An investigation of breathing patterns in a selected cerebral palsy population

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AN INVESTIGATION OP BREATHING PATTERNS IN A SELECTED CEREBRAL PALSY POPULATION

A Thesis Presented to the Faculty of the Graduate School The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Master of Arts

by Patti Murray Fothergill August

1950

UMI Number: EP66026

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TABLE OF CONTENTS CHAPTER

PAGE

I. THE P R O B L E M ................................... Statement of the problem

II.

.................

1

Origin of the p r o b l e m .....................

2

Review of the literature... ................

6

SUBJECTS, APPARATUS AND PROCEDURE ........... Subjects

III.

8

A p p a r a t u s ..................................

10

P r o c e d u r e ..................................

11

Exploratory study .........................

13

ANALYSIS OF BREATHING R E C O R D S ...............

18

Treatment of d a t a .........................

18

Vegetative breathing

32

..................... avowel

Breathing for connected speech

V.

8

..................................

Breathing for phonation of

IV.

1

RESULTS OF EXPLORATORY STUDY

. . . .

45

...........

60

...............

67

SUMMARY AND C O N C L U S I O N S ......................

BIBLIOGRAPHY .......................................

J6

79

LIST OF TABLES

Cerebral Palsy Females Vegetative Breathing

34

Cerebral Palsy Males Vegetative Breathing .

33

Normal Females Vegetative Breathing . . . .

36

Normal Males Vegetative Breathing ........

37

Cerebral Palsy Females Voiced Vowel . . . .

47

Cerebral Palsy Males Voiced Vowel ........

48

Normal Females Voiced Vowel ........

49

. . .

Normal Males Voiced Vowel .................

50

Cerebral Palsy Females Whispered Vowel

. .

55

. . .

56

Cerebral Palsy Males Whispered Vowel Normal Females Whispered Vowel Normal Males Whispered Vowel

.......... .............

57 58

Cerebral Palsy Females Connected Speech Voiced and Whispered ....................

62

Cerebral Palsy Males Connected Speech Voiced and Whispered

...................

63

Normal Females Connected Speech Voiced and Whispered ........................... Normal Males Connected Speech Voiced and Whispered ................................

64

LIST OF FIGURES FIGURE

PAGE

1.

Respirator-Polygraph Set-up ....................

15

2.

Normal Female Regular Pattern .................

21

3.

Athetoid Female Irregular Pattern .............

22

4.

Normal Female Equal Thoracic and Abdominal M o v e m e n t ..................................... ..................

23

5.

Normal Male Connected Speech

6.

Athetoid Male Connected Speech

...............

27

7.

Normal Male Small P e a k s ........................

28

8.

Athetoid Female Unmeasurable Record ...........

40

9.

Spastic M a l e ...................................

42

10.

Athetoid Male Voiced V o w e l ....................

53

11.

Athetoid Female Vegetative Breathing

68

12.

Athetoid Female Pattern from Respirator . . . .

69

13*

Athetoid

Male Vegetative Breathing

70

14.

Athetoid

Male Pattern from R e s p i r a t o r ..

.........

. . . . . .

15 . Athetoid

Male Voiced Vowel from Respirator

16 . Athetoid

Male Vegetative Breathing

26

72 . .

..........

73

74

CHAPTER I THE PROBLEM I.

STATEMENT OP THE PROBLEM

The general purpose of this study was to Investigate the breathing patterns in two selected groups of cerebral palsied subjects, diagnosed athetoid quadriplegias and diag­ nosed spastic quadriplegias, and to compare these breathing patterns with breathing patterns of normal individuals. Specifically the problems to be studied were: a.

To determine whether observable differences in

thoracic and abdominal breathing movements for vegetative breathing exist between cerebral palsied subjects and normal individuals. b.

To determine whether observable differences in

thoracic and abdominal breathing movements for phonation of a vowel, voiced and whispered, exist between cerebral palsied subjects and normal individuals. c.

To determine whether observable differences in

thoracic and abdominal breathing movements for connected speech, voiced and whispered, exist between cerebral palsied subjects and normal individuals. Finally, as a matter of interest and as an explor­ atory study, certain athetoid subjects who showed atypical

breathing patterns were put into the Drinker-Collins respirator to discover if this instrument might be used clinically to alter their breathing patterns. II.

ORIGIN OF THE PROBLEM

Those individuals who have been concerned with the speech problems of the cerebral palsied have not infre­ quently mentioned ineffective breathing as one of the major difficulties.

Strother and Pittenger have mentioned that

if the muscles of the respiratory mechanism are affected by spasticity the person has difficulty in controlling the expiratory air stream, thus causing a disturbed speech rhythm, shortness of breath during speech and fluctuations 1,2 of intensity. Other writers have been less specific in regard to spasticity in the breathing mechanism; Lundeen says, "Their (spastics) breathing during speech often is faulty too."

And in addition to this, "The spastic may

have trouble breathing, especially during speech."

Moore

1 C. R. Strother, "Diagnosis of Disorders of Speech, Physiotherapy Review, 18:81-84, March-April, 1938. 2

Katherine Pittenger, "Spastic Speech Disorders and Their Treatment," Physiotherapy Review, 22:138-42, May-June, 1942. 3 Phyllis Lundeen, "Cerebral Palsy of Spastic Paralysis," Physiotherapy Review, 23:17-22, JanuaryFebruary, 1943.

3 who was concerned with speech correction in birth injury cases noted that: There are few spastics that do not exhibit symptoms of faulty breath control, most serious of which are complete lack of force due to flaccidity, and complete blocking due to spasms of the intercostals muscles.4 Rutherford has suggested: A spastic is likely to have difficulty in dir­ ecting the breath stream. The spastic's inability to move all or part of the palate, the back tongue, or the throat muscles makes it difficult for him to direct the breath stream through his mouth. Sometimes rigidity in the lung or back-tonguepalate regions inhibits movement and results in shallow breathing.5 Perlstein and Shere have observed, "Breathing diffi­ culties are common among children with cerebral palsy. Many spastic patients have true 1reversed breathing.1’ Breathing difficulties in the athetoid group have also been discussed by several authors. report that:

Gesell and Amatruda

"With involvement of diaphragm, respiratory,

phonetic and articulatory movements may be so disco-ordinate

4

n

Ellen H. Moore, Emotional and Physical Responses of Birth Injury Cases to Speech Correction," Journal of Exceptional Children, 100-106, January, 1942. ^ Berniece R. Rutherford, Give Them a Chance to Talk. Minneapolis, Minnesota: Burgess Publishing Company, T P H , p. 4. ^ M. A. Perlstein and Marie Shere, "Speech Therapy for Children with Cerebral Palsy," American Journal of Diseases of Children, 72:389-98, October, 1945"!

4 that not even a whisper can be produced.' speech in athetosis, Phelps says, " . . .

7

Concerning there is invol­

untary motion present either in the diaphragm, breathing mechanism, larynx, tongue, lips or any combination of g these." Rutherford mentions in regard to breathing in the athetoid: The breathing pattern of the athetoid may not have forward flowing, controlled movements because of spasming of the diaphragm: because of the in­ ability of the child to direct the air stream through the mouth as he talks, and/or because of the Inability of the muscles of the thorax and of the abdomen to work "in phase." The thoracic muscles, for example, move for inhalation while the abdominal muscles move for exhalation, or vice versa; breathing lacks syn­ chronization and is said to be "out of phase."9 Blumenthal observed that ". . . it is essential to correct bad breathing habits due to stretch reflexes or involuntary motions."10 In regard to the tension athetoid Perlstein and Shere say, "Athetoid children with severe tension may also have this reversal, but more often than not their breath­ ing follows no predictable pattern."11

7

Arnold Gesell and Catherine S. Amatruda, Develop­ mental Diagnosis. New York: Paul B. Hoeber, Inc.V 1941, p. 199. g Winthrop M. Phelps, "Treatment of Cerebral Palsy," Medical Record, September 18, 1940, p. 218. ^ Rutherford, o£. clt., p. 4. 10 Edna M. Blumenthal, "Speech Correction for Cerebral

5 The only specific difficulty which the present investigator found described was that which Phelps calls "reverse breathing.11

Reverse breathing, according to

Hansen, Longerich and Longerich, is: The incorrect coordination is an attempt to inhale with chest muscles while using the diaphragm and abdominal muscles as though exhaling, and vice versa. Thus sometimes the attempt to speak is being made in partial inhalation. ^ 13 14 Paulitsch and Proeschels describe essentially the same action.

13 Brown ^ refers to it as reverse dia­

phragm action, Lundeen apparently suggests the same thing, al­ though she does not call it "reverse breathing" in her statement:

" . . .

However, in the spastic*s speech the

Palsy," Physiotherapy Review, 21:71-72, March-April, 1941. ^ Perlstein and Shere, loc. clt., p. 393* 12 Ruth Hansen, Edward Longerich and Mary Longerich, "Physical Therapy Approach to Speech Problems in Spasticity and Athetosis," Physiotherapy Review, 27:174-81, May-June, 1947. 13 Gladys D. Paulitsch, "Treatment of Cerebral Palsy," Physiotherapy Review, 21:67-68, March-April, 1941. 14 Emil Froeschels, "A Contribution to the Pathology and Therapy of Dysarthria Due to Certain Cerebral Lesions," Journal of Speech Disorders, 8:301-321, December, 1943. ^ Caroline M. Brown, "A Brief Outline for Treating the Birth Injured," Physiotherapy Review, 15:226-28, November-December, 1935*

6 chest often expands and rises while the abdomen is ex*j /T

cessively contracted, causing breathiness and tension." This study was set up in an effort to obtain more objective information concerning the breathing problems of the two

17

major groups of cerebral palsied individuals.

