Aims: Increase knowledge base of swallowing mechanics and impairment Understand SLT’s scope of practice and interventions Consider impact of interventions Gain practical advice for patients Experience for yourself texture modification

1. Management of Communication and
Swallowing Impairment in MS:
‘a view from everyday clinical
practice‘
Maggie Griffith
Principal Speech and Language Therapist.
Herts Community NHS Trust

2. Session Aims
• Increase knowledge base of swallowing
mechanics and impairment
• Understand SLT’s scope of practice and
interventions
• Consider impact of interventions
• Gain practical advice for patients
• Experience for yourself texture modification

3. Overview
• Normal swallowing mechanics
• Dysphagia in MS – prevalence and risk
• Swallow impairments in MS signs and
symptoms
• Assessment and management
• Impact of swallowing interventions
• Communication impairments
• Case Histories

4. Swallowing
• Upper aerodigestive tract has dual functions via
the same anatomic pathway
• Swallowing depends on configuration of
structures that change respiratory path to a
digestive one and then reconfigures back to a
respiratory one
• Complex process with multiple modalities
including motor, sensory and psychological
components
• More than 40 muscles involved
• Speed of swallowing 600-1000ms – healthy

6. Normal swallow

7. Normal biscuit swallow

8. Normal Liquid swallow

9. Oro-pharyngeal swallow stages
• Has voluntary and reflex elements
• Pre-oral –ability to take sip from cup or food from
spoon/ fork and transfer into front of the mouth
• Oral – formation of bolus ie gathering it up and
containing it between tongue and palate
• Includes mastication – break down food and mix with
saliva , moving it from one side to the other using the
tongue , forming cohesive bolus
• Action of soft palate and tongue prevent loss over back
of tongue prior to swallow trigger
• Transfer of bolus posteriorly towards faucial arches
where swallow reflex initiated

10. Oro-pharyngeal swallow stages 2
Tongue base moves downwards to drop bolus into the
vallecular space and palate raises to prevent reflux into
nasopharynx
Tongue base contacts posterior pharyngeal wall and both
constrict to propel bolus down towards oesophagus
Simultaneously the hyoid bone is pulled up and forwards
elevating the larynx with it
Larynx closes at 3 levels
Upper oesophageal sphincter relaxes and allows passage
of bolus – beginning of oesophageal phase
Larynx descends to normal position and airway is open

11. Neuroanatomy of Swallowing
• Motor nuclei and pattern generators for reflex
are located in the brainstem – nucleus tractus
solitarius and nucleus ambiguous- major
contribution of cranial nerves
• Cortical control in precentral and inferior
frontal gyrus and regions adjacent to sylvian
fissure and lateral precentral cortex -
required for voluntary control and some parts
of pharyngeal phase

13. Overview
• Normal swallowing mechanics
• Dysphagia in MS – prevalence and risk
• Swallow impairments in MS signs and symptoms
• Assessment and management
• Impact of swallowing interventions
• Communication impairments
• Alternative and augmentative communication
• Case Histories

14. Prevalence
• Systematic review in 2015 Guan 1 et al confirmed that
more than 1/3 of people with MS have swallowing
difficulties
• Study by Astero Constantinou at Trinity Dublin
(unpublished)
• Examined a representative sample with wide age range
and disease progression
• Mild dysphagia 46%, very small percentage had severe
problem
• Males with more than 15 yrs of disease at highest risk
had more severe dysphagia
• Being female 82% less risk of dysphagia

15. Overview
• Normal swallowing mechanics
• Dysphagia in MS – prevalence and risk
• Swallow impairments in MS signs and symptoms
• Assessment and management
• Impact of swallowing interventions
• Communication impairments
• Alternative and augmentative communication
• Case Histories

16. Impairment
• 53% oral phase impairment-prolonged
preparation of the bolus , prolonged
mastication, reduced lingual coordination,
delayed initiation of pharyngeal swallow
• 68% Pharyngeal phase impairment – reduced
tongue base retraction, poor laryngeal
elevation and closure resulting in penetration
into larynx

17. Why is it important to manage
dysphagia in Neuromuscular Disease?
• Reduce risk of respiratory infection
• Maintain nutritional and hydration needs
• Preserve quality of life and psychosocial
benefit of eating and drinking

18. Mild impairment- signs and symptoms
• I can’t drink continuously
• I can’t take large amounts
• It takes me ages to eat a meal
• Sometimes I seem to forget to swallow
• Weight loss
• Appetite loss
• I cough on food and drink occasionally

19. Severe impairment
• Can be difficult to detect if cough reflex
impaired
• Food sticking in throat
• Poor ability to chew
• Nasal regurgitation
• Frequent for chest infections
• Dehydration and malnutrition
• Frequent coughing and choking

20. What is aspiration ?
• Bolus moves below the vocal folds or glottis =
aspiration
• If bolus enters larynx but does not go below
vocal cords it is termed ‘laryngeal penetration’
• What causes aspiration pneumonia ?
• -infected saliva
• -orally ingested material
• -gastroesophageal contents

