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Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Welcome to today’s Webinar:
Speech and Swallowing in Multiple
Sclerosis
Your Presenter is Kate Morris
Your Facilitator is Ms Nicola Graham
Handouts
Handouts have been sent separately.
This contains a copy of the slides presented
today.
Multiple Sclerosis Limited
1
Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
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Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Acknowledgement
We acknowledge and pay respect to the traditional
custodians past and present on whose lands we
meet today.
We acknowledge the deep feelings of attachment
and the relationship of Aboriginal people to
country and respect the cultural authority of the
elders in each community
Multiple Sclerosis Limited
Welcome to today’s Webinar:
Speech and Swallowing in Multiple
Sclerosis
Your Presenter is Kate Morris
Your Facilitator is Ms Nicola Graham
3
Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Introduction to Presenter
Kate Morris
• Graduated 1999 from University of Newcastle.
• 19 years working in a variety of settings across
NSW including private/public hospitals, aged car
facilities, community, home, schools.
• Strong background working with adults with
neurological conditions.
• Currently at Everyday Independence where I
continue to work with this caseload. Team leader of
interdisciplinary team including speech
pathologists, physiotherapists and occupational
therapists.
Multiple Sclerosis Limited
Informed Choice
This presentation has been prepared and is
presented by an independent expert.
The views presented are not necessarily the views
of Multiple Sclerosis Limited.
Individuals are encouraged to seek further advice
regarding the relevance of the information
presented for their situation.
Multiple Sclerosis Limited
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Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Multiple Sclerosis – Speech, Swallowing and the Role of
the Speech Pathologist
Click to edit Master title style
Kate Morris
Speech Pathologist/Team Leader (Newcastle/Hunter New England Region)
Everyday Independence
katem@everydayind.com.au
May 2019
Outline
- Speech Pathology and MS
- Why is speech/voice important?
- Normal speech and voice production
- Speech difficulties in MS and typical speech changes
- Why is swallowing important?
- Swallowing difficulties in MS and typical swallowing changes
- When might someone be referred for speech pathology assessment?
- What is involved in speech pathology assessment?
- What is involved in the management of speech difficulties?
- Speech strategies
- What is involved in the management of swallowing difficulties?
- Safe swallowing strategies and oral hygiene
- The interdisciplinary team
- Questions?
5Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Speech Pathology and Multiple Sclerosis
• The demyelinating lesions caused by MS may result in spasticity, weakness,
slowness and/or incoordination of the lips, tongue, mandible, soft palate, vocal
cords and diaphragm. There can be varying degrees of motor, sensory and
cognitive impairments which can affect speech and swallowing.
• Speech and swallowing difficulties can have a negative impact on the person’s
quality of life and independence.
• Although speech and swallowing difficulties are common in MS, referral rates to
speech pathology tend to be low.
• Providing therapy for speech, swallowing and cognitive difficulties may not
improve the person to premorbid baseline, but can be helpful in re-establishing
functional daily activities and independence as much as possible.
Why is speech and having a voice important?
• Being able to read to our children
• Being able to talk on the phone
• Being able to participate in meetings at work
• Being able to have a conversation with our friends
• Being able to express an opinion or feeling
• Being able to ask for directions
6Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Normal Speech and Voice Production
Normal speech and voice production requires these processes to work together
smoothly and rapidly:
• Respiration – how we control our breathing for speech
• Phonation – how we use our vocal cords to produce voice
• Resonance – how we direct our airflow for speech
• Articulation – how we coordinate our muscles for clear speech
• Prosody – how natural our speech sounds
Speech Difficulties in MS
• Approximately 40% of people with MS may have speech problems at some
time. This may occur due to lesions (or damaged areas) in the part of the brain
responsible for muscle control of the lips, tongue, soft palate, vocal cords or
diaphragm.
• Symptoms and severity can depend on the the extent and location of the MS
lesions.
• Speech problems are more prevalent as the disease progresses.
• Speech problems are more prevalent in those with mobility issues.
7Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
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Typical speech changes in MS
• Dysarthia is a speech disorder that can occur in MS. It is caused by
neuromuscular impairment which results in disturbances in motor control of the
speech mechanism. Dysarthria can often be described as spastic, ataxic or
mixed and this based on what symptoms are present.
This can lead to problems such as
- slurred speech,
- imprecise articulation,
- reduced loudness or difficulties controlling volume,
- slower rate of speech,
- monotone or lack of intonation, “scanning speech”
- dysfluency.