According to Phelps’ classification of cerebral palsy, which is the most widely accepted, there are five main types of cerebral palsy with several sub-types.

It was

decided, however, to investigate the breathing patterns of only the two main groups, spasticity and athetosis, since they comprise approximately 65 to 75 per cent of all cerebral palsies.

The percentages which Phelps gives

are 30 to 35 percent athetosis, 35 to 40 percent spasti­ city, 15 percent ataxias and 15 percent tremors and rigid­ ities . III.

REVIEW OF THE LITERATURE

In a review of the literature only one previous study on respiration in cerebral palsied cases was found.

ifi

Lundeen, 0£. clt., pp. 17-22.

Viola E. Cardwell, The Cerebral Palsied Child and His Care in the Home (Cerebral- Palsy Series: Revision of Pamphlet l"]T New Ifork: Association for the Aid of Crippled Children, 1947* P* 20.

7 Hull and Bryngelson

18

made a study in which they investi­

gated the respiration of fourteen cases.

A discussion of

their findings will be found in the third chapter of the present study. By way of summary, the two general purposes of this investigation were:

(1) to determine whether ob­

servable differences in vegetative breathing and speech breathing exist between cerebral palsied subjects and normal subjects, and (2) to determine whether in certain cerebral palsied individuals who show atypical breathing patterns a more nearly ’'normal" breathing pattern can be superimposed on them.

18

Henrietta C. Hull and Bryng Bryngelson, "A Study of the Respiration of Fourteen Spastic Paralysis Cases During Silence and Speech," Speech Monographs, 8:114-21, 1941.

CHAPTER II SUBJECTS, APPARATUS AND PROCEDURE I.

SUBJECTS

Two groups of subjects were used for the study, thirty cerebral palsied and thirty normals.

The cerebral

palsied subjects were secured from the out-patient depart­ ment of the Orthopaedic Hospital, Los Angeles, California. There were nineteen female subjects and eleven male sub­ jects.

All subjects were diagnosed by the same doctor

and were diagnosed either athetoid quadriplegia or spastic quadriplegia.

The diagnosis of the patientfs condition

was obtained from his hospital medical records.

There

were seventeen diagnosed athetoid subjects, eleven females and six males, ranging in age from eight years to twentyone years.

There were thirteen diagnosed spastic subjects,

eight females and five males, ranging in age from eight years to nineteen years.

The reason quadriplegias were

selected was that breathing might be expected to be dis­ turbed in a more wide spread condition than If the in­ volvement were to only one side of the body (hemiplegia), both arms (diplegia) or both legs (paraplegia). The criteria for selection of cases were that the

9 subject be diagnosed either athetoid or spastic quadri­ plegia between the ages of eight and twenty-one years, be able to cooperate with the investigator and have suf­ ficient speech to say what was necessary to the study. None of the cerebral palsied group had hearing losses. In the Hull and Bryngelson study certain aspects of the cerebral palsied subjects1 breathing were compared with breathing norms set up by Fossler in his study on stuttering.1

Since the subjects used in the present study

were in a different age group than Fossler's subjects, it was decided to select thirty normals and set up norms on these for comparison with the thirty cerebral palsied subjects in this study.

The normals in this study were

in the same age group as the cerebral palsied. Eleven subjects in the normal group were secured from the posture clinic at the Orthopaedic Hospital.

It

was determined that none of them had had poliomyelitis or any other disease that might affect normal movements of respiration. The remainder of the normal group was obtained from public speaking classes at the University of Southern California.

H. Stuttering,"

None of these subjects had had any diseases

R. Fossler, "Disturbances in Breathing During Psychological Monographs, 40:1-32, 1930.

10 that might affect the respiratory mechanism.

The possi­

bility of speech defects in the normal subjects was ruled out since the investigator talked with the subjects before and after recording and no defects were noted.

In the

normal group there were thirteen females ranging in age from nine years to nineteen years, and seventeen male sub­ jects ranging in age from eight years to twenty-one years. The criteria for selection of normal subjects were that the people be within the age range of eight years to twenty-one years and that they have had no diseases which might affect the muscles of the respiratory mechanism. II.

APPARATUS

A Multipurpose Polygraph made by the Lafayette Instrument Company, with two accordion-type pneumographs attached, was used for recording breathing movements.

One

pneumograph was placed at the level of the nipples for the purpose of recording breathing movements in the thoracic region.

The second pneumograph was placed at the level

of the umbilicus for the purpose of recording breathing movements in the abdominal region. A watch with a sweep second hand was used for timing purposes.

11 III.

PROCEDURE

To obtain data for the first part of the study five different records were made on each subject.

All of

the records were made while the subjects were seated in a comfortable chair.

The cerebral palsied subjects were

well braced in order to avoid as many extraneous movements as possible.

The pneumographs were strapped on over street

clothes; bulky sweaters, jackets or coats were removed. The subjects were seated with their backs to the polygraph and were told not to try to turn around to look at it. It was explained to the subject that a breathing record was being made.

If he showed any apprehensions about it,

it was explained that it was not a test and could not be failed.

This was in answer to the question most frequently

asked about the recording.

The investigator had time to

establish rapport with the subjects while strapping the pneumographs in place.

The pneumographs were always at­

tached to the machine in the same position so that the thoracic record was always on the left side and the ab­ dominal record on the right side as the record came off the polygraph.

Thus, when the record was laid on the

desk for study purposes the lower line was the thoracic record and the upper line, the abdominal record.

In the

photographs of the breathing records it will be noted

12 that there is a middle line.

This line should be disre­

garded, since it was made by the needle used for record­ ing pulse.

Several recording trials were made before the

actual breath-record was made.

This was necessary because

if the pneumograph is fastened too tightly or too loosely it will not record movements. The nursery rhyme, "Baa, Baa, Black Sheep," was chosen to be used for a record of connected speech since most people know it.

It was determined before each re­

cord was made that each subject knew and could say it. After the pneumographs were in place and the pre­ liminary trials were made, these instructions were given the subject:

"Sit as quietly as possible and breathe as

you normally do.

Do not force yourself to breathe."

Three minutes of vegetative breathing were then recorded. The breathing was timed and the records were marked at the end of each minute by the timing needle on the machine. This was operated manually by the investigator.

In making

records on the cerebral palsied group the timing was done by another individual who signaled the Investigator to mark the record.

This enabled the investigator to watch

the subjects and mark extraneous movements or sighs which were recorded on the record but were no part of the breath­ ing pattern.

This was not a problem in the normal group.

When the records of three minutes of vegetative

13 breathing were completed the subjects were asked to say aloud every time the investigator indicated.

The

vowel was repeated six times at intervals of ten seconds. The investigator marked the record with the timing needle as the subjects phonated the vowel. When the recording of the voiced vowel was com­ pleted, the same procedure was repeated with the instruc­ tions that this time the subjects were to whisper the vowel.

The whispered vowels were timed and marked as the

voiced vowels were. The subjects were then asked to say, uBaa, Baa, Black Sheep,” aloud.

The record was marked when the sub­

jects said the first word of the rhyme and when they said the last word.

When this record was completed they were

asked to whisper the rhyme.

It was marked in the same

manner as the voiced rhyme. About ten minutes were required to make each re­ cord, and this included the giving of instructions.

Ap­

proximately three months was spent in obtaining records on the cerebral palsied and normal groups. IV.

EXPLORATORY STUDY

Some speech therapists in attempting to deal with breathing disturbances in the cerebral palsied have used

Ik

exercises and drills.

The assumption is that through

repeated exercise and drill the subject will attain bet­ ter control of the breathing mechanism.

It was thought

perhaps the respirator might be a useful clinical in­ strument in aiding in the re-training of breathing pat­ terns of the cerebral palsied. Pour subjects, three females and one male, were selected who showed atypical breathing patterns; these subjects were put into the respirator to determine whether their breathing patterns could be altered by the respir­ ator.

There was no attempt to determine whether such

changes lasted over a period of time but rather what the immediate changes were, if any. The two pneumographs were strapped on the subjects as they had been before.

The hoses from the pneumographs

were run out through the portholes in the sides of the respirator to the polygraph.

For a picture of the re-

spirator-polygraph set-up see Figure 1. In order to maintain the pressure in the respir­ ator, metal discs were fitted over the portholes, and holes were drilled through these discs the size of the outer circumference of the hoses.

This arrangement per­

mitted the pressure to be maintained in the respirator and breathing to be recorded directly from the subject

FIGURE 1 RESPIRATOR-POLYGRAPH SET-UP

in the machine. The question of the effect of the pressure of the respirator on the pneumographs arose.

In other words,

were the breathing movements on the records really breath­ ing movements or was the movement an artifact introduced when the pneumographs were put under pressure?

This pos­

sibility was checked by placing the pneumographs in the respirator, maintaining pressure.

No movement was recorded

hence, it was concluded that the movements which were re­ corded were actually breathing movements of the subject. The respirator is capable of exerting positive and negative pressures.

However, for this study no positive

pressure was exerted.

Only negative pressure, which was

the equivalent, depending upon the subject, of ten to twenty-five centimeters of water was used.

This was done

in order to expand the chest during negative pressure, allowing the subject to exhale when the chest assumed its original position.

By allowing the chest to assume its

original position without use of positive pressure there was no forced exhalation.

The reason for not using posi­

tive pressure was that the exhalation movements of the subjects thus theoretically approached more nearly normal movements of respiration. After each subject was put into the respirator and

17 before the respirator was turned on, a three-minute record of vegetative breathing was obtained.

The timer on the

polygraph was used to mark the record at the beginning and end of this recording of vegetative breathing.

The mach­

ine was then turned on and several minutes more of vege­ tative breathing recorded. ingly.

The record was marked accord­

Then the subjects were asked to phonate the vowel

several times.

