Speech & Swallowing

People with MS often have trouble with swallowing (dysphagia) and speech (dysarthria) due to the nerves in the brain and spinal cord that make these tasks happen becoming damaged. These difficulties are more common in those with advanced MS, but can occur at any stage. Speech and swallowing problems also vary in severity but treatments and techniques can help you improve speech and make swallowing easier.

It is important to discuss any concerns with your health professional as food or liquids in the lungs can cause pneumonia or abscesses, or a person may be at risk for malnutrition or dehydration if food is not reaching the stomach.­ A person can also inhale small amounts of food or liquids without being aware of it. This is called silent aspiration.

What difficulties might be experienced?

You may notice:

• Possible changes in swallowing
• Coughing when eating or drinking
• Food sticking in the throat or mouth
• Difficulty swallowing medications
• Sniffing or sneezing during meals
• Food or drink travelling up into the nasal passages
• Reduced consumption of food or liquid
• Time required to finish meals notably increases
• Difficulty controlling saliva

As each person’s experience will be different, individual management strategies are essential. It is better to seek assessment sooner rather than later, to ensure effective management. It is important to see a Speech and Language Therapist if any of the following occur:

• Possible changes in speech
• Slurred speech
• Overly nasal speech
• Voice changes (e.g. reduced volume or poor pitch control)
• Experiencing fatigue after talking
• Problems with vocabulary (“finding the words”)
• Speech slows down, or requires more effort

Early intervention is vital as problems with swallowing can also result in weight loss, poor nutrition, dehydration and chest infections.

MS and Speech

Difficulties with speech are fairly common with MS. Speech changes may begin with a slight slurring of speech, with a later weakening of the muscles of the mouth and throat. There are many areas in the brain, and brainstem, that control speech patters and when lesions appear and damage certain areas changes to speech patterns occur. Changes may stem from mild to severe making it difficult for people to speak and be understood.  Not only can clarity of speech be impacted but also and non-verbal communication such as facial expressions. Additionally, you may have trouble ‘finding the right words’, as lesions on the brain affect the ways the brain finds words. A Speech and Language Therapist can help you focus on breathing techniques, learn energy conservation and find strategies to improve the volume and pace of your speech. Dysarthrias are commonly associated with other symptoms caused by lesions in the brainstem which may include tremor, head shaking or incoordination.

Common issues that occur:

• Scanning speech: the normal “melody” or speech pattern is disrupted, with abnormally long pauses between words or individual syllables of words.
• Slurring: a common occurrence resulting from the weakness and/or incoordination of the muscles of the tongue, lips, cheeks and mouth.
• Nasal speech: the persons speech sounds like having a cold or nasal obstruction.

Alternative communication methods
If speech becomes too difficult, other ways of communicating may be easier. There are many options available, such as: using pen and paper; pointing to pictures or written words; or using electronic communication devices. If communication technologies become necessary, a Speech and Language Therapist can discuss which technology is most appropriate and teach the best use of aids that can support or substitute speech. Your GP should be able to refer you for a review. Carers, family and friends should be taught about these technologies as well, as they will be communicating with you via the alternative system.

MS and Swallowing

MS can damage the nerve fibres in the brain that control swallowing, or damage the nerves in the muscles that execute this function. As a result, chewing and readying food for swallowing may become difficult. Triggering a swallow and clearing food from the mouth may become harder and coughing may be weaker. Some food and fluid loss from between the lips may also occur. It is important that you, your carers and family members are alert to the possibility of swallowing problems, so that advice regarding management can be sought early. Modifications to the texture of your food and drink may increase food intake and safety. Other factors also play a part, such as posture and the eating environment. A Speech and Language Therapist will need to assess your situation before recommending specific management strategies.

Changing what you eat

• Water may be the most difficult item to swallow. However, use a commercial thickener for this and any other thin liquids, Check with your local chemists for availability and recommendations.
• Be wary of using ice cubes or gelatines, as they melt into liquid before they can reach the back of the mouth.
• Smoothies can be an easy way to consume nutritious food.
• Chop, mince or blend meat and other coarse food and moisten with broths, juices, gravies or soups.
• It may be necessary to avoid large chunks of any solid food, as they can lodge in your airway.
• Try nut butters instead of individual nuts (providing your tongue is able to move the sticky food around your mouth).
• Try food that is warmer or colder than the body.
• Add herbs, stocks and sauces to food that may be bland.
• Chew each mouthful at least 30 times, slowing down your eating, breathe, think about how it tastes and feels.

For maximum enjoyment, try and vary your diet as much as possible. A dietician can match food preferences with adequate nutrition and the textures required for safe swallowing.

