenance program,



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This study was designed to investigate the

short and long term effects of behaviouralfluency treatment on the cortical and

subcortical activations seen in stuttering

adults.



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Subjects

Thirteen stutterers (20-40 years) and 10 non-

stutterers.

All are native english speakers Screened for history of neurological or the

other medical problems and current drug

use.

Both groups matched-handedness andeducation level


Stuttering participants has to qualify for the


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intensive behavioral treatment, followed by a

1-year maintenance program.

Tasks Silent reading-25 words (2s each)

Oral reading-25 words

PET Scans were obtained at 3 time intervals

A) immediately before starting treatment.

B)immediately after termination of the

treatment.C)after 1-year interval of maintenance

program.



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Silent reading

For non stuttering participants, the analysisrevealed that neural activation was

primarily left hemisphere localized in the

anterior cingulate gyrus,inferor and middle

frontal gyrus, and middle temporal gyrus.

Pre treatment-activation was elevated in

stutterers compared to non-stutterers and it

is in the inferior frontal gyrus ,precentralgyrus and cerebellum of right hemisphere.


Post treatment overall activation levels in


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Post-treatment-overall activation levels in

the stutterers is decreased compared to pre-

treatment.

Area of activation were increasingly left

localized in the inferior frontal gyrus

,precentral gyrus .

After 1-year follow up- mainly activation is in

regions involved in speech motor controland

most of the activation was left localized.


Oral reading


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Oral reading.

Pre-treatment-bilateral activation in the pre

and the post central gyrus, superior temporalgyrus,insula and cerebellum.

Post treatment-wide spread activation

thought the brain

After 1-year follow up-activation was mostly

in the motor execution areas bilaterally


s


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