The record was marked when the subject

phonated the vowel.

After the vowels were recorded, the

respirator was turned off and three minutes more of vege­ tative breathing were recorded for the purpose of compar­ ing this record to vegetative breathing with the aid of the respirator and to the record made prior to the use of the respirator. The results of this exploratory study are dis­ cussed in Chapter IV.

CHAPTER III ANALYSIS OP BREATHING RECORDS I.

TREATMENT OP DATA

General discussion of measures used in treating data.

It was assumed before the measuring of the records

began that a purely quantitative measure of the records would show the differences which seem to exist in breath­ ing between normals and the cerebral palsied.

One such

quantitative measure, which is used in this study, is the I-Fraction.^

Hull and Bryngelson used the I-Praction in

their study.

In order to obtain an I-Praction on a cycle

the cycle must be measurable, i.e., the point where in­ spiration begins and expiration begins and ends must be well defined on the record.

Inspiration is considered

to be that point where the line begins to rise to the point where it reaches its peak; expiration is considered to be from the peak to that point where the line begins to rise at the beginning of another cycle.

If cycles are suffi­

ciently well defined to permit measurements to be made,

^ The I-Praction or Inspiration-Fraction is the proportion of time spent in inspiration. It is obtained by dividing the length of the inspiration phase by the length of the total cycle.

19 they can also be counted.

Counting of cycles was another

quantitative measure used in this study. Vertical and horizontal distances are two compon­ ents of a cycle.

Horizontal distances on the record, as 2 Woodworth says, denote time. The total cycle is a time characteristic of the record; it is the inspiration phase plus the expiration phase of respiration.

Since it was

known at the outset of this study that the polygraph turns at a constant speed of 237 millimeters per minute, it was possible to make quantitative judgments on the basis of horizontal distances, or the time factor in breathing records.

Vertical distances indicate more or less indir­

ectly changes in amplitude of breathing and movement in the chest and abdomen caused by the action of respiratory muscles.

Woodworth says in regard to such changes,

"Very careful calibration would be necessary before the breathing record could be made to yield any absolute measures of muscular contraction or air volume.

i « 4

Since

the careful calibration which Woodworth mentions was not done, no attempt will be made to make any quantitative

2 New York:

Robert S. Woodworth, Experimental Psychology. Henry Holt and Company, l938> P* 259.

3 Ibid., p. 259. ^ Ibid., p. 259.

20 interpretation of the excursion or amplitude of the lines in the breathing records of the subjects in this study. However, casual inspection shows that in some records ex­ cursion is predominantly thoracic, predominantly abdominal or that the excursion is about equal, i.e., of the same amplitude thoracically as abdominally. tative measurement that was used.

This is one quali­

By observing excursion

it was possible to classify the movement as predominantly thoracic, predominantly abdominal or that the thoracic and abdominal excursions were about equal.

For an illus­

tration of what was considered to be predominantly abdom­ inal movement see Figure 2; for predominantly thoracic movement see Figure 3 and for what was considered to be equal thoracic and abdominal movement see Figure 4. The only quantitative measures that were possible were the computation of the I-Fractions, which, of course, necessitated measuring the cycles and the counting of the cycles. One qualitative measure mentioned thus far was the classification of the records into predominantly abdom­ inal, predominantly thoracic or equal thoracic and abdom­ inal movement.

In addition to this qualitative measure

several others were used. First, it was found that the breathing movements,

w^w.^_AJUU\A^-^AAA/UUA^Jfw'

FIGURE 2 CASE 1. NORMAL FEMALE. LOWER LINE IS THORACIC. UPPER LINE ABDOMINAL THE GENERAL PATTERN IS REGULAR WITH PREDOMINATELY ABDOMINAL MOVEMENT NOTE SYNCHRONIZATION OF THORACIC AND ABDOMINAL MOVEMENT.

t FIGURE 3 CASE 2. ATHETOID FEMALE. LOWER LINE IS THORACIC, UPPER LINE ABDOMINAL. THE GENERAL PATTERN IS IRREGULAR WITH PREDOMINATELY THORACIC MOVEMENT. ARROWS DENOTE REVERSAL. NOTE ASYNCHRONIZATION OF THORACIC AND ABDOMINAL MOVEMENT.

FIGURE 4 CASE 21. NORMAL FEMALE. LOWER LINE IS THORACIC, UPPER LINE ABDOMINAL. THE GENERAL PATTERN IS REGULAR WITH EQUAL THORACIC AND ABDOMINAL MOVEMENT.

in addition to being predominantly thoracic, abdominal 5 6 or equal were also either regular or irregular. Such a classification is purely descriptive and is of little value other than it permits a more accurate description to be made of the breathing records studied. Another classification of the records which was possible was on the basis of their measurability.

The

records may be classified into three mutually exclusive

7

groups:

Negligible,1 Recordable,

ment.^

8 and Measurable Move­

Such a classification was necessary because some

5 ^ Regular patterns are considered to be those in which casual inspection shows the excursions of all cycles to be about equal and the length of all cycles to be about the same. See Figure 2 for an example of a regular pat­ tern with predominately abdominal movement. Irregular patterns are considered to be those in which casual inspection shows wide deviations in the ex­ cursion and the length of cycles. See Figure 3 for an example of an Irregular pattern with predominately thor­ acic movement. 7 Negligible movement is considered to be that which is so slight that the polygraph does not record or there is movement but not well defined cycles.

it

Q

Recordable movement is considered to be that in which the cycles may be counted but not measured because of slight excursion. 9 Measurable movement is considered to be that movement which the polygraph will record and which is of sufficient excursion to permit measurements to be made.

25 of the records could not be measured either because of lack of movement or lack of well defined cycles. In addition to the three previously mentioned qualitative measurements, a fourth was used which was counting the reversals.^

A subject may have an asyn­

chronous pattern, with more abdominal than thoracic cycles or more thoracic than abdominal cycles or no abdominal movement at all, but no reversals as described above are discernable.

Such movements may be said to

be ’’out of phase” or are asynchronous.

True reversals

as defined above are not easy to see, although casual inspection shows that breathing movements are not syn­ chronized.

For what is considered to be synchronization

of abdominal and thoracic movement on vegetative breath­ ing see Figure 2; for asynchronization on vegetative breathing movements see Figure 3 .

This asynchroniza­

tion occurs on vegetative and speech breathing.

For

asynchronization of breathing movements on speech breath­ ing see Figure 5; for asynchronization of breathing move­ ments on speech breathing see Figure 6.

10

Reversal is narrowly defined for this study. Although asynchrony of movements is found In the cerebral palsy group and the normal group, a reversal was not counted as a reversal unless it was very obvious that the recording needles were working in direct opposition. See Figure 3 for the criterion for a reversal.

FIGURE 5 CASE 11. NORMAL MALE. LOWER LINE IS THORACIC, UPPER LINE ABDOMINAL. ARROWS AT RIGHT MARK INTERVAL OF TIME DURING WHICH VOICED "BAA, BAA, BLACK SHEEP" WAS SAID. ARROWS AT LEFT MARK INTERVAL OF TIME DURING WHICH WHISPERED "BAA, BAA, BLACK SHEEP" WAS SAID. NOTE SYNCHRONY OF THORACIC AND ABDOMINAL MOVEMENTS.

FIGURE 6 CASE 6 . ATHETOID MALE. LOWER LINE IS THORACIC, UPPER LINE IS ABDOMINAL. ARROWS MARK INTERVAL OF TIME DURING WHICH VOICED "BAA, BAA, BLACK SHEEP" WAS SAID. NOTE ASYNCHRONY OF THORACIC AND ABDOMINAL MOVEMENT. COMPARE ALSO LENGTH OF TIME WITH NORMAL IN FIGURE 5 .

FIGURE 7 CASE 23. NORMAL MALE. UPPER LINE IS THORACIC; LOWER LINE IS ABDOMINAL. THORACIC LINE SHOWS FIVE SMALL PEAKS. CYCLE 1 SHOWS NO PEAK: CYCLE 2 ONE PEAK ON OR WITHIN A CYCLE AND IS MEASURABLE; CYCLE 4 A PEAK BETWEEN TWO CYCLES. NOTE SYNCHRONY OF THORACIC AND ABDOMINAL MOVEMENTS.

29 A final qualitative measure was necessary for describing the breathing movements on voiced and whis­ pered phonation of a vowel.

A change in breathing which

occurred in cerebral palsied and normal subjects in breath­ ing for voiced and whispered phonation of a vowel was the appearance of what were called, for descriptive purposes, small peaks.

These small peaks were much smaller cycles

than the average cycle on the breathing record.

Some of

them occurred within or on a regular cycle and some of them occurred between cycles. the vowel was phonated.

They appeared only when

Although the general contour of

these small peaks was that of a regular cycle, they were too small to be measured and the I-Praction computed. However, if they occurred on or within a cycle as the second one did in Figure 7 > it was possible to measure the cycle and compute the I-Fraction. illustration of small peaks.

See Figure 7 for

The small peaks on each

record were counted for the purpose of qualitative des­ cription. The data have been treated quantitatively by com­ puting the I-Fractions, measuring the cycles and count­ ing the cycles.

Qualitatively they have been classified

according to predominate movement, to general pattern, on the basis of measurability, reversals and small peaks.

30 Measurement of breathing records.

Since three-

minute records of vegetative breathing were obtained on each subject, it was possible to pick out one minute or 237 continuous millimeters of the breathing record which seemed to be the most typical of that subject.

It was

decided in the beginning to measure the second minute of the three-minute record; however, it was found that the subjects sometimes sighed or otherwise disturbed the re­ cording process so that the second minute was not always a true record of breathing in that individual.