Changing how you eat

• Sit upright and lean slightly forward when eating or drinking, and stay upright for half an hour after finishing.
• Keep the chin parallel with the table or slightly tucked down, as this ensures the mouth and throat are in a good position for handling food.
• Take one small bit at a time. Clear your mouth before your next bite.
• Never wash food down with liquid; moisten the food instead.
• Choose soft, moist foods and thick, cold liquids first, as they are the easiest to swallow. Dry solids and thin liquids are more difficult, and require closer attention for safe swallowing.
• Begin a meal with something cold, e.g. a sorbet or smoothie.
• Consider avoiding thin liquids altogether when fatigued. Thus, consume thin items in the morning and thick ones in the evening.
• If your eating seems to slow down, pause and switch to something icy, as the sensation can help trigger the swallowing action.
• With solids, swallow at least two times per mouthful-the first time to send the food down, followed by a dry swallow to clear any residual particles.
• With liquids, especially hot, thin liquids, swallow, then clear your throat, then swallow again before taking more liquid.
• Voluntarily coughing during the meal may help to clear your throat.

Changing the eating environment

Distractions during mealtimes can make managing problems more difficult, especially if you have to pay particular attention to a therapy technique.

Some suggestions that may make mealtimes easier are:

• Quieten your self and your surroundings during a meal. It’s always a good idea to make mealtimes a calm part of the day and to save discussion of “hot” or contentious topics for other times.
• Limit conversations during mealtimes to yes/no questions that can be answered by a nod of the head. In this way, you avoid being rushed to finish your mouthful and respond.
• If you like to watch television, or if eating at a social gathering, try to eat food with ‘safe’ meal textures to reduce the need for intense concentration on the act of swallowing. This will make your meal more enjoyable.

Taking medications
Swallowing difficulties may affect how you take any medications. It may be better to take tablets whole with pureed food or smoothies rather than water. Alternatively, check with a pharmacist if it is acceptable to cut or crush the tablets, or whether the medication comes in liquid form. Note: It is essential to discuss any changes to how you take your medications with your pharmacist.

You should be aware that:

• Some medications increase saliva production, so be sure to discuss this issue with your GP if you think this may be the case.
• Some patches and medications may be useful for reducing saliva production. However, they can reduce all other body fluids, which creates other problems. You should consult your GP and SLT about using these medications.

Alternative solutions
Sometimes swallowing problems may mean eating becomes too difficult and alternative feeding methods (i.e. a tube) will be suggested. An Speech and Language Therapist can describe the various options in your case to help you and your support team make the best decision.

Associated Difficulties – Excessive Saliva
Some people may find they have more saliva in their mouths than they can manage. This is not the result of increased saliva production, but of lip, cheek and tongue weakness and less frequent swallowing. This can cause drooling.

The following strategies have been found to be useful:

• Sealing lips firmly
• Swallowing more frequently
• Sipping drinks regularly
• Sucking sugar-free lozenges (if your SLT says it is safe to do so)
• Swallowing reminders (e.g. a timer set to ‘ding’ every so often)
• Swallowing before talking

Other potential remedies include:

• Soft collar: may help to keep the head in an upright position and stop saliva falling out of the mouth.
• Suctioning machine: particularly if the swallow is very difficult to ‘trigger’. However, check with a physiotherapist first.

Xerostomia (dry mouth)
Xerostomia is caused by a lack of saliva in the mouth. Saliva production commonly decreases as a result of dehydration, as a side effect of certain medications, or because the saliva glands are not functioning correctly. It is uncomfortable and can make chewing, swallowing and speaking difficult.

Some strategies for coping with a dry mouth include:

• Clean your mouth and tongue with toothpaste (or a baking soda solution) on a very soft toothbrush.
• Use mouthwash to cleanse and relieve dryness (e.g. dissolve 1/4 teaspoon baking soda with 1/4 teaspoon salt in warm water.).
• If able to swallow easily, take regular sips of fluid throughout the day. Avoid coffee or tea, as these are diuretics.
• Remember to keep your mouth closed when not speaking or eating as breathing through the mouth dries it out.
• Use over-the-counter medications, such as artificial saliva, or saliva stimulants. There are also medications available on prescription from a GP.

Xerostomia alters the acid balance in the mouth, and makes teeth susceptible to cavities. Thus, it is very important to stay vigilant about oral health – including checking for ulcers and tooth decay. If using a mouthwash, it is important to avoid those with alcohol as this can damage the lining of the mouth. Also, dry mouth can affect the lips and skin around the mouth. Lip balm can be used to prevent cracking, but should be nonpetroleum based to avoid skin reactions and dryness.

Final Thoughts

Because MS brings ongoing changes to functional abilities, regular monitoring and reviews are essential. Sometimes this will involve full reassessment, but may simply require informal discussions with you and those involved in your care. As with any other MS-related issues, managing speech and swallowing impairments works best when you, your family and carers, and other support services take a positive and collaborative approach.

For more information please view our MSNZ Information Series booklet: Multiple Sclerosis Speech and Swallowing