People may have one, some or all of these symptoms.
These speech difficulties can often lead to difficulties being understood and
difficulties participating in conversations.
Typical speech changes in MS cont…
• Dysphonia is a difficulty with your voice and often occurs alongside dysarthria
as the same muscles, structures and neural pathways are used for both speech
and voice production.
This can lead to problems such as
- changes in voice quality .g hoarseness, harshness, breathiness
- changes in resonance e.g hypernasality.
• People with MS may also have cognitive or language difficulties e.g difficulties
finding words, difficulties with memory, concentration and problem solving.
8Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Why is swallowing important?
• Being able to have coffee with friends
• Being able to attend family celebrations and events eg birthdays, weddings,
anniversaries
• Being able to participate in family dinners
• Being able to eat and drink the same things as everyone else
Normal Swallowing
There are many different processes involved in swallowing, many without
conscious thought.
- Food enters mouth. It can take some effort to even get to this point!
- Tongue and teeth grind the food, food mixes with saliva to make a “ball” or
bolus and tongue sends it backwards (we consciously control this phase)
- Soft palate raises to block off nasal passages, tongue pushes bolus out of the
mouth and into the throat (now becomes involuntary).
- Epiglottis and vocal cords move to close the airway that leads to the lungs
(stops food going down the wrong way).
- Throat muscles squeeze together to push bolus down further towards the
stomach (oesophagus).
- Muscles in the oesophagus contract and push the food into the stomach.
- Once the bolus reaches the stomach it opens to let it in and then closes again
to prevent food coming back up (reflux).
9Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Swallowing Difficulties in MS
• The same muscles and organs involved in speech are also involved in
swallowing. 30-40% of people with MS experience difficulties with swallowing
(dysphagia) at some time. These problems can come and go and range from
mild to severe. Some people may have difficulties swallowing during a relapse
and these may resolve as they recover.
• MS can cause dysphagia if there is damage to any part of the brain that
controls swallowing or damage to the connections between the brain and the
spinal cord (the brainstem). Messages in the brainstem control movements of
the body so damage to this area can lead to a combination of symptoms
affecting muscles used in swallowing.
• People who are more physically impaired are more likely to have swallowing
difficulties due to the role the brainstem plays in mobility and swallowing.
• Swallowing difficulties are easier to manage if they are picked up early. Often
you can still enjoy a normal diet by using compensatory strategies or making
minor modifications to texture.
• Your needs and difficulties may change over time so you may need to be
reviewed regularly by the speech pathologist.
Typical swallowing changes with MS
• Slow oral preparation e.g difficulties chewing food
• Food sticking in the throat
• Difficulties initiating a swallow or increased effort in swallowing
• Coughing during and after eating and drinking, or choking on foods
• Difficulties managing saliva eg dribbling
• Dry mouth (sometimes side effect of medications) which can lead to tooth
decay, gum disease and discomfort
• Food or drink coming back up
• Excess saliva or dribbling
These difficulties if left untreated may lead to more serious difficulties e.g
aspiration pneumonia, malnutrition or dehydration.
10Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
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Other factors to consider
• Symptoms can fluctuate throughout the day and can be impacted upon by
stress, fatigue, heat and pain.
• Distracting environments and lapse in attention may also contribute to
difficulties.
• Often swallowing difficulties are overlooked until a choking episode occurs.
• Difficulties at mealtimes can be compounded by difficulties feeding self due to
hand tremor.
• Some people who experience cognitive changes may also have difficulties
swallowing due to impaired judgement eg take bites that are too big or choose
foods which are difficult to chew and swallow.
• Sensory difficulties eg lack of feeling cold or pain may also interfere with
swallowing.
When might someone be referred to speech
pathology?
• When speech problems begin interfering with everyday communication eg if the
person is being asked to repeat words, it’s harder to carry on conversations
because the speech is unclear or too quiet, if the person can’t talk fast enough
to keep up with their thoughts.
• When symptoms of dysphagia are observed e.g if the person is experiencing
frequent chest infections or losing weight, the person is taking a long time to
eat meals, the person is reporting coughing when eating, the person is
describing difficulties chewing or swallowing
11Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
What is involved in speech pathology
assessment?
The Speech Pathologist will talk to you about your goals - what is important to you,
what is working and what is not working, look at your strengths and areas of
difficulty, what are the barriers you have to living an everyday life.
Assessment of Speech:
• Discuss your concerns – can people understand you? Hear you?