When a

section of the record had been decided upon as the most typical, a line was drawn vertically across the record, i.e., from edge to edge.

With this line as a reference

point, 237 millimeters were measured horizontally from it. Another vertical line was then drawn across the record. This marked off the minute which was to be measured.

This

measurement was checked three times to determine the ac­ curacy.

The time marker on the left-hand side of the re­

cord made a solid line along the edge of the record so that this was used as a guide in measuring horizontal distances.

If a cycle was cut in half by the vertical

line or the expiration phase of the cycle was not complete the cycle was not counted.

The number of complete cycles

was then counted and recorded for the thoracic record.

31 Then each cycle was measured.

The total length of the

cycle was measured, the length of inspiration, the length of expiration and the I-Fraction computed. 153 millimeter rule was used for measuring.

A plastic When a thor­

acic record was completely measured the column ’’Total Length” was added to ascertain that 237 millimeters had been measured.

If there was a discrepancy the record

was remeasured until the error was found.

Since there

was not always a complete cycle at the beginning or end of a record there was sometimes a remainder of several millimeters which was not measured as any part of a cycle.

The remainder was included in the 237 millimeter

measurement but it had no effect on any of the cycles measured.

When the measurements were completed on the

thoracic part of the record, the abdominal part of the record was measured in the same way with the number of complete cycles counted first, the measurements made and the I-Fractions computed. The cycles were measured and the I-Fraction com­ puted for the voiced and whispered vowels in the same manner as were the cycles and I-Fraction for vegetative breathing except that only isolated cycles were measured. The timer on the polygraph was used to mark the record when a subject phonated the vowel.

Using these markings

32 as a guide, a straight edge was placed on the record vertically and a small mark marked on the upper or ab­ dominal record line and one on the lower or thoracic line. These marks identified the cycles on which the subjects phonated the vowel. No attempt was made to measure the cycles or to compute the I-Praction on the breathing for connected speech.

The reason for this is given in the discussion

of connected speech breathing. Determining reliability.

After all records were

measured and the I-Fractions obtained, every fifth cycle during vegetative breathing was selected to be remeasured for the purpose of checking the reliability of the mea­ surements.

The second and fourth voiced and whispered

vowels were also remeasured for the purpose of determin­ ing the reliability of the measurements.

Using the Pear­

son Product-Moment Coefficient method for obtaining the coefficient of reliability, a correlation of .91 was ob­ tained between the first and second measurements. II.

VEGETATIVE BREATHING

It will be remembered that the first specific problem to be studied was to determine whether observable differences in thoracic and abdominal breathing movements

33 for vegetative breathing exist between cerebral palsy subjects and normal individuals. Comparison of cerebral palsied with normals.

The

two most obvious differences which casual inspection of Tables I, II, III and IV will reveal are that:

First,

twenty-one of the cerebral palsy subjects had predomin­ antly thoracic movement, four had equal thoracic and ab­ dominal movement and five had predominantly abdominal move­ ment.

In the normal group only three subjects, all females,

showed predominantly thoracic movement, five had equal thoracic and abdominal movement and twenty-two showed pre­ dominantly abdominal movement.

Thus, twenty-one cerebral

-

palsy subjects had predominantly thoracic movement as com­ pared with twenty-two normals who had predominantly abdom­ inal movement; four cerebral palsy subjects had equal thor­ acic and abdominal movement as compared with five normal subjects who had equal thoracic and abdominal movement; and five cerebral palsy subjects had predominantly abdom­ inal movement as compared with three normals who had pre­ dominantly thoracic movement.

The second most obvious

difference is that in the cerebral palsy group thirteen subjects showed regular patterns and seventeen subjects showed irregular patterns; in the normal group twenty showed regular patterns and ten showed irregular patterns.

34 TABLE I CEREBRAL PALSY FEMALES VEGETATIVE BREATHING

Age Case and N o . Type

T H 0 R A C I C C/M

I-P

GP

C

.366 .508 .417 .473 .328

RR RR RR RR

M M M M

IR

M

.404 •383 .497 .483 .482

RR RR RR

M M

.441 .413 .412 -

RR IR RR

.442 .499 •337 •357

RR IR

27 3 4 14 15

US 15S 17S 17S 17S

21 13

25 5 29 10 23

17S 18S 18S 8a 11A

25

1 21 17 2 9

13A 13 A* i 4a 15A 17A

13 30 7

19A 19A i 8t a i 8t a

28

18 16 9

18

22 27 17

18 24 15 17 15 18

16 19

Thoracic Mean: Standard deviation: Key: RR S A TA — I-F C/M GP — IR r -

A B D O M

IR IR

IR IR

Regular Spastic Athetoid Tension Athetoid I-Fraction Cycles per Minute General Pattern Irregular Reversals

GP

C

PM

r

_ -

N N N N

t t t t t

n n n n n

e e t t t

n n n n n

t a t t t

n n n 1 n

t t e a

n 3 1 1

.131

IR

M

.374 .365

RR RR

M M

M M M

25 18 -

IR

N N

M

18

IR IR IR

M

R M M

R

IR IR

M

,056

I-F

7

M M M

,426

C/M

I N A L

27 14 -

16 18

-

.435 -

_

-

.261 .285

IR IR IR IR

R R R R R R R

IR

M

IR

M

Abdominal Mean: Standard deviation:

.308

.085

e - Equal n - None C - Classification N - Negligible R - Recordable M - Measurable PM - Predominant Movement t — Thoracic a — Abdominal

35 TABLE II CEREBRAL PALSY MALES VEGETATIVE BREATHING

Case No.

Age and Type

19 18 11 8 24 12

16 20 6 22

26

T H O R A

A B D O M

C/M

I-F

GP

C

C/M

8S US 17S 19S 14A

19 20 17 22 17

.404 .415 .473 .432 .328

IR IR IR RR RR

M M M M M

16 18

16 a 17A 17A 18TA

16 22 20 20

.480 *459 .439 .445

IR RR IR IR

21TA 21TA

17 26

.412 .456

IR IR

Thoracic mean: Standard deviation: Key: S A TA I-F C/M GP IR RR r -

C I C

.431 .044

Spastic Athetoid Tension Athetoid I-Fraction Cycles per Minute General Pattern Irregular Regular Reversals

—

I-F

— —

I N A L GP

C

PM

r

IR IR IR RR IR

R R N M M

t t t a e

n n n n 1

16

.400 .349

M M M M

22 19 23

.420 .335 .394

RR IR IR

N M M M

t a a t

n n n n

M M

12 16

.294 .348

IR IR

M M

t t

n n

22

mm

Abdominal mean: Standard deviation:

C - Classification N - Negligible R - Recordable M - Measurable PM - Predominent Movement t - Thoracic a - Abdominal e - Equal n - None

.362 .047

36 TABLE III NORMAL FEMALES VEGETATIVE BREATHING

Case Age

18

M M M M M

a a a a e

n n n n n

M M M M M

21 13 15 11 13

.480 .352 .433 .392 -

RR IR RR RR RR

M M M M t

a a a a n

n n n n

M M M

21 11 14

RR RR IR

R M R

t a t

n n n

18 21 21 17

18

19

21 13 15 11 13

.389 .442 .471 .476 .384

IR RR RR RR RR

19 19 19

21 11 14

.437 .450 .458

RR RR RR

16 28

14 14 17

18

Thoracic mean: Standard deviation:

.433 ■035

r

IR IR IR RR RR

M M M M M

21 21 17

PM

.378 .424 .489 .389 .391

IR IR RR RR RR

9 9 11 13 13

10 21 22

18

A B D 0 M I N A L GP C C/M I-F

.383 .401 .497 .422 .426

2 24 20 1 30

27 5 8

T H: 0 R A C I C I-F GP C C/M

—

.422 —

Abdominal mean: Standard deviation:

.415 .041

Ke^: I-F C/M GP IR RR r C N

-

I-Fraction Cycles per Minute General Pattern Irregular Regular Reversals Classification Negligible

R M PM t a e n

-

Recordable Measurable Predominent Movement Thoracic Abdominal Equal None

37 TABLE IV NORMAL MALES VEGETATIVE BREATHING

Age

Case 3 4

26 6 12

T H 0 R A C I C GP C C/M I-P

8 9 10 14 18

17 25 15 15 12

18 18

15 21 22 20

.381

A B D O M I N A L C/M GP C I-P

M M M M M

17 25 15 15 12

.411 .442 .550 .406 .375

IR RR IR IR RR

M M M M M

a a a e a

n n n n n

.327 .461

IR RR RR RR RR

M M M M M

15 21 22 20

18

.594 .432 .519 .380 .405

IR RR IR IR RR

M M M M M

a e a a a

n n n n n

M M M M M

e a a a e

n n n n n

M M

a a

n n

.485 .449 .474 .431

19 19 19

15 19 23 9 17

19 19 19 20 20

.537 .487 .426 .435 .409

IR IR RR RR RR

M M M M M

16

.415

12 14 12 12

12 14 12 12

.388 •392 .431 .504

IR IR RR RR RR

29 11

20 21

12 17

.446 .556

IR RR

M M

12 17

.428 .509

IR RR

16

r

IR RR IR IR RR

18 25 7 13 14

18

PM

.593 .421

.522

Thoracic m e a n : Standard deviation:

461 063

Abdominal Mean: Standard deviation:

.445 .063

Key;: I-P C/M GP IR RR r C N

-

I-Praction Cycles per Minute General Pattern Irregular Regular Reversals Classification Negligible

R M PM t a e n

-

Recordable Measurable Predominant Movement Thoracic Abdominal Equal None

38 Less obvious differences are that the mean number of cycles per minute of vegetative breathing for the cer­ ebral palsy group was 19 , as compared with 16 for the normals.

