Speech and Swallowing:
The Basic Facts
If people are asking you to repeat words;
if it’s getting harder to carry on conversations because your speech is
slurred, slow, or quiet; if you can’t talk fast enough to keep up with your
thoughts—you may be experiencing a speech or voice disorder.
If you are constantly clearing your throat
or coughing when you drink thin liquids like water, you may be experiencing a
Both are associated with MS, and both need
As many as 40% of people with MS may have
speech problems at some time. Specialists believe they are caused by MS
lesions (or damaged areas) in the part of the brain responsible for muscle
control of the lips, tongue, soft palate, vocal cords, or diaphragm.
Dysarthria is a speech disorder. It means speech is slurred
or poorly articulated. There may be loss of volume control, unnatural
emphasis, and slower rate of speech. Dysphonia is a voice
disorder. It involves changes in vocal quality, such as harshness,
hoarseness, breathiness, or a hypernasal sound. In MS, these conditions may
result from muscle weakness, spasticity,
or ataxia (lack of muscle coordination).
The organs involved in speech are also needed
for swallowing and many people with MS have some swallowing problems or dysphagia.
These problems range from an occasional cough or a throat that just can’t be
cleared to a slowing down of the whole swallowing process. Chronic swallowing
problems can lead to dehydration or poor nutrition. The most severe problem
occurs when food particles or liquids accidentally enter the lungs. This can
cause “aspiration” pneumonia, a serious illness.
Help is available
The good news is that most speech
and swallowing problems can be managed. A speech/language pathologist (SLP)
is the specialist who can best diagnose and treat them.
“A person with MS may not notice
his or her own speech problems. Many times a family member or physician
brings it up,” said Pam Sorensen, a speech/language pathologist who has
treated people with MS for two decades at the Rocky Mountain MS Center, the
Jimmie Heuga Program, and in private practice. “Often people adapt, but when
speech problems begin interfering with everyday communication, it’s time for
an evaluation with a speech therapist.” A speech therapist is more formally
known as a speech/language pathologist or SLP.
During an evaluation, the SLP will examine
the oral muscles that are necessary for speech—your lips, tongue, and soft
palate—and assess how you control their movement with regard to strength,
speed, range, accuracy, timing, and coordination. Your teeth and hard palate
will also be examined. The SLP will check your breath support and control,
how precisely you pronounce words, and how well you are understood by others.
The therapist may then offer strategies
and exercises for specific problems. Some exercises can strengthen and
improve the muscles involved in speech production. There are techniques for
slowing down, over-articulating, phrasing, and pausing.
Active listening and self-monitoring
skills are also essential. Listening to yourself on a tape recorder can help
you hear and learn to correct your speech. Some people practice new speaking
skills in group therapy.
Medications that relieve other MS symptoms
can sometimes help dysphonia. For example, baclofen
(Lioresal), which relieves spasticity, may improve a harsh, strained voice
quality. In rare cases, injections of small amounts of Botox into affected
muscles can relieve spasms and improve dysphonia. There are also exercises to
promote relaxation and improve breath support.
People with severe speech problems may
need to use voice amplification devices, electronic aids, or
computer-assisted alternative communication systems. Again, an SLP can make
an evaluation to determine which technology is most appropriate, and teach
the best use of aids that substitute for or augment speech. Family and
friends should be trained in these communication techniques, as well.
The art of the
To evaluate a swallowing problem,
an SLP will want to observe the action. You will probably be asked to swallow
various preparations containing barium while your mouth and throat are
x-rayed and videotaped. When the tape is viewed, the barium reveals details
so the SLP can diagnose the problems. The SLP may suggest specific exercises
to improve muscle strength or coordination. A change in the position of your
head or certain head movements may improve swallowing and reduce coughing for
The following food safety rules may help
people with swallowing problems avoid dehydration, poor nutrition, or the
risk of aspiration pneumonia, which can be a consequence of food particles
entering the lungs.
- Sit upright or lean slightly forward when eating
- Keep the chin parallel with the table or
slightly tucked down.
- Begin a meal with something icy and thick—a
sherbet shake, or a fruit or vegetable smoothie. The cool temperature
will improve crucial nerve conduction.
- Take one small bite or sip at a time. Never
try consecutive swallowing.
- Never wash food down with a liquid. Your
throat nerves and muscles can become confused if you mix liquids and
solids. Instead, add moisture to the solid food. Use sauces, broth,
water, or milk.
- Choose soft, moist foods first, as they are
easier to swallow. Dry solids and thin liquids are more difficult, and
require closer attention to safe swallowing.
- Avoid thin liquids altogether when fatigued. A
good rule: consume thin things in the morning and thick things in the
late afternoon or evening.
- Identify and then avoid foods your throat
finds irritating. And avoid foods that make you choke, such as potato
chips. Try small variations to see if that makes a difference. For
example, if orange juice is a problem, try orange juice with pulp.
- Experiment with a kitchen blender. Some
favorite dishes can be pureed without losing their familiar flavor.
- If you feel yourself slowing down during a
meal, pause and switch to something icy.
- Quiet yourself and your surroundings during a
meal. It’s always a good idea to make mealtimes a calm and social part
of the day and to save discussion of “hot” topics for times when no one
is trying to eat.
- With solids, swallow at least two times per
mouthful—the first time to send the food down, followed by a dry swallow
to catch any residual particles.
- With liquids, especially hot thin liquids,
swallow; then clear the throat; then swallow again before taking more
If you are experiencing speech or swallowing
difficulties, speak up! Call your doctor or the National MS
Society for a referral to a speech/language pathologist in your area and
speak and eat more freely again.
A note about dry
Some speech or swallowing
difficulties might stem from dry mouth, which is a common side effect of some
drugs used to
treat other MS symptoms, especially bladder problems. Dry mouth may
contribute to tooth decay and gum disease, as well as cause discomfort, and
it should be discussed with your health-care provider. The medication causing
the problem may be adjusted or you may be advised to use mouthwashes,
artificial saliva, or other approaches to protect your teeth and increase
New Rehabilitation Guidelines
The Medical Advisory Board of the
National MS Society has adopted a set of recommendations to provide
guidance to physicians, nurses, and therapists—and to insurers and policy
makers—regarding the appropriate use of rehabilitative therapies in MS. The
recommendations were developed by a multidisciplinary task force comprised
of physical therapists, occupational therapists, a speech and language
pathologist, rehabilitation nurses, psychologists, psychiatrists, and
neurologists, as well as staff of Professional Resource Center.
The guidelines address professional
questions about the importance of rehabilitation as part of MS care. They
stress the need to refer patients to rehabilitation specialists, and they
are designed to serve as a professional consensus statement to be used when
insurance companies seek to deny coverage of physical rehabilitation
services to people with MS.
All people with MS, and their
physicians, should be aware of these important recommendations. Copies are
available on the Society's Web site (go to “For Professionals” and then “Expert
Opinion Papers”). A copy can also be obtained from your chapter or by
writing to: Professional Resource Center, National MS Society, 733 Third
Avenue, New York, NY 10017.