21. Aspiration

22. Aspiration

23. Aspiration Pneumonia
• Not all patients who aspirate material into
their lungs will develop aspiration pneumonia
• Strong cough can eject matter from larynx and
then even if it enters lungs it can trigger a
secondary cough
• Immune response from cells in lungs absorb
and transport foreign materials out of the
lungs
• No studies to link amount and type of aspirant
to development of pneumonia

24. Aspiration Pneumonia
• A predictive tool would make decisions
around risk feeding much easier
• Risk factors identified ( in elderly)
• - heart failure and COPD
• -multiple medications esp sedatives
• -dependence for feeding inc enteral feeding
• -poor oral hygiene
• Suctioning
• bdebound

25. Overview
• Normal swallowing mechanics
• Dysphagia in MS – prevalence and risk
• Swallow impairments in MS signs and symptoms
• Assessment and management
• Impact of swallowing interventions
• Communication impairments
• Alternative and augmentative communication
• Case Histories

26. Investigating swallow problems
• Screening :
• Swallow specific questionnaires – EAT -10
(89% sensitivity) , Sydney Swallow
Questionnaire- visual analogue scale , and
Swallowing Disturbance Scale (79.7%
sensitivity)
• Specific questionnaire for MS
• DYsphagia in Multiple Sclerosis or DYMUS
• (Bergamaschi et al 2008)(2)
• Swallow screening tests – locally agreed
• Clinical assessment :
• Referral to SLT on identification of OD ( oro-
pharyngeal dysphagia)
• Clinical (bedside =) swallow exam – only 60%
reliable at detecting aspiration
• Use of cervical auscultation – no robust
evidence to support it
• Pulse Oximetry-uses oxygen desaturation as
a possible marker of aspiration but only one
study supports its use
• Objective assessment : videofluoroscopy (
modified barium swallow ), feess-
endoscopic evaluation of swallow – mainly
looks at the pharyngeal phase
• Cough reflex testing

27. FEESS

28. FEESS- endoscopic view

29. DYMUS
• Do you have difficulties swallowing solid food (such as
• meat. bread. and the like)?
• Do you have difficulties swallowing liquid (such as water,
• milk, and the like)?
• Do you have a globus sensation in your throat during
• swallowing?
• Do you have food sticking in your throat?
• Do you cough or do you have a choking sensation after solid
• ingestion?
• Do you cough or do you have a choking sensation after
• liquid ingestion?
• Do you need to swallow more and more times before
• completely swallowing solid food?
• Do you need to cut food in small pieces before swallowing?
• Do you need to take more and more sips before completely
• swallowing liquid?
• Do you have weight loss?

30. Aims of SLT working in Dysphagia
• Unique role in assessment diagnosis and management of
OD
• Overall aims
• Detailed and accurate assessment –leading to accurate
diagnosis – this can assist with medical diagnosis
• Maximising safety with regard to reducing or preventing
aspiration
• Balancing safety with quality of life and accounting for
individual’s preferences
• Working with MDT ( esp Dietitians) to optimise Nutrition
and hydration
• Stimulating improved swallowing with oral motor/sensory
exercises, swallow techniques and positioning

31. Swallowing Interventions
• Counselling and reassurance – demystify the
swallow mechanism – explode myths eg I will
choke to death on a liquid
• Show people their videofluoroscopy study –
gives reassurance in mild cases and informed
decision making in more severe cases
• Swallow manoeuvres- designed to maximise
airway protection and optimise swallow
biomechanics

32. Swallowing Interventions
• Swallow Rehab training specific muscular
groups eg suprahyoids , tongue
• Different levels of evidence eg Shaker exercise
or chin tuck against resistance- Level A (3)
• Expiratory muscle strength training
• Electrical Stimulation (NMES ) – not endorsed
by RCSLT due to lack of quality evidence and
therefore safety not ensured

33. Swallowing safely
• Posture – optimum sitting upright with chin tucked
down
• Allow plenty of time for E and D
• Concentrate – avoid distractions
• Smaller amounts and slow pacing
• Masticate thoroughly before swallowing
• Don’t talk while E and D
• Manage fatigue – use snacks and have bigger meal
earlier in the day
• Avoid mixing liquid and food in the same mouthful

34. Texture Modification-Fluids
• Why ? Slows down transit of fluid to allow
more time to successfully coordinate
swallowing . Can prevent aspiration .
• Stage 1 syrup -should pour like single cream
• Stage 2 custard – should easily drop off spoon
but not pour
• Stage 3 pudding – stays on spoon

35. Texture modification- Food
• SLT determines safe textures of fluids and
foods for a given individual
• National descriptors of food from BDA ,
RCSLT,Nutrition Nurses, Hospital Caterers
Assoc.(4)
• B=thin puree
• C=thick puree
• D=pre-mashed E=Fork mashable

36. Use of Thickener
• 2 main types- Xanthan gum based and maize
starch
• XG mixed differently liquid added to drink rather
than the other way round
• Better compliance due to improved mouth feel ,
resistant to amylase
• Standardised dosage
• Mixing instructions are crucial – should not
increase in thickness after 1 min – if it does then
it has been mixed incorrectly

