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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.
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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.
KUNNAMPALLIL GEJO JOHN,MASLP
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.
KUNNAMPALLIL GEJO JOHN,MASLP
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
KUNNAMPALLIL GEJO JOHN,MASLP
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
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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.
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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.
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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
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