Lower nonword syllable sequence repetition accuracy in adults who stutter is related to differences in audio-motor oscillations.

OBJECTIVE: The goal of this study was to use independent component analysis (ICA) of high-density electroencephalography (EEG) to investigate whether differences in audio-motor neural oscillations are related to nonword syllable repetition accuracy in a group of adults who stutter compared to typically fluent speakers. METHODS: EEG was recorded using 128 channels from 23 typically fluent speakers and 23 adults who stutter matched for age, sex, and handedness. EEG was recorded during delayed, 2 and 4 bilabial nonword syllable repetition conditions. Scalp-topography, dipole source estimates, and power spectral density (PSD) were computed for each independent component (IC) and used to cluster similar ICs across participants. Event-related spectral perturbations (ERSPs) were computed for each IC cluster to examine changes over time in the repetition conditions and to examine how dynamic changes in ERSPs are related to syllable repetition accuracy. RESULTS: Findings indicated significantly lower accuracy on a measure of percentage correct trials in the AWS group and for a normalized measure of syllable load performance across conditions. Analysis of ERSPs revealed significantly lower alpha/beta ERD in left and right µ ICs and in left and right posterior temporal lobe α ICs in AWS compared to TFS (CC p < 0.05). Pearson correlations with %CT for frequency across time showed strong relationships with accuracy (FWE<0.05) during maintenance in the TFS group and during execution in the AWS group. CONCLUSIONS: Findings implicate lower alpha/beta ERD (8-30 Hz) during syllable encoding over posterior temporal ICs and execution in left temporal/sensorimotor components. Strong correlations with accuracy and interindividual differences in ∼6-8 Hz ERSPs during execution implicate differences in motor and auditory-sensory monitoring during syllable sequence execution in AWS.

Research activities in general medicine: a scoping survey by the Internal Medicine Society of Australia and New Zealand.

BACKGROUND: In developing an effective framework for a collaborative research network (RN) that supports members involved in research, the Internal Medicine Society of Australia and New Zealand (IMSANZ) required a better understanding of the current level of research activity and engagement by general physicians, and factors influencing such engagement. AIMS: To explore the current research landscape amongst general physicians in Australia and Aotearoa New Zealand. METHODS: A questionnaire exploring research participation, scope, research enablers and barriers was disseminated to IMSANZ members over a 3-month period. Core functions of IMSANZ-RN, research priorities, potential solutions to perceived barriers and required level of support were also evaluated. RESULTS: A total of 82 members, mostly senior medical staff (74.4%), responded to the survey (11.8% response rate). More than 70% were involved in impactful research across multiple disciplines, encompassing a wide range of research themes and topics. However, there is limited support and resources available to conduct research, with most projects being self-instigated and self-funded. There is overwhelming support to increasing the profile of research in general medicine through the establishment of IMSANZ-RN, whose principal purposes, as identified by respondents, are to foster collaboration, promote research, provide research education and training, and share information among general physicians. Quality improvement studies (56.1%) and clinical trials (41.5%) were also identified as priority research types. CONCLUSIONS: This study has profiled the constraints faced by general physicians in conducting high-quality collaborative research and provides insights into what is needed to support greater research engagement, through development of a discipline-specific clinical RN.

The Application of EEG Mu Rhythm Measures to Neurophysiological Research in Stuttering.