The range of cycles per minute in the cerebral

palsy group was from nine to twenty-seven.

For the normal

group the range was from eleven to twenty-five. The thoracic mean I-Fraction for vegetative breath­ ing for cerebral palsy subjects was .428 with an S.D.11 of .050; the abdominal mean I-Fraction for cerebral palsy subjects was .335 with an S.D. of .066.

The thoracic mean

I-Fraction for vegetative breathing for normal subjects was .447 with an S.D. of .049; the abdominal mean I-Fraction for normal subjects was .430 with an S.D. of .052 . Hull and Bryngelson found that the mean I-Fraction for silent breathing was .414 with an S.D. of .077 for their fourteen spastic subjects. obtained only on thoracic records.

These measurements were The mean I-Fraction

for vegetative breathing for the thirty cerebral palsied subjects in the present study was .428 with an S.D. of .050; the abdominal mean was .335 with an S.D. of .066. Hull and Bryngelson compared their I-Fraction to norms set by Fossler on thirteen subjects of college age.

11 Standard deviation.

Their

39 subjects were between the ages of ten and sixteen.

The

subjects in the present study were between the ages of eight and twenty-one.

Inasmuch as no significant differ­

ences were found between the I-Practions on vegetative breathing for normals and cerebral palsied subjects when t-scores were computed, t-scores were not computed for voiced and whispered vowels because inspection of the mean I-Practions show that if significant differences were present they would be on vegetative breathing. With the exception of two cases thoracic movement was measured on all cerebral palsy subjects.

In Case 21

the movement was predominantly abdominal with recordable thoracic movement according to the definition previously given.

In Case 9 no part of the record was measured al­

though the movement was recordable.

The reason for this

was that of the peculiar nature of the pattern. similar to no other pattern found.

It was

See Figure 8 for a

portion of the vegetative breathing of this individual. Thoracic movement was measured on all normal subjects. Comparison of spastics with normals.

It might be

interesting to compare certain aspects of vegetative breathing of spastics to the vegetative breathing of normals.

Of the twelve spastic subjects, eight showed

regular breathing patterns, seven of these were females;

FIGURE 8 CASE 9. ATHETOID FEMALE. LOWER LINE IS THORACIC; UPPER LINE IS ABDOMINAL. NOTE LACK OF WELL DEFINED CYCLES AND ASYNCHRONY OF THORACIC AND ABDOMINAL MOVEMENTS.

£

41 however, of these seven subjects five had negligible ab­ dominal movement.

For a picture of a spastic breathing

pattern see Figure 9*

The regularity of the pattern is

characteristic of the spastic but the abdominal movement is not.

Of the twelve spastic subjects only four had

measurable abdominal movement.

Nine showed predominantly

thoracic movement, two showed equal thoracic and abdom­ inal movement and one showed predominantly abdominal movement.

Three of the twelve spastics had regular pat­

terns on both thoracic and abdominal movement.

Four of

the twelve spastics had measurable abdominal movement. Comparison of these figures with normals shows that twenty normals had regular breathing patterns, ten of whom were females and ten of whom were males.

Thor­

acic and abdominal measurements were obtained on all nor­ mal subjects with the exception of three females who had predominantly thoracic movement but recordable abdominal movement.

In all normal subjects without exception there

were the same number of thoracic and abdominal cycles. This was true of the three female subjects, although it was not possible to measure the abdominal cycles.

In

three of the four spastic subjects who had measurable abdominal movement an equal number of thoracic and ab­ dominal cycles was found.

In the fourth subject there

were nine thoracic cycles and seven abdominal cycles.

FIGURE 9 CASE 8. SPASTIC MALE. LOWER LINE IS THORACIC; UPPER LINE IS ABDOMINAL NOTE REGULARITY OF PATTERN AND PREDOMINANTLY ABDOMINAL MOVEMENT.

43 No reversals were found in the spastic subjects in vegetative breathing conctrary to statements found in the current literature regarding breathing difficulties in the spastic. Comparison of athetoids with normals.

A comparison

of the athetoid subjects with normal subjects show that of the eighteen athetoid subjects, five showed regular breath­ ing patterns, three of whom were females.

In the normal

group twenty of the thirty showed regular patterns, half of these being females.

Only one of the five athetoid

subjects had a regular breathing pattern for abdominal and thoracic breathing.

Only two athetoids showed neg­

ligible abdominal movement.

None of the normals had

negligible thoracic or abdominal movement.

Seven of the

eighteen athetoids showed recordable abdominal movement. Of the eighteen athetoid subjects nine had measurable abdominal and thoracic movement.

In the normal group

thirty had measurable thoracic movement and twenty-seven measurable abdominal movement.

Of the eighteen athetoids

only three had the same number of abdominal and thoracic cycles.

Two athetoids had more cycles in the abdominal

record line than in the thoracic record line.

It will

be remembered that all normals had the same number of thoracic and abdominal cycles.

There were from one to ten

less abdominal than thoracic cycles, in the athetoid

subjects who had measurable thoracic and abdominal move­ ment.

Five of the athetoids showed reversals in the min­

ute of vegetative breathing that was measured. showed reversals in the minute measured.

No normals

In the athetoid

group twelve of the eighteen had predominantly thoracic movement, four had predominantly abdominal movement and two had equal thoracic and abdominal movement. Comparison of spastics with athetoids.

A compar­

ison of spastics with athetoids shows that of the thirteen regular patterns found in the cerebral palsied group eight of these were in the spastic group.

Of the eight subjects

in the cerebral palsy group who had negligible abdominal movement six were spastics.

The five cerebral palsy sub­

jects who showed breathing reversals In vegetative breath­ ing were athetoids. Comparison of tension athetoids with non-tension athetoids.

Five of the eighteen athetoids were diagnosed

tension athetoids, two females and three males.

All had

irregular breathing patterns but also all of them had mea­ surable abdominal movement as compared with thirteen other athetoids of whom only four had measurable abdominal move­ ment.

Of the five athetoid subjects who showed reversals,

two were tension athetoids.

45 Summary of vegetative breathing.

The differences

between normals and the cerebral palsied on vegetative breathing are:

(1)

The cerebral palsied group show mainly

thoracic breathing while the normals show mainly abdominal breathing.

(2)

The cerebral palsied show mainly irregular

patterns and the normals showed mainly regular patterns. The cerebral palsied had a mean number of cycles per min­ ute of vegetative breathing of nineteen as compared with sixteen for the normal group.

No significant differences

in the I-Fraction for thoracic and abdominal breathing were found between the cerebral palsied and the normals when t-scores were computed.

III.

BREATHING FOR PHONATION OF A VOWEL

The second specific problem to be studied was to determine whether observable differences in thoracic and abdominal breathing movements for phonation of a vowel, voiced and whispered, exist between cerebral palsied sub­ jects and normal individuals. A.

Breathing for voiced vowel.

Quantitative

measures that were possible for interpretation of these data was that of computing the I-Fraction.

The thoracic

mean I-Fraction for a voiced vowel for cerebral palsied

46 subjects was .441 with an S.D. of .083; the abdominal mean I-Fraction for the same group for the same activity was .305 with an S.D. of .080.

For the normals for the same

activity the thoracic mean I-Fraction was .421 with an S.D. of .080 and an abdominal mean I-Fraction of .385 with an S.D. of .080. For vocalized "ah” Hull and Bryngelson found an average I-Fraction of .623 with an S.D. of .168.

The

range of I-Fractions was from .325 to .981. Quantitative measures on individual subjects will be found in Tables V, VI, VII and VIII. Since the I-Fraction will not give an accurate picture of what happens to vegetative breathing when speech is superimposed on it in the cerebral palsied sub­ ject, some description is necessary.

For interpretation

of these records it is necessary to rely on certain qual­ itative measures. Comparison of cerebral palsied with normals.

In

breathing for a voiced vowel only one of the thirty cer­ ebral palsied showed a regular pattern; twenty-nine of them showed irregular patterns as compared with the norm­ als of whom eleven showed regular patterns and nineteen irregular patterns.

Reversals on a voiced vowel were

found in two normals, both males; and in four cerebral

47 TABLE V CEREBRAL PALSY FEMALES VOICED VOWEL

T H O R H 1 •=a

Age and Type

GP

27 3 4 14 15

US 15S 17S 17S 17S

.349 .413 .338 .407 .376

IR IR IR IR IR

25 5 29

17S l8S 18S 8a 11A

.590

IR RR IR IR IR

Jase

10 23

1 21 17

2 9 13 30 7

28

.361 .373 .556 .534

13A 13A 14A 15A 17A

.320

19 A 19 A 18TA i 8t a

•557 .567 .525 .311

.396

.722 .425 -

Thoracic mean: Standard deviation: Key: $ A TA I-F GP IR RR r C -

A C I C C

SP

I-F

M M M

2 1

_ -

N N N N

_

-

r

n n

t t t t t

n n n n n

n n n n n

t a t t t

n n n

n n n n n

t e e t t

n n n n n

a t t a

n n n

-

IR RR IR IR IR

M

.380 .431 .313 —

IR IR IR IR IR

M M

R

3 n n n n

M M M M

.376 — .196

IR IR IR IR

M

1

n 1 n

R R

n n n

M

M M

M

n n n

1

2

.451 .112

Spastic Athetoid Tension Athetoid I-Fraction General Pattern Irregular Regular Reversals Classification

_

PM

.225 .387 .307 .265

M M M

IR

SP

n n n n

M M

IR

C

.232

M

IR IR

GP

IR

M

IR IR IR IR IR

A B D 0 M I N A L

-

M M

M R

M

M R R

M

Abdominal mean: Standard deviation:

N-,— R M — PM — t — a e n SP -

Negligible Recordable Measurable Predominant Movement Thoracic Abdominal Equal None Small Peaks