• Examination of the person’s oral muscles that are used for speech (lips,
tongue, soft palate) and assessment of how you control their movement eg
range, rate, strength and coordination.
• Assessment of breath support and control
• Assessment of voice quality
• Assessment of how clear the person’s speech sounds
Speech Pathology Assessment cont…
Swallowing:
• Discuss your concerns – which foods/drinks are you having? Which ones are
difficult? Have you lost weight? Have you had chest infections?
• Examination of oral muscles used for chewing and swallowing
• Observation of person eating and drinking various foods and drinks.
• Assessment of initiation of the swallow, movements of the muscles during
swallowing and observe for signs of difficulty.
• Sometimes a speech pathologist might refer you for a videofluroscopy (also
called a modified barium swallow) if they need further information about your
swallow. This is a moving x-ray of the swallowing process and allows us to see
problems happening inside the body.
12Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
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What is involved in the management of speech
difficulties?
In mild to moderate cases, the speech pathologist may:
- Offer strategies and exercises to assist in strengthening function.
- Teach and demonstrate strategies to help make speech clearer and more
natural e.g slowing down, overarticulating, phrasing and pausing.
- Teach and demonstrate strategies/exercises targeting loudness and breath
control.
- Assist you to learn the skill of self monitoring.
- There is some emerging evidence that speech can be improved by a course of
LSVT (Lee Silverman Voice Treatment).
- In some cases, medication or Botox injections have been used to improve
voice.
In severe cases when a person is unable to communicate functionally or their
safety and wellbeing is affected, the speech pathologist may introduce
augmentative forms of communication e.g alphabet boards, iPads or other high
tech devices. This is relatively uncommon.
Speech Strategies
It is important to remember that MS can affect each person differently and no two
people are the same. These strategies may or may not be helpful to you and if
unsure, please see your speech pathologist!
• Speak loudly and slowly.
• Minimise background noise.
• Face your listener.
• Separate words with little pauses.
• Exaggerate your speech sounds/overarticulate.
• Take a deep breath before starting to speak. Let air out slowly as you speak.
• Ask your communication partners to let you know if they are having difficulty
understanding you.
• Work on your self monitoring.
• Consider aids such as voice amplifiers, alphabet boards, picture cards or
speech generating devices.
13Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
What is involved in the management of
swallowing difficulties?
The speech pathologist may:
• Offer advice regarding appropriate diet textures, diet modifications
• Suggest exercises or strategies which assist with safe swallowing
• Monitoring and managing symptoms early may prevent more serious problems
such as aspiration pneumonia, malnutrition or dehydration.
• In later stages, weakness and fatigue may lead to inadequate oral intake and
alternative feeding options may need to be considered.
Safe Swallowing strategies
It is important to remember that MS can affect each person differently and no two
people are the same. These strategies may or may not be helpful to you and if
unsure, please see your speech pathologist!
• Always sit upright for meals, preferably at the dining table.
• Take small mouthfuls of food or drink at a time.
• Chew carefully.
• Make sure you have cleared your mouth before putting any more food in.
• Concentrate. Minimise distractions while eating.
• Avoid talking whilst eating.
• If you feel yourself getting tired when eating, stop and have a rest.
• Keep your chin down rather than throwing your head back.
• Think about swallowing – bring swallow under voluntary control.
• Eat often – smaller more frequent meals may be easier than larger meals.
• Remain upright after you have eaten for at least 20 minutes.
14Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Safe swallowing strategies continued…
• Drink lots of fluids and keep hydrated.
• If you have muscle weakness, you may need to place food in the back of your
mouth.
• Choose foods carefully. Consider textures, taste, temperature of foods. Avoid
foods which are difficult eg those that are hard or have tough skins, those that
fall apart in your mouth and dry, sticky foods.
• Don’t sacrifice nutrition! Monitor your weight.
• Take your time and don’t rush your meal.
• Try to remain relaxed when eating. Anxiety can often make swallowing worse.
• Alternating mouthfuls of food and fluid can sometimes help with the sensation
of food getting stuck in the throat.
• Do an extra swallow (two swallows per mouthful of food).
• If you are needing to clear your throat, or notice coughing or a gurgly voice
during mealtimes, you may be at risk of food/drink going down the wrong way.
