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MS information for health and social care professionals Communication and swallowing problems

Studies have shown that many people with multiple sclerosis experience communication or swallowing difficulties. Early referral to a registered speech and language therapist is therefore important so that a comprehensive assessment can be made. The therapist will provide advice that aims to maintain or slow down loss of ability, or will suggest strategies to adapt to the effects of changes in normal function. This will involve working not only with the person with MS but also family members where appropriate. Speech and language therapy is ongoing throughout the course of the disease.

Communication

Communication is central to quality of life and it needs little imagination to appreciate just how frustrating communication problems can be both for the person with MS and for those around him or her.

At a physical level, MS can affect the production of speech, usually by delays in messages passing through affected nerve pathways to the muscles involved in speech production. The term used to describe this is dysarthria. Very precise control and coordination of a range of muscles is required for speech and anything affecting the muscles of breathing, larynx, tongue, lips or jaw can result in alterations in speech intelligibility.

Darley et al[1] studied 168 patients and 41% displayed dysarthric speech. In a more recent large group study of MS patients, Hartelius et al[2] found that 62% of their group reported speech and voice impairments. Symptoms are variable and often relate to fatigue and stress levels. Some people experience a mild reduction in volume when tired or a slight slurring of speech at the end of the day. Others find their thoughts run ahead of their words.

There has been very little research into the effects of speech therapy on people with MS. Work reported so far does indicate that therapy can be beneficial[3]. General advice may include reducing background noise before speaking, saying half words on each breath, speaking slowly and facing listeners when speaking. Traditional speech exercises may be beneficial if the problem is very mild (eg exercises to assist breath control for volume). Developments in technology mean that there is a range of communication aid equipment which can assist some people with very dysarthric speech. Recently, there has been a shift towards viewing communication in the wider context of the person with MS within his/her family and friends. In this sense the most effective help is based on explanation, understanding and sharing of ideas. If the speech therapist can build up a trusting relationship with the person with MS and their family, then problems relating to speech and communication can be discussed and possible solutions explored.

A small number of people with MS can have dysphasia, or impairment of language function, but this is unusual. Associated problems include difficulty understanding and producing written and / or spoken words. Together with physical speech difficulties, cognitive problems can be a barrier to communication. A study of 100 individuals with MS found that 48% displayed cognitive dysfunction[4]. The main deficits relate to attention, memory and speed of processing information, so that difficulties in retrieving the name of something or being unable to concentrate in a noisy environment are often experienced. Clearly this can interfere with both employment and social functioning.

Swallowing

Dysphagia (difficulty in swallowing) is not generally regarded as a common symptom of MS. However, in a study of 203 people, Hartelius and Svensson[5] found that 33% reported swallowing difficulties. There may be disturbances of both oral and pharyngeal phases of swallowing. This can include difficulty chewing, pocketing food in the cheek, drink dribbling from the mouth, and episodes of coughing/choking when eating or drinking.

The severity of dysphagia varies widely. A speech and language therapist will be able to assess adequacy of swallowing through manual assessment and videofluoroscopy. Following assessment, the therapist will advise on posture, consistencies of food, amounts and eating environment.

If swallowing is considered unsafe and recurrent chest infections or marked weight loss develop then alternative ways of feeding will be recommended, eg nasogastric feeding or percutaneous endoscopic gastrostomy (PEG) feeding.

A PEG is a thin tube placed through the abdominal wall into the stomach, through which specially formulated feeds, fluids and medication can be given. The tube is inserted under mild sedation with the assistance of an endoscope passed through the mouth into the stomach. PEGs are indicated for those who cannot maintain their nutritional status, when eating has become intolerably difficult or when swallowing has become unsafe and aspiration results. One of the advantages of this method of feeding is that it can allow people to be more safely cared for at home.

Ultimately, the most effective management of communication and swallowing in MS results from close collaboration between the person with MS, the Speech and Language Therapist and other professionals and carers.

References

  1. Darley FL. Motor Speech Disorders. Philadelphia; WB Saunders: 1975.
  2. Hartelius L, Runmarker B, Andersen O. Prevalence and characteristics of dysarthria in a multiple-sclerosis incidence cohort: relation to neurological data. Folia Phoniatr Logop 2000;52(4):160-177.
  3. Hartelius L, Wising C, Nord L. Speech modification in dysarthria associated with multiple sclerosis: an intervention based on vocal efficiency, contrastive stress, and verbal repair strategies. J Med Speech Lang Pathol 1997;5(2):113-139.
  4. Rao SM, Leo GJ, Ellington L et al. Cognitive dysfunction in multiple sclerosis II, impact on employment and social functioning. Neurology 1991;41(5):692-696.
  5. Hartelius L, Svensson P. Speech and swallowing symptoms associated with Parkinson's disease and multiple sclerosis: a survey. Folia Phoniatr Logop 1994;46(1):9-17.

Bibliography

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  • Herbert S. A team approach to the treatment of dysphagia. Nurs Times 1996; 92(50):26-29.
  • Langley J. Working with Swallowing Disorders. Bicester: Winslow Publications; 1988.
  • Marchese-Ragona R, Restivo DA, Marioni G et al. Evaluation of swallowing disorders in multiple sclerosis. Neurol Sci 2006;27(Supp 4):S335-337.
  • Murdoch B, Theodoros D, editors. Speech and language disorders in multiple sclerosis. London: Whurr Publishers; 2000.
  • Restivo DA, Marchese-Ragona R, Patti F. Management of swallowing disorders in multiple sclerosis. Neurol Sci 2006;27(Supp 4):S338-340.
  • Thompson AJ. Multiple sclerosis: symptomatic treatment. J Neurol 1996;243(50):559-565.
  • Yorkston KM, Klasner ER, Bowen J, et al. Characteristics of multiple sclerosis as a function of the severity of speech disorders. J Med Speech-Lang Pathol 2003;11(2):73-84.
  • Yorkston KM, Klasner ER, Swanson KM. Communication in context: a qualitative study of the experiences of individuals with multiple sclerosis. Am J Speech and Lang Pathol 2001;10(2):126-137.
  • Yorkston, K., Miller R., Strand E. Management of speech and swallowing in degenerative diseases. Austin, Texas: Pro-Ed Inc; 1995.