Deficits in basal ganglia-based inhibitory and timing circuits along with sensorimotor internal modeling mechanisms are thought to underlie stuttering. However, much remains to be learned regarding the precise manner how these deficits contribute to disrupting both speech and cognitive functions in those who stutter. Herein, we examine the suitability of electroencephalographic (EEG) mu rhythms for addressing these deficits. We review some previous findings of mu rhythm activity differentiating stuttering from non-stuttering individuals and present some new preliminary findings capturing stuttering-related deficits in working memory. Mu rhythms are characterized by spectral peaks in alpha (8-13 Hz) and beta (14-25 Hz) frequency bands (mu-alpha and mu-beta). They emanate from premotor/motor regions and are influenced by basal ganglia and sensorimotor function. More specifically, alpha peaks (mu-alpha) are sensitive to basal ganglia-based inhibitory signals and sensory-to-motor feedback. Beta peaks (mu-beta) are sensitive to changes in timing and capture motor-to-sensory (i.e., forward model) projections. Observing simultaneous changes in mu-alpha and mu-beta across the time-course of specific events provides a rich window for observing neurophysiological deficits associated with stuttering in both speech and cognitive tasks and can provide a better understanding of the functional relationship between these stuttering symptoms. We review how independent component analysis (ICA) can extract mu rhythms from raw EEG signals in speech production tasks, such that changes in alpha and beta power are mapped to myogenic activity from articulators. We review findings from speech production and auditory discrimination tasks demonstrating that mu-alpha and mu-beta are highly sensitive to capturing sensorimotor and basal ganglia deficits associated with stuttering with high temporal precision. Novel findings from a non-word repetition (working memory) task are also included. They show reduced mu-alpha suppression in a stuttering group compared to a typically fluent group. Finally, we review current limitations and directions for future research.

Power and phase coherence in sensorimotor mu and temporal lobe alpha components during covert and overt syllable production.

The sensorimotor dorsal stream is known to activate in both overt and covert speech production. However, overt production produces sensory consequences that are absent during covert production. Thus, the purpose of the current study is to investigate differences in dorsal stream activity between these two production conditions across the time course of utterances. Electroencephalography (EEG) was recorded from 68 channels while 23 participants overtly (Op) and covertly (Cp) produced orthographically cued bisyllabic targets. Sensorimotor mu and auditory alpha components (from anterior and posterior aspects of the dorsal stream) were identified using independent component analysis (ICA). Event-related spectral perturbation (ERSP) analyses identified changes in mu and alpha oscillatory power over time, while intercomponent phase coherence (IPC) measured anterior-posterior connectivity in the two conditions. Results showed greater beta (15-25 Hz) suppression during speech planning across left and right hemisphere sensorimotor and temporal ICs for Op relative to Cp. By contrast, greater intrahemispheric beta coherence was observed for Cp compared to Op during speech planning. During execution, greater beta suppression was observed along with greater low frequency (< 10 Hz) power enhancement and intrahemispheric phase coherence in Op compared to Cp. The findings implicate low frequency sensorimotor and posterior temporal phase coherence in the integration of somatosensory and acoustic feedback in overt relative to covert execution. Findings are consistent with early frontal-temporal forward models involved in planning and execution with modulations depending on whether the task goal is internal or overt syllable production.

Phonological working memory in developmental stuttering: Potential insights from the neurobiology of language and cognition.

The current review examines how neurobiological models of language and cognition could shed light on the role of phonological working memory (PWM) in developmental stuttering (DS). Toward that aim, we review Baddeley's influential multicomponent model of PWM and evidence for load-dependent differences between children and adults who stutter and typically fluent speakers in nonword repetition and dual-task paradigms. We suggest that, while nonword repetition and dual-task findings implicate processes related to PWM, it is unclear from behavioral studies alone what mechanisms are involved. To address how PWM could be related to speech output in DS, a third section reviews neurobiological models of language proposing that PWM is an emergent property of cyclic sensory and motor buffers in the dorsal stream critical for speech production. We propose that anomalous sensorimotor timing could potentially interrupt both fluent speech in DS and the emergent properties of PWM. To further address the role of attention and executive function in PWM and DS, we also review neurobiological models proposing that prefrontal cortex (PFC) and basal ganglia (BG) function to facilitate working memory under distracting conditions and neuroimaging evidence implicating the PFC and BG in stuttering. Finally, we argue that cognitive-behavioral differences in nonword repetition and dual-tasks are consistent with the involvement of neurocognitive networks related to executive function and sensorimotor integration in PWM. We suggest progress in understanding the relationship between stuttering and PWM may be accomplished using high-temporal resolution electromagnetic experimental approaches.