.311

.076

2 n

1

48 TABLE VI CEREBRAL PALSY MALES VOICED VOWEL

Age and Type

I-F

GP

C

SP

I-F

GP

C

SP

PM

r

.447 .450 .390 .367

IR IR IR IR

M M M M

3 1 2 1

.124

11 8

8S US 17S 19 S

IR IR IR IR

M N N M

n n n n

t t t t

n n n n

24 12

14A

16a

.353 •553 .413

.386

IR IR IR IR

M M M M

1 3 2 1

IR IR IR IR

M M M M

n n 2 n

a t t t

n n n n

.490 .439 .439

IR IR IR

M M M

2 2 3

IR IR IR

M M M

4 n n

a t t

1 n 2

Jase 19

18

16

17A 17A

20

18TA 21TA 21TA

6 22

26

Thoracic mean: Standard deviation:

A B D 0 M I N A L

A C I C

T H O R

— —

.300 .313 .294

.286 .299 .480 .317

.288

*431 .055

Abdominal mean: Standard deviation:

Key: Spastic S Athetoid A TA Tension Athetoid I-F I-Fraction GP General Pattern IR Irregular RR - Regular Reversals r C Classification -

-

—

-

-

-

-

—

N R M PM t a e n SP

— — — — — —

Negligible Recordable Measurable Predominant Movement Thoracic Abdominal Equal None Small Peaks

.300 .084

49 TABLE VII NORMAL FEMALES VOICED VOWEL

A B D 0 M I N A L GP C I-F SP

T H 0 R A C I C GP C SP ±-r

PM

r

1 n 2 1 1

a a a a a

n n n n n

M M M M R

2 n 4 6 n

a t a a t

n n n n n

R M R

n 3 n

t a a

n n n

Jase

Age

2 24 20 I 30

9 9 11 13 13

.396 .455 .410 •329 .317

IR IR RR RR RR

M M M M M

2 3 4 1 1

.360 .412 .405 .344 .333

IR IR RR RR RR

M M M M M

16

14 14 17

.387 .342 .480

M M M M M

1 2 5 4 n

.496 .341 .437 .237

RR IR RR IR RR

M M M

3 5 3

.358

RR RR IR

28 27 5 8 10 21 22

18

.508

19

.276

RR RR IR IR RR

19 19 19

.436 .413 .450

RR RR IR

Thoracic mean: Standard deviation:

-

Abdominal mean: Standard deviation:

.407

.056

Key: I-F GP IR RR r C N

-

I-Fraction General Pattern Irregular Regular Reversals Classification Negligible

R M PM t a e SP

-

Recordable Measurable Predominant Movement Thoracic Abdominal Equal Small Peaks

.372 .066

50 TABLE VIII NORMAL MALES VOICED VOWEL

Case Age 8 9 10 14

T H 0 R A C I C C SP I-P GP

A B D O M I-F GP

3 5 4 3 2

.469 .544 .382 .364 .491

RR IR IR IR IR

M M M M M

1 2 5 3 2

a a a e a

n n n n n

IR IR RR IR IR

M M M M M

3 2 2 3 n

a e a a a

n 1 n n 1

IR IR IR IR IR

M M M M M

1 n 3 2 2

e a a a a

n n n n n

IR RR

M M

1 3

a a

n n

18

18 25 7 13 14

18 18 19 19 19

•769 .416 .490 .380 ■352

IR IR RR RR IR

M M M M M

5 2 2 2 3

.653 .441 .434 •357

15 19 23 9 17

19 19 19 20 20

•343 •335 •355

IR IR IR IR IR

M M M R M

1 4 5 6 2

.308 .312 •357

29 11

20 21

.500

IR RR

M M

1 2

.300

-

.538 .394

Thoracic mean: Standard deviation: Key: I-F GP IR RR r C N -

r

M M M M M

6 12

26

PM

RR IR IR IR IR

•383 .461 •371 •397 .480

3 4

I N A L C SP

I-Fraction General Pattern Irregular Regular Reversals Classification Negligible

.308

.436 .328 .293

-435 .105

Abdominal mean: Standard deviation:

R M PM t a e n SP

-

Recordable Measurable Predominant Movement Thoracic Abdominal Equal None Small Peaks

*398 .095

51

palsied subjects, two males, tension athetoids, and two females, non-tension athetoids.

Reversals found in the

cerebral palsied were all in the athetoid group.

No re­

versals were found in the spastic group on a voiced vowel. In the cerebral palsied group five subjects, all spastics, had negligible abdominal movement on voicing of a vowel as compared with eight cerebral palsied sub­ jects who had negligible abdominal movement on vegeta­ tive breathing.

Nineteen of the cerebral palsied sub­

jects showed measurable abdominal movement on

voicing

of a vowel while only thirteen of them had showed it on vegetative breathing. In the thoracic records of seventeen cerebral palsied subjects small peaks as previously described were found; only three showed them in the abdominal re­ cords.

Twenty-nine normals showed small peaks in the

thoracic records while twenty-three normals showed them in abdominal records. Reversals were found in four cerebral palsied on breathing for a voiced vowel as compared with five who had reversals on vegetative breathing.

No reversals

were found on normal subjects In vegetative breathing but two subjects, both males, showed reversals on voiced vowels.

52 Some indication of what happens to vegetative breathing when speech is superimposed on it is to be noted from the fact that only one cerebral palsy sub­ ject had a regular pattern while twenty-nine had an irregular pattern for phonation of a vowel as compared with eleven normals who maintained a regular pattern and nineteen who did not.

It should be stated that no

normal subject deviated in breathing for speech to such a degree as did the cerebral palsied. For comparison of cerebral palsied subject phonating a vowel with a normal phonating the vowel, see Figure 10 and Figure 7* 5*

Breathing for whispered vowel.

Quantitative

measures that were possible for interpretation of these data was that of computing the I-Fraction.

The thoracic

mean I-Fraction for a whispered vowel for cerebral pal­ sied subjects was .447 with an S.D. of .073; the abdom­ inal mean I-Fraction for the same group for the same activity was .360 with an S.D. of .100. I-Fractions was from .293 to .625*

The range of

For the normals for

the same activity the thoracic mean I-Fraction was .465 with an S.D. of .071 and an abdominal mean I-Fraction of .406 with an S.D. of .078 . was from .176 to .600.

The range of I-Fractions

FIGURE 10 CASE 6. ATHETOID MALE. LOWER LINE IS THORACIC; UPPER LINE IS ABDOMINAL. SUBJECT IS PHONATING VOWEL; NOTE ASYNCHRONY OF THORACIC AND ABDOMINAL MOVEMENTS.

54 For whispered "ah" Hull and Bryngelson found an average I-Fraction of .594, with an S.D. of .191.

The

range of I-Fractions was from .367 to .975« Quantitative measures on individual subjects will be found in Tables IX, X, XI and XII. Since the I-Fraction will not give an accurate picture of what happens to vegetative breathing when speech is superimposed on it in the cerebral palsy sub­ ject, some description is necessary.

For interpretation

of these records it is necessary to rely on certain qual­ itative measures. Comparison of cerebral palsied to normals.

In

breathing for a whispered vowel two of the cerebral pal­ sied subjects had regular breathing patterns.

Ten normals

had regular breathing patterns for the same activity. Four cerebral palsied subjects showed reversals on the whispered vowels; three normals showed reversals.

The

reversals were all in the athetoid group of the cerebral palsied subjects. In the cerebral palsied group twelve subjects, seven of whom were spastics, had negligible abdominal movement on the whispered vowel as compared with eight cerebral palsied subjects who had shown negligible ab­ dominal movement on a voiced vowel.

55 TABLE IX CEREBRAL PALSY FEMALES WHISPERED VOWEL

Jase

Age, Type

A C I C SP C

T H O R GP I-F

A B D 0 M I N A L GP C I-F SP _

IR RR IR IR IR

M M M R M

n n n n n

t e t t a

n n n n n

IR IR IR IR IR

M M M N R

n n n n n

t a a t t

4 n t n t

IR IR IR IR

M R M M

n n n n

t t t a

n n n n

.460 .310 .540 •573 .455

IR RR IR IR IR

M M M M M

n n n 1 n

1 21 17 2 9

13A 13A 14A 15A 15A

.421 .433 .410 .450 -

IR IR IR IR IR

M M M M R

1 n n n n

.542 .347 .600

13 30 7

19A 19A 18TA i 8t a

.404 .477 .309 .293

IR IR IR IR

M M M M

n 5 n n

.387

28

Thoracic mean: Standard deviation: Key: S A TA I-F GP IR RR r C -

.430 .068

Spastic Athetoid Tension Athetoid I-Fraction General Pattern Irregular Regular Reversals Classification

n n n n n

.263

17S 18S l8S 8a 11A

25 5 29 10 23

.512

t t t t t

IR

n 2 n 1 1

.397 .489 .413

n n n n n

.363

.403

M M M M M

US 15S 17S 17S 17S

r

N N N N M

IR RR IR IR IR

27 3 4 14 15

PM

-

-

-

-

-

.3^8

.237 -

.301

-

-

.210 .293

-

Abdominal mean: Standard deviation:

N-•Negligible R - Recordable M - Measurable PM - Predominant Movement t - Thoracic a - Abdominal e - Equal n - None SP - Small Peaks

•353 .115

56 TABLE X CEREBRAL PALSY MALES WHISPERED VOWEL A C I C C SP

8S US 17S 19S

.326 •558 .478 .432

IR IR IR IR

M M M M

1 n n 1

24 12

i 4a 16a

.625

16

17A 17 A

IR IR IR IR

M M M M

3 1 n 1

IR IR IR

M M M

1 n 4

20

i 8t a 21TA 21TA

6 22

26

.495 .387 .436

.518 .423 .433

Thoracic mean: Standard deviation:

n n n n

t t t e

n n n n

.376 .357

IR IR IR IR

M R M M

1 n n 2

a t t t

n n 1 n

.435 .176 .465

IR IR IR

M M M

1 n 3

a t t

n n n

-

-

Abdominal mean: Standard deviation:

.464

Key: S A TA I-F GP IR RR r C

— —

Spastic Athetoid Tension Athetoid I-Fraction General Pattern Irregular Regular Reversals Classification

N R M PM t a e n SP

-

r

R R N M

.381

.078

PM

IR IR IR IR

-

00 00

19 18 11 8

•

Jase

A B D 0 M I N A L I-F C GP SP

u>

T H O R I-F GP

Age, Type

Negligible Recordable Measurable Predominant Movement Thoracic Abdominal Equal None Small Peaks

.368 .085

57 TABLE XI NORMAL FEMALES WHISPERED VOWEL

Case Age

2

9 9

24

20 1

11 13 13

30

16 28

14 14 17

27 5

18

8

19

10 21 22

19 19 19

T H 0 R A C I C C GP SP I-F .402 .474 .474 .413 •353

IR IR IR RR IR

M M M M M

•595 .477 .444 .493 •514

IR IR IR IR IR

M M M M M

.435

RR RR RR

M R M

-

.475

Thoracic mean: Standard deviation:

A B D 0 M I N A L C I-F GP SP

1 1 1 2 1 n

2 6 2

.321

n

a a a a e

•539 .369 •397 .398 -

IR IR RR IR IR

M M M M R

n n 3 3 n

a e a a t

n n n n n

RR RR IR

R M R

n

t a t

n n n

•355

5 3

1 1 1

1 n

Abdominal mean: Standard deviation:

.461

.058

Key: I-F GP IR RR r C N R

-

I-Fraction General Pattern Irregular Regular Reversals Classification Negligible Recordable

M PM t a e n SP

-

n n n n n

M M M M M

_

1

n

r

IR IR RR RR IR

.347 .333 .358 .346

3

PM

Measurable Predominant Movement Thoracic Abdominal Equal None Small Peaks

.376 .059

58 TABLE XII NORMAL MALES WHISPERED VOWEL

1

8 9 10 14

A B D 0 M I N A L C GP SP

A C I C C SP

H

Case Age

T H O R I-F GP

PM

r

RR IR IR IR IR

M M M M M

1 2 4 1 4

.422 .474 .370 .446 •593

RR IR IR IR IR

M M M M M

1 1 4 5 2

a a a a a

n n n n n

M M M M M

2 n 1 1 n

a e a a a

n 1 n n n

6 12

18

.421 .456 .488 .421 .583

18

18

.722

25 7 13 14

18 19 19 19

.434 .517 .394 .440

IR RR RR IR IR

M M M M M

2 n n 1 3

•727 .427 .565 .384

.382

IR RR RR IR IR

15 19 23 9 17

19 19 19 20 20

.397 .315 .441 .503 .493

RR IR IR IR IR

M M M M M

n 6 2 2 4

.424 .298 .470 .442 .415

RR IR IR IR IR

M M M M M

n 1 1 2 2

e a a a a

n n n n n

29 11

20 21

.508 .452

IR RR

M M

2 3

.258

IR RR

M M

1 3

a a

1 1

3 4

26

Thoracic mean: Standard deviation:

.348

Abdominal mean: Standard deviation:

.469

.085

Key: I-F GP IR RR r C N R

-

I-Fraction General Pattern Irregular Regular Reversals Classification Negligible Recordable

M PM t a e n SP

-

Measurable Predominant Movement Thoracic Abdominal Equal None Small Peaks

.437 .108

59 Eighteen of the cerebral palsied subjects showed measurable abdominal movement on whispered vowels, while only thirteen of them had showed it on vegetative breath­ ing. The small peaks which were described above were also found in whispered vowels.

Thirteen cerebral pal­

sied subjects showed them in the thoracic records; four in the abdominal records.

Twenty-six of the normals

showed them in the thoracic records and twenty showed them in the abdominal records.

Some of the subjects

showed no peaks while some showed as many as six, which was the number of vowels phonated. Summary.

When speech, phonation of a vowel, is

superimposed on vegetative breathing it disturbs to a greater degree the pattern of breathing in the cerebral palsied than it does the pattern of the normal.

Although

the I-Fraction does not show this, certain qualitative measures do.

Reversals were found in the athetoid and

even a few in the normal group, but none were found in the spastic group.

More cerebral palsied subjects

showed abdominal movement on phonation of a vowel than they did on vegetative breathing.

Small peaks were

noted in normals and cerebral palsied breathing records. Although normals show irregular breathing patterns during

60 phonation of a vowel none

of them are irregular to the

extent thecerebral palsied are.

Whispering of vowels

seems to make more demands on the breathing mechanism than does voicing of vowels, i.e., more cerebral palsied subjects had measurable abdominal movement on whispered vowels than they did on voiced vowels.

IV. The

BREATHING

FOR CONNECTED SPEECH

third specific problem to be studied was to

determine whether observable differences in thoracic and abdominal breathing movements for connected speech, voiced and whispered, exist between cerebral palsied subjects and normal individuals. A*

Voiced connected speech— cerebral palsied

compared with normals.

It was not feasible to measure

the cycles for connected speech breathing because in the cerebral palsied the cycles were so deviate or so poorly defined that it was felt they could not be measured with any degree of accuracy.

The only quantitative measure

possible was that of counting the number of complete cycles in the period of time in which it took the sub­ ject to say the rhyme, nBaa, Baa, Black Sheep."

Data

on connected speech breathing are found in Tables XIII,

6l XIV, XV and XVI. In the cerebral palsied group twenty-one subjects were able to say the rhyme on ten cycles or less.

Five

subjects were able to say the rhyme on between eleven and twenty cycles.

One subject needed thirty-eight com­

plete cycles to say the rhyme.

The rhyme contains thirty-

eight syllables, which would seem to indicate that this individual said one syllable per breath.

Thirteen cere­

bral palsied subjects had well defined, countable abdom­ inal cycles on the rhyme.

The greatest deviations in

number of cycles to say the rhyme were found in the athetoid group. In the normal group, with the exception of two subjects who said the rhyme on eight cycles, slightly over half of the subjects said the rhyme on two or three cycles. The single most obvious difference in the breath­ ing for speech between the cerebral palsied and the normals is the asynchrony of thoracic and abdominal movements in the cerebral palsy group. Since Hull and Bryngelson did not have their subjects use memorized material there is nothing to compare in their study with the present study.

62 TABLE XIII CEREBRAL PALSY FEMALES CONNECTED SPEECH VOICED AND WHISPERED

Age, Type

CASE No.

VOICED C-A C-T •m

WHISPERED C-T C-A

27 3 3 14 15

US 15S 17S 17S 17S

5 2 1 3 2

25 5 29 10 23

17S 18S l8S 8a 11A

N N 4 38 18

N N N R 13

6 5 9 34 13

R 10

1 21 17 2 9

13A 13A 14 a 15A 17A

4 9 N 12 15

3 10 N 7 R

14 7 N N 17

9 10 N N R

13 30 7

19A 19A i 8t a i 8t a

1 14 5 4

R R R 4

4 15 7 5

2 R 6 5

28 Key: S A TA C-T C-A N R

-

Spastic Athetoid Tension Athetoid Cycles Thoracic Cycles Abdominal Negligible Recordable

—

5 3 2 3 2

-

2 6 5 —

63 TABLE XIV CEREBRAL PALSY MALES CONNECTED SPEECH VOICED AND WHISPERED

Case No.

Age, Type

C-T

VOICED C-A

19 18 11 8

8s US 17S 19S

9 7 1 10

24 12 16 20

14a i 6a 17A 17A

8 10 10 3

6 22 26

18TA 21TA 21TA

19 6 9

Key: S A TA C-T C-A

-

Spastic Athetoid Tension Athetoid Cycles Thoracic Cycles Abdominal

WHISPERED C-T C-A

4 7 2 8

8

9 4

10 7 9 5

11 3 12 4

14 4 7

15 4 9

8 4 9

9 -

7 8 —

5 5 -

64 TABLE XV NORMAL FEMALES CONNECTED SPEECH WHISPERED AND WHISPERED

Case

Age

VOICED C-T C-A

WHISPERED C-T C-A

2 24 20 1 30

9 9 11 13 13

3 3 4 3 2

3 4 4 3 1

4 6 6 4 4

4 6 6 4 3

16 27 5 8

14 14 17 18 19

5 3 1 2 3

5 3 1 1 R

7 5 6 3 3

6 3 5 3 3

10 21 22

19 19 19

2 R 2

R R R

3 2 3

R 2 R

28

Key: C-T - Cycles Thoracic C-A - Cycles Abdominal R - Recordable

65 TABLE XVI NORMAL MALES CONNECTED SPEECH VOICED AND WHISPERED

Case

Age

VOICED C-A C-i

WHISPERED C-T C-A

8 9 10 14 18

8 3 3 2 3

8 2 3 2 3

8 3 3 3 5

8 3 2 3 5

18 25 7 13 14

18 18 19 19 19

4 3 8 6 2

4 2 7 5 2

R R 4 5 3

2 2 4 5 3

15 19 23 9 17

19 19 19 20 20

R 2 4 5 2

R 2 4 5 3

1 6 3 4 3

R 5 3 5 3

29 11

20 21

1 5

1 5

1 3

1 3

3 4

26 6 12

Key; C-T - Cycles Thoracic C-A - Cycles Abdominal R - Recordable

66 B.

Whispered connected speech--cerebral palsied

compared with normals.