Oral Hygiene
Home Oral Care Program
Use toothbrushes with built up handles; consider electric toothbrushes and flossing
devices
Brush twice daily
Sit to brush and floss if standing is tiring
Floss at bedtime without fail
Allow family member or personal carer to assist with brushing or flossing
Manage tremors by wearing weighted gloves
Use products such as Biotene to help manage xerostomia
Avoid caffeine, alcohol, tobacco, use humidifier at night to help with xerostomia
Use fluoridated toothpaste
Use tongue scraper or brush to clean the tongue daily
Eat a well-balanced diet without excessive sweets
Replace toothbrush every 3-4 months
15Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
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Other important members of the team and how
we work together
• Physiotherapist – posture and trunk control
• Occupational Therapist – feeding, adaptive equipment
• Dietitian - nutrition
• Medical team eg GP, neurologist, nurses
• Support workers and carers
• Family members
References
MS Essentials – Speech and Swallowing
Dysarthria in Multiple Sclerosis – A Resource for HealthCare Professionals
(National MS Society)
Management of Speech and Swallowing in Degenerative Diseases, Yorkston,
Miller, Strand, 2004
MS Website and Fact Sheets
16Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
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Question Time
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Thank you!
MSL Services
Multiple Sclerosis Limited
17Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Free E-books
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1800 042 138
Multiple Sclerosis Limited
Get Your Act Together
• Online Tool – designed to help you better manage your multiple
sclerosis symptoms
• Focuses on some of the common symptoms of MS – emotions,
fatigue, continence, cognition, pain and heat sensitivity
• Designed for people living in the ACT but includes useful information
for all people living with MS
• Complete the tool to receive a personalized report (listing services,
resources, tips etc)
Visit www.ms.org.au and search Get Your Act Together
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18Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
The National Disability Insurance Scheme
A major change to the way disability supports and
services are funded and delivered
• Available to people who are: under 65, satisfy residency
requirements and are able to demonstrate that their disability
substantially affects daily living
• Promoting choice, control and social and economic participation
• Providing a whole-of-life approach
• It is not means tested
• Providing reasonable and necessary supports and services
• Ensuring equity of access
Multiple Sclerosis Limited
We can help you to
• understand the eligibility requirements
• understand the pathways to access the NDIS
• prepare for a planning conversation
• understand your current supports and any
unmet need
• develop your goals
Multiple Sclerosis Limited
19Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
We are an NDIS ‘Registered Provider’
MS is a registered NDIS provider in NSW, ACT, Vic and Tas. MS is approved to provide:
• Preplanning prior to your conversations (All areas)
• Support Coordination/Connection – assistance to help make your plan active (All areas)
• Short term accommodation (Vic)
• Community Participation (NSW)
Want to learn
• Exercise physiology and personal training (NSW) more?
Please call
• Specialist Continence Assessment (NSW and Vic) MS Connect
1800 042 138
• Physiotherapy and Occupational Therapy (NSW and Vic)
• Plan Management
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My Aged Care
My Aged Care is an Australian Government initiative,
website and phone line to help you find about aged care
services.
Available to people who are 65 years of age and over.
Why Contact My Aged Care?
Information
Assistance in mapping out your needs
An assessment for further supports
Phone: 1800 200 422 Free call Australia wide
20/05/2019
Website: https://www.myagedcare.gov.au
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20Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Other Services
MS Financial Assistance program
MS Financial Assistance program provides one-off funds for those facing
financial hardship. The funds can be used to purchase equipment or air
conditioners to promote quality of life and help with health related matters
MS Go for Gold Scholarships
MS Go for Gold Scholarships are open to people living with multiple
sclerosis who wish to follow a dream. The scholarships can be used to
achieve dreams such as education, travel, the arts, music, sport,
employment and lifestyle. Each scholarship is up to $3,000 in value
(depending on the circumstances, see the MS Go for Gold Application
Guidelines on our website for more information). Applications now open.
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RESEARCH
Are you part of the MS community and interested in volunteering in a study ?
We are looking for adults who:
• Have a confirmed diagnosis of Multiple Sclerosis
• Are able to walk 50m with or without a walking aid
• Are able to stand 1 minute unaided
• Have had no worsening of MS symptoms in the past 30 days
Interested, please contact Anna Butler on 0408368244 or ifims.melbourne@neura.edu.au
www.neura.edu.au/clinical-trial/step-training-ms/
21Speech and Swallowing in Multiple Sclerosis Tuesday, 21 May 2019
Webinar
Thank you
MS Connect
1800 042 138
msconnect@ms.org.au
Multiple Sclerosis Limited
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