The Effects of Fluency Enhancing Conditions on Sensorimotor Control of Speech in Typically Fluent Speakers: An EEG Mu Rhythm Study.

Objective: To determine whether changes in sensorimotor control resulting from speaking conditions that induce fluency in people who stutter (PWS) can be measured using electroencephalographic (EEG) mu rhythms in neurotypical speakers. Methods: Non-stuttering (NS) adults spoke in one control condition (solo speaking) and four experimental conditions (choral speech, delayed auditory feedback (DAF), prolonged speech and pseudostuttering). Independent component analysis (ICA) was used to identify sensorimotor µ components from EEG recordings. Time-frequency analyses measured µ-alpha (8-13 Hz) and µ-beta (15-25 Hz) event-related synchronization (ERS) and desynchronization (ERD) during each speech condition. Results: 19/24 participants contributed µ components. Relative to the control condition, the choral and DAF conditions elicited increases in µ-alpha ERD in the right hemisphere. In the pseudostuttering condition, increases in µ-beta ERD were observed in the left hemisphere. No differences were present between the prolonged speech and control conditions. Conclusions: Differences observed in the experimental conditions are thought to reflect sensorimotor control changes. Increases in right hemisphere µ-alpha ERD likely reflect increased reliance on auditory information, including auditory feedback, during the choral and DAF conditions. In the left hemisphere, increases in µ-beta ERD during pseudostuttering may have resulted from the different movement characteristics of this task compared with the solo speaking task. Relationships to findings in stuttering are discussed. Significance: Changes in sensorimotor control related feedforward and feedback control in fluency-enhancing speech manipulations can be measured using time-frequency decompositions of EEG µ rhythms in neurotypical speakers. This quiet, non-invasive, and temporally sensitive technique may be applied to learn more about normal sensorimotor control and fluency enhancement in PWS.

Auditory cortical deactivation during speech production and following speech perception: an EEG investigation of the temporal dynamics of the auditory alpha rhythm.

Sensorimotor integration (SMI) across the dorsal stream enables online monitoring of speech. Jenson et al. (2014) used independent component analysis (ICA) and event related spectral perturbation (ERSP) analysis of electroencephalography (EEG) data to describe anterior sensorimotor (e.g., premotor cortex, PMC) activity during speech perception and production. The purpose of the current study was to identify and temporally map neural activity from posterior (i.e., auditory) regions of the dorsal stream in the same tasks. Perception tasks required "active" discrimination of syllable pairs (/ba/ and /da/) in quiet and noisy conditions. Production conditions required overt production of syllable pairs and nouns. ICA performed on concatenated raw 68 channel EEG data from all tasks identified bilateral "auditory" alpha (α) components in 15 of 29 participants localized to pSTG (left) and pMTG (right). ERSP analyses were performed to reveal fluctuations in the spectral power of the α rhythm clusters across time. Production conditions were characterized by significant α event related synchronization (ERS; pFDR < 0.05) concurrent with EMG activity from speech production, consistent with speech-induced auditory inhibition. Discrimination conditions were also characterized by α ERS following stimulus offset. Auditory α ERS in all conditions temporally aligned with PMC activity reported in Jenson et al. (2014). These findings are indicative of speech-induced suppression of auditory regions, possibly via efference copy. The presence of the same pattern following stimulus offset in discrimination conditions suggests that sensorimotor contributions following speech perception reflect covert replay, and that covert replay provides one source of the motor activity previously observed in some speech perception tasks. To our knowledge, this is the first time that inhibition of auditory regions by speech has been observed in real-time with the ICA/ERSP technique.

Temporal dynamics of sensorimotor integration in speech perception and production: independent component analysis of EEG data.

