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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 swallowing disorder.

Both are associated with MS, and both need professional attention.

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, tremor, 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.

Speaking freely
“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 swallow
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 some people.

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 or drinking.
  • 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 liquid.

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 mouth
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 your comfort.

 

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.

 

 

 

 

 

 

For additional information

Managing MS Through Rehabilitation

 

 

 

Reviewed by the Client Education Committee of the National MS Society’s Medical Advisory Board. Special thanks to Pamela Miller Sorensen, MA, CCC-SLP, for her valuable assistance.

 

 

 

 

 

Copyright © National Multiple Sclerosis Society, 2004

 

 

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