The asynchrony of breathing move­

ments was present for whispered speech as it had been in the breathing for voiced speech in the cerebral palsied group.

Synchrony of breathing movements was character­

istic of the normals in whispered speech breathing as it had been in voiced breathing.

Thirty of the normals

and cerebral palsied needed more breath, i.e., more cycles were used, for whispered speech than voiced speech in the rhyme; others used the same number of cycles or less. Summary.

The two obvious differences in breath­

ing for connected speech, voiced and whispered, were: (1)

Asynchrony of thoracic and abdominal breathing move­

ments in the cerebral palsied as compared with the syn­ chrony of breathing movements in the normal;

(2)

the

large number of cycles which it took the cerebral palsied to say the rhyme as compared with the small number of cycles it took the normals to say the rhyme.

CHAPTER IV RESULTS OF EXPLORATORY STUDY No quantitative measures were used in treating the records obtained on respirator subjects.

The two subjects

discussed here have been chosen for illustrative purposes only.

Case 1 7 » an athetoid female (see Figure 11), shows

negative abdominal movement when the subject was lying in the respirator without the respirator turned on.

The

pattern is very similar to the one the subject showed during vegetative breathing when she was in a sitting position.

Figure 12 is a picture of a portion of this

subjectfs vegetative breathing after several minutes of the respirator working at twenty centimeters of water, negative pressure.

Note that abdominal movement was

present and the thoracic and abdominal movements were synchronized for the most part, although not perfectly

so . The vegetative breathing pattern of the second subject, Case 6, an athetoid male, used here for illus­ trative purposes, in the respirator without turning it on, is shown in Figure 13.

This pattern is different

from the vegetative breathing pattern which the subject has in a sitting position.

In the sitting position the

FIGURE H CASE 17

ATHETOID FEMALE. LOWER LINE IS THORACIC, UPPER LINE ABDOMINAL SUBJECT IS LYING DOWN. NOTE LACK OF ABDOMINAL MOVEMENT. "

g

FIGURE 12 CASE 17. ATHETOID FEMALE. LOWER LINE IS THORACIC, UPPER LINE ABDOMINAL. RESPIRATOR IS WORKING AT TWENTY CENTIMETERS OF WATER, NEGATIVE PRESSURE. NOTE PRESENCE OF ABDOMINAL MOVEMENT, SYNCHRONIZATION.

FIGURE 13 CASE 6.

ATHETOID MALE. LOWER LINE IS THORACIC, UPPER LINE ABDOMINAL. SUBJECT IS LYING DOWN. NOTE IRREGULARITY, ASYNCHRONY.

o

71 subject has well defined cycles with predominantly thor­ acic movement, although the pattern is irregular.

Fig­

ure 14 shows the vegetative breathing pattern of this subject after several minutes of the respirator working at twenty-five centimeters of water, negative pressure. Note improved synchrony of thoracic and abdominal move­ ment and the well defined cycles. cord of the subject phonating was working.

c a d

Figure 15 is a re­ while the respirator

Compare this with Figure 10, which is a

record of the same subject phonating the same vowel without respirator aid.

Note in Figure 15 the lack of the

exaggerated cycles in the abdominal record on phonation of the vowels as compared with those in Figure 10.

Note

also in Figure 15 better defined abdominal cycles. Figure 16 shows a record of the vegetative breathing of this subject after the respirator was turned off for several minutes.

Compare this with Figure 13.

In

Figure 16 note that the pattern is more regular; the cycles are better defined and the movement is predom­ inantly abdominal . No attempt was made to see whether repeated respirator treatment would have a long-range effect on the breathing patterns of these subjects, hence no definite conclusions can be drawn in that regard from

FIGURE 14 CASE 6. ATHETOID MALE. LOWER LINE IS THORACIC, UPPER LINE IS ABDOMINAL. RESPIRATOR IS WORKING AT TWENTY-FIVE CENTIMETERS OF WATER, NEGATIVE PRESS­ URE. NOTE IMPROVED SYNCHRONY AND WELL DEFINED CYCLES.

FIGURE 15 CASE 6. ATHETOID MALE. LOWER LINE IS THORACIC, UPPER LINE IS ABDOMINAL. SUBJECT IS PHONATING VOWEL WHILE THE RESPIRATOR IS WORKING. COMPARE WITH FIGURE 10 FOR LACK OF EXAGGERATED ABDOMINAL MOVEMENT ON PHONATION OF VOWELS IN FIGURE 15-

*

FIGURE 16 CASE 6. ATHETOID MALE. LOWER LINE IS THORACIC, UPPER LINE IS ABDOMINAL. RESPIRATOR IS TURNED OFF. NOTE REGULARITY OF PATTERN, BETTER DEFINED CYCLES AND PREDOMINANT ABDOMINAL MOVEMENT AS COMPARED WITH FIGURE 13-

75 the records here.

However, these records and the

records of the other subjects who were put into the respirator seem to suggest that a more nearly "normal” breathing pattern can be superimposed for the moment on the disturbed breathing patterns of the cerebral palsied subject.

However, further research is indi­

cated before this can be known with certainty.

CHAPTER V SUMMARY AND CONCLUSIONS I.

SUMMARY

The general purpose of this study was to investi­ gate the breathing patterns in two selected groups of cerebral palsied subjects and to compare these breathing patterns with breathing patterns of normal individuals. Thirty cerebral palsied subjects and thirty normal subjects, between the ages of eight and twenty-one, were used. A polygraph and two pneumographs were used for recording purposes. The data were treated quantitatively and quali­ tatively. In addition to the general purpose, an exploratory study was made of the effect of the respirator on breath­ ing patterns of four cerebral palsied subjects.

Two sub­

jects were used for illustrative purposes. II.

CONCLUSIONS

The results of this study seem to suggest the following conclusions:

77 1.

The thoracic mean I-Fraction of the cerebral

palsied was .428 and the mean abdominal I-Fraction for cerebral palsied was .335* earlier findings.

This was consistent with

The I-Fraction is not an adequate

measure for analyzing the breathing differences of cer­ ebral palsied and normal subjects. 2.

The cerebral palsied subjects used in this

study, as a group, use thoracic breathing to a greater degree than do the normals used in this study who, as a group, have predominantly abdominal movement. 3.

Synchronization of thoracic and abdominal

breathing movements seemed to be characteristic of the normals used in this study while asynchrony of thoracic and abdominal breathing seemed to be characteristic of the cerebral palsied subjects used in this study. 4.

The spastic subjects used in this study did

not show reversals, contrary to the reports in the lit­ erature.

Reversals seemed to be more characteristic of

the athetoid subjects used in this study. 5.

The athetoid group used in this study show more

irregular patterns of breathing than either the spastics or the normals. 6.

Superimposing a speech activity upon vegeta­

tive breathing seemed to disturb to a greater degree the

78 vegetative breathing of the cerebral palsied used in this study than it did with the normals.

This disturbance of

breathing with the complexity of speech activity was con­ sistent with earlier investigations. 7*

The cerebral palsied subjects used in this

study tended to say fewer words per cycle than did the normal subjects. 8.

Preliminary investigation of the effect of

the respirator on the breathing movements of cerebral palsied subjects seems to warrant further investigation.

B I B L I O G R A P H Y

BIBLIOGRAPHY Blumenthal, Edna M . , "Speech Correction for Cerebral Palsy," Physiotherapy Review, 21:71-72, March-April, 1941. Brown, Caroline M . , "A Brief Outline for Treating the Birth Injured," Physiotherapy Review, 15:226-28, November-December, 1935* Cardwell, Viola Care in the of Pamphlet of Crippled

E . , The Cerebral Palsied Child and His Home. Cerebral Palsy Series: Revision I. New York: Association for the Aid Children, 1947*

Fossler, H. R . , "Disturbances in Breathing During Stut­ tering," Psychological Monographs, University of Iowa, 40:1-32, 1930. Froeschels, Emil, "A Contribution to the Pathology and Therapy of Dysarthria Due to Certain Cerebral Le­ sions, ' Journal of Speech Disorders, 8:301-321, December^ 1943* Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis. New York: Paul B. Hoeber, Inc., 1941. Hansen, Ruth, Edward Longerich and Mary Longerich, "Physical Therapy Approach to Speech Problems in Spasticity and Athetosis," Physiotherapy Review, 27:174-81, May-June, 1947Hull, Henrietta C., and Bryng Bryngelson, "A Study of the Respiration of Fourteen Spastic Paralysis Cases During Silence and Speech," Speech Monographs, 8: 114-121, 1941. Lundeen, Phyllis, "Cerebral Palsy of Spastic Paralysis," Physiotherapy Review, 23:17-22, January-February, Moore, Ellen H . , "Emotional and Physical Responses of Birth Injury Cases to Speech Correction, Journal of Exceptional Children, 100-106, January, 1942. Paulitsch, Gladys D., "Treatment of Cerebral Palsy," Physiotherapy Review, 21:67-68, March-April, 1941.

81 Perlstein, M. A . , and Marie Shere, "Speech Therapy for Children with Cerebral Palsy," American Journal of Diseases of Children, 72:389-98, October, 1946. Phelps, Winthrop Morgan, "Treatment of Cerebral Palsy," Medical Record, p. 218, September 18, 1940. Pittenger, Katharine, "Spastic Speech Disorders and Their Treatment," Physiotherapy Review, 22:128-42, May-June, 1942. Rutherford, Berneice R . , Give Them a. Chance to Talk. Minneapolis, Minnesota: Burgess Pub1is hi ng Company, 1948. Strother, C. R . , "Diagnosis of Disorders of Speech," Physiotherapy Review, 18:81-84, March-April, 1938. Woodworth, Robert S., Experimental Psychology. Henry Holt and Company, 1938.

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