Activity in anterior sensorimotor regions is found in speech production and some perception tasks. Yet, how sensorimotor integration supports these functions is unclear due to a lack of data examining the timing of activity from these regions. Beta (~20 Hz) and alpha (~10 Hz) spectral power within the EEG µ rhythm are considered indices of motor and somatosensory activity, respectively. In the current study, perception conditions required discrimination (same/different) of syllables pairs (/ba/ and /da/) in quiet and noisy conditions. Production conditions required covert and overt syllable productions and overt word production. Independent component analysis was performed on EEG data obtained during these conditions to (1) identify clusters of µ components common to all conditions and (2) examine real-time event-related spectral perturbations (ERSP) within alpha and beta bands. 17 and 15 out of 20 participants produced left and right µ-components, respectively, localized to precentral gyri. Discrimination conditions were characterized by significant (pFDR < 0.05) early alpha event-related synchronization (ERS) prior to and during stimulus presentation and later alpha event-related desynchronization (ERD) following stimulus offset. Beta ERD began early and gained strength across time. Differences were found between quiet and noisy discrimination conditions. Both overt syllable and word productions yielded similar alpha/beta ERD that began prior to production and was strongest during muscle activity. Findings during covert production were weaker than during overt production. One explanation for these findings is that µ-beta ERD indexes early predictive coding (e.g., internal modeling) and/or overt and covert attentional/motor processes. µ-alpha ERS may index inhibitory input to the premotor cortex from sensory regions prior to and during discrimination, while µ-alpha ERD may index sensory feedback during speech rehearsal and production.

Dynamic modulation of shared sensory and motor cortical rhythms mediates speech and non-speech discrimination performance.

Oscillatory models of speech processing have proposed that rhythmic cortical oscillations in sensory and motor regions modulate speech sound processing from the bottom-up via phase reset at low frequencies (3-10 Hz) and from the top-down via the disinhibition of alpha/beta rhythms (8-30 Hz). To investigate how the proposed rhythms mediate perceptual performance, electroencephalographic (EEG) was recorded while participants passively listened to or actively identified speech and tone-sweeps in a two-force choice in noise discrimination task presented at high and low signal-to-noise ratios. EEG data were decomposed using independent component analysis and clustered across participants using principle component methods in EEGLAB. Left and right hemisphere sensorimotor and posterior temporal lobe clusters were identified. Alpha and beta suppression was associated with active tasks only in sensorimotor and temporal clusters. In posterior temporal clusters, increases in phase reset at low frequencies were driven by the quality of bottom-up acoustic information for speech and non-speech stimuli, whereas phase reset in sensorimotor clusters was associated with top-down active task demands. A comparison of correct discrimination trials to those identified at chance showed an earlier performance related effect for the left sensorimotor cluster relative to the left-temporal lobe cluster during the syllable discrimination task only. The right sensorimotor cluster was associated with performance related differences for tone-sweep stimuli only. Findings are consistent with internal model accounts suggesting that early efferent sensorimotor models transmitted along alpha and beta channels reflect a release from inhibition related to active attention to auditory discrimination. Results are discussed in the broader context of dynamic, oscillatory models of cognition proposing that top-down internally generated states interact with bottom-up sensory processing to enhance task performance.

Suppression of the µ rhythm during speech and non-speech discrimination revealed by independent component analysis: implications for sensorimotor integration in speech processing.

BACKGROUND: Constructivist theories propose that articulatory hypotheses about incoming phonetic targets may function to enhance perception by limiting the possibilities for sensory analysis. To provide evidence for this proposal, it is necessary to map ongoing, high-temporal resolution changes in sensorimotor activity (i.e., the sensorimotor µ rhythm) to accurate speech and non-speech discrimination performance (i.e., correct trials.). METHODS: Sixteen participants (15 female and 1 male) were asked to passively listen to or actively identify speech and tone-sweeps in a two-force choice discrimination task while the electroencephalograph (EEG) was recorded from 32 channels. The stimuli were presented at signal-to-noise ratios (SNRs) in which discrimination accuracy was high (i.e., 80-100%) and low SNRs producing discrimination performance at chance. EEG data were decomposed using independent component analysis and clustered across participants using principle component methods in EEGLAB. RESULTS: ICA revealed left and right sensorimotor µ components for 14/16 and 13/16 participants respectively that were identified on the basis of scalp topography, spectral peaks, and localization to the precentral and postcentral gyri. Time-frequency analysis of left and right lateralized µ component clusters revealed significant (pFDR<.05) suppression in the traditional beta frequency range (13-30 Hz) prior to, during, and following syllable discrimination trials. No significant differences from baseline were found for passive tasks. Tone conditions produced right µ beta suppression following stimulus onset only. For the left µ, significant differences in the magnitude of beta suppression were found for correct speech discrimination trials relative to chance trials following stimulus offset. CONCLUSIONS: Findings are consistent with constructivist, internal model theories proposing that early forward motor models generate predictions about likely phonemic units that are then synthesized with incoming sensory cues during active as opposed to passive processing. Future directions and possible translational value for clinical populations in which sensorimotor integration may play a functional role are discussed.

Manual disfluency in drawing while producing and listening to disfluent speech.

This study investigated the extent to which manual fluency was associated with speech fluency in fluent speakers engaged in dual motor tasks. Thirteen right-handed adult females repeatedly drew circles with a pen on a digitizer tablet under five conditions: (1) a baseline (without reading or listening to speech), (2) reading fluently, (3) reading disfluently, (4) listening to fluent speech, and (5) listening to disfluent speech. The primary measure of disfluency was normalized mean squared jerk (NJ) in the pen strokes. Pen stroke time (ST) and pressure (PP) were also measured. NJ of the circle movements was significantly increased in both the disfluent reading and the disfluent listening conditions (p<0.05), compared to the baseline condition. In the fluent listening and reading conditions, NJ in circle drawing was unaltered compared to the baseline condition. Relative to baseline, ST increased significantly (p<0.05), but to a similar extent in all experimental conditions. Significantly (p<.05) greater pen pressure were also found in the disfluent versus fluent conditions. Positive correlations (r=0.33-0.63) were found between NJ and ST across conditions. These findings demonstrate that in dual-tasks, speech fluency can influence manual fluency. This is consistent with the corpus of data showing neural connectivity between manual and speech tasks, as well between perception and production. The mirror neuron system is implicated as a mechanism involved in forging these links.

Mu suppression as an index of sensorimotor contributions to speech processing: evidence from continuous EEG signals.

Mu rhythm suppression is an index of sensorimotor activity during the processing of sensory stimuli. Two present studies investigate the extent to which this measure is sensitive to differences in acoustic processing. In both studies, participants were required to listen to 90second acoustic stimuli clips with their eyes closed and identify predetermined targets. Experimental conditions were designed to vary the acoustic processing demands. Mu suppression was measured continuously across central electrodes (C3, Cz, and C4). Ten adult females participated in the first study in which the target was a pseudoword presented in three conditions (identification, discrimination, discrimination in noise). Mu suppression was strongest and reached significance relative to baseline only in the discrimination in noise task at C3 (indicative of left hemisphere sensorimotor activity) when measured in a 10-12Hz bandwidth. Thirteen adult females participated in the second study, which measured mu suppression to acoustic stimuli with 'segmentation' (i.e., separating a parsed stimulus into individual components) versus non-segmentation requirements in both speech and tone discrimination conditions. Significantly greater overall suppression to speech relative to tone tasks was found in the 10-12Hz bandwidth. Further, suppression relative to baseline was significant only at C3 during the speech discrimination with segmentation task. Taken together, findings indicate that mu rhythm suppression in acoustic processing is sensitive to dorsal stream processing. More specifically, it is sensitive to (1) increases in overall processing demands and (2) processing linguistic versus non-linguistic information.

Autonomic arousal in adults who stutter prior to various reading tasks intended to elicit changes in stuttering frequency.

This study examined relationships between anticipatory autonomic arousal and stuttering in four reading tasks. 13 adult persons who stutter (PWS) reported their 'feared' (expected to elicit more stuttering) sounds. They read phrases initiated by feared (F) and neutral (N) phonemes. Both stimuli sets were read solo (S) and with choral accompaniment (C), creating FS, FC, NS, and NC conditions. Skin conductance (SC) and heart rate (HR) measures were made during a 9s window that followed stimulus presentation and preceded speaking. Only SC measures produced significant differences across conditions. Choral conditions produced decreases in SC measures and stuttered trials. Feared conditions produced increases in SC but not stuttering. HR measures were variable, undifferentiated by condition, but produced a gradually increasing triphasic response pattern. No differences in anticipatory SC or HR measures were found in stuttered versus fluent trial comparisons. However, the NC condition, which eliminated stuttering, produced significantly lower SC measures than the fluent utterances in the other conditions (FS, FC, NS). Furthermore, SC measures from the fluent and stuttered trials were similar in these three conditions. These findings suggest that anticipatory autonomic arousal is better differentiated by the possibility of stuttering than by a fluent/stuttered speech outcome. Trials that produced anticipatory SC responses showed greater final HR deceleration, suggesting autonomic coactivation, a response pattern that is associated with aversive stimuli and herein, likely indicative of speech-related state anxiety. However, these physiological markers of anxiety appear to be neither necessary nor sufficient to induce observable stuttering.

Gaze aversion to stuttered speech: a pilot study investigating differential visual attention to stuttered and fluent speech.

BACKGROUND: People who stutter are often acutely aware that their speech disruptions, halted communication, and aberrant struggle behaviours evoke reactions in communication partners. Considering that eye gaze behaviours have emotional, cognitive, and pragmatic overtones for communicative interactions and that previous studies have indicated increased physiological arousal in listeners in response to stuttering, it was hypothesized that stuttered speech incurs increased gaze aversion relative to fluent speech. The possible importance in uncovering these visible reactions to stuttering is that they may contribute to the social penalty associated with stuttering. AIMS: To compare the eye gaze responses of college students while observing and listening to fluent and severely stuttered speech samples produced by the same adult male who stutters. METHODS & PROCEDURES: Twelve normally fluent adult college students watched and listened to three 20-second audio-video clips of the face of an adult male stuttering and three 20-second clips of the same male producing fluent speech. Their pupillary movements were recorded with an eye-tracking device and mapped to specific regions of interest (that is, the eyes, the nose and the mouth of the speaker). OUTCOMES & RESULTS: Participants spent 39% more time fixating on the speaker's eyes while witnessing fluent speech compared with stuttered speech. In contrast, participants averted their direct eye gaze more often and spent 45% more time fixating on the speaker's nose when witnessing stuttered speech compared with fluent speech. These relative time differences occurred as a function of the number of fixations in each area of interest. Thus, participants averted their gaze from the eyes of the speaker more frequently during the stuttered stimuli than the fluent stimuli. CONCLUSIONS & IMPLICATIONS: This laboratory study provides pilot data suggesting that gaze aversion is a salient response to the breakdown in communication that occurs during stuttering. This response may occur as a result of emotional, cognitive, and pragmatic factors in communication partners. Regardless of the factors contributing to the response, its primary importance may be that gaze aversion is a visible communication partner signal informing the person stuttering that something is amiss in the interaction and hence, may contribute to inducing negative emotions in the persons stuttering, via engagement of the mirror neuron system. We suggest that witnessing and interpreting communication partner responses to stuttering may play a role when a person who stutters engages in future interactions, perhaps contributing to the development of covert strategies to hide stuttering.

Mu wave suppression during the perception of meaningless syllables: EEG evidence of motor recruitment.

Motor involvement in speech perception has been recently studied using a variety of techniques. In the current study, EEG measurements from Cz, C3 and C4 electrodes were used to examine the relative power of the mu rhythm (i.e., 8-13 Hz) in response to various audio-visual speech and non-speech stimuli, as suppression of these rhythms is considered an index of 'mirror neuron' (i.e., motor) activity. Fourteen adult native English speaking females watched and listened to nine audio-video stimuli clips assembled from three different auditory stimuli (speech, noise, and pure tone) combined with three different video stimuli (speech, noise, and kaleidoscope-made from scrambling an image from the visual speech). Relative to the noise-noise (baseline condition), all visual speech conditions resulted in significant levels of suppression, a finding that is consistent with previous reports of mirror activity to visual speech and mu suppression to 'biological' stimuli. None of the non-speech conditions or conditions in which speech was presented via audition only resulted in any significant suppression of the mu rhythm in this population. Thus, visual speech perception appears to be more closely associated with motor activity than acoustic speech perception. It is postulated that in this study, the processing demands incurred by the task were insufficient for inducing significant mu suppression via acoustic speech only. The findings are discussed in theoretical contexts of speech perception and the mirror system. We suggest that this technique may offer a cost-efficient, non-invasive technique for measuring motor activity during speech perception.

Comparisons of stuttering frequency during and after speech initiation in unaltered feedback, altered auditory feedback and choral speech conditions.

BACKGROUND: Stuttering is prone to strike during speech initiation more so than at any other point in an utterance. The use of auditory feedback (AAF) has been found to produce robust decreases in the stuttering frequency by creating an electronic rendition of choral speech (i.e., speaking in unison). However, AAF requires users to self-initiate speech before it can go into effect and, therefore, it might not be as helpful as true choral speech during speech initiation. AIMS: To examine how AAF and choral speech differentially enhance fluency during speech initiation and in subsequent portions of utterances. METHODS & PROCEDURES: Ten participants who stuttered read passages without altered feedback (NAF), under four AAF conditions and under a true choral speech condition. Each condition was blocked into ten 10 s trials separated by 5 s intervals so each trial required 'cold' speech initiation. In the first analysis, comparisons of stuttering frequencies were made across conditions. A second, finer grain analysis involved examining stuttering frequencies on the initial syllable, the subsequent four syllables produced and the five syllables produced immediately after the midpoint of each trial. OUTCOMES & RESULTS: On average, AAF reduced stuttering by approximately 68% relative to the NAF condition. Stuttering frequencies on the initial syllables were considerably higher than on the other syllables analysed (0.45 and 0.34 for NAF and AAF conditions, respectively). After the first syllable was produced, stuttering frequencies dropped precipitously and remained stable. However, this drop in stuttering frequency was significantly greater (approximately 84%) in the AAF conditions than in the NAF condition (approximately 66%) with frequencies on the last nine syllables analysed averaging 0.15 and 0.05 for NAF and AAF conditions, respectively. In the true choral speech condition, stuttering was virtually (approximately 98%) eliminated across all utterances and all syllable positions. CONCLUSIONS & IMPLICATIONS: Altered auditory feedback effectively inhibits stuttering immediately after speech has been initiated. However, unlike a true choral signal, which is exogenously initiated and offers the most complete fluency enhancement, AAF requires speech to be initiated by the user and 'fed back' before it can directly inhibit stuttering. It is suggested that AAF can be a viable clinical option for those who stutter and should often be used in combination with therapeutic techniques, particularly those that aid speech initiation. The substantially higher rate of stuttering occurring on initiation supports a hypothesis that overt stuttering events help 'release' and 'inhibit' central stuttering blocks. This perspective is examined in the context of internal models and mirror neurons.