37. PEG Feeding Decisions
• Ethical , moral and legal dilemmas- ‘right
choice vs prudence’
• Human right to nutrition
• Mental Capacity – can be very difficult to
establish with severe communication disability
• Risks of PEG insertion – morbidity and
mortality
• Provision of information essential
• Need to be sensitive to diversity of opinions

38. Overview
• Normal swallowing mechanics
• Dysphagia in MS – prevalence and risk
• Swallow impairments in MS signs and symptoms
• Assessment and management
• Impact of swallowing interventions
• Communication impairments
• Alternative and augmentative communication
• Case Histories

39. Impact of altered eating : QoL and
psychological burden
• Definition of altered eating by Duika Burgess
Watson – reasearch at Durham University funded
by NIHR(4)
• ‘any change of state of physical, emotional and
social interactions around food that has a
negative impact on health and well being ‘
• Accounts of food hedonics ‘ie flavour and texture’
very limited – the science of deliciousness
• V ltd research into how to improve appetite

40. Flavour
• Flavour comes from combined sensory input :
smell , trigeminal nerve stimulation, temperature ,
texture, visual cues
Olfaction triggers powerful memories( retronasal
olfaction stimulates the olfactory bulb associated
with emotional memory) – research has shown that
triggering smell memories can stimulate appetite
even if they are not food smells

41. Consequences of altered eating
• Is putting someone on a modified diet a form
of sensory deprivation ?
• Eating together strengthens family bonds-
communal aspect of food
• Need to balance attention to physical
anatomical and functional aspect with
cognitive, cultural /social and emotional
aspects of dysphagia

42. PEG Feeding Decisions
• Ethical , moral and legal dilemmas
• Human right to nutrition
• Mental Capacity – can be very difficult to
establish with severe communication disability
• Risks of PEG insertion – morbidity and
mortality
• Provision of information essential
• Need to be sensitive to diversity of opinions

43. Overview
• Normal swallowing mechanics
• Dysphagia in MS – prevalence and risk
• Swallow impairments in MS signs and symptoms
• Assessment and management
• Impact of swallowing interventions
• Communication impairments
• Alternative and augmentative communication
• Case Histories

44. How is speech affected ?
• Mechanics of speech production
• Respiration
• Voice ( phonation)
• Resonance
• Articulation
• Prosody-loudness, pitch patterns ( intonation)
• Signals meaning and emotions

45. How it sounds
• Spastic –ataxic dysarthria ( slurred speech )
• Voice sounds weak and strained ( absent in
severe )
• Pitch v variable
• Articulation imprecise
• Slow rate of speech

46. Communication Changes
Language
• Naming
• Word fluency
• Verbal explanation and
reasoning
• High level comprehension
• Study by Klugman and Rose
2002 62% self reported
these changes
Cognitive factors
• Memory
• Info processing speed
• concentration

47. Communicative Participation
• Taking part in life situations
• Affected by more than just speech and
language impairment eg fatigue, ataxia and
spasticity, and vision
• Baylor , Yorkston et al 2013 – Communicative
Participation Item Bank – tries to combine
qualitative and quantitative information. Takes
account of experience of people with the
communication disorder

48. Interventions
• Improving compensation even when
intelligibilty is 100%
• Voice quality and prosodic aspects such as
intonation and loudness
• Once speech is severely affected it becomes
very difficult to modify and use of AAC can be
introduced
• Goals will depend on individual

49. Overview
• Normal swallowing mechanics
• Dysphagia in MS – prevalence and risk
• Swallow impairments in MS signs and symptoms
• Assessment and management
• Impact of swallowing interventions
• Communication impairments
• Alternative and augmentative communication
• Case Examples

50. Case Example 1
• AB 45 year old
• Referral stated ‘coughing and choking on food
and fluids daily’ No history of chest infections
• Background secondary MS since 18 yrs –
ataxia onset a t 40yrs
• Patient reported symptoms – liquids go down
the wrong way , choking on saliva, no
problems with food

51. Case Example 1
• Clinical swallow assessment : NAD
• No able to detect v subtle problems with
bolus control
• Intervention: Reassurance and safety
instructions -specifically chin tuck
• Referred for VF to get objective view of
baseline , and refine any therapeutic
interventions. VF was within limits of normal

52. Case Example 1
• Review – c/o speech feels out of control and
slurred and after a while talking ‘hearing dulls’
• Features noted on informal assessment
• -100% intelligibility
• -Articulation speed slows on multisyllabic words
• -reduced pitch variation
• Effortful and incoordinated breathing pattern in
speech
• Mild ataxic dysarthrophonia

53. Therapy Aims
• Reduce level of neck tension to allow greater
control of speech mechanism
• Improve coordination of breathing thereby
reducing vocal tract tension
• Methods; neck and shoulder stretches with
relaxation; strap muscle stretches ,hierarchical
approach to coordination of phonation and
respiration ( Accent Method )

54. • Mixed outcome for communication:
• Understood and able to practise and apply
techniques- positive about feeling able to
control speech better
• Not talking much – issues with depression and
high cognitive demand of speaking
• Agreed discharge and ability to self refer

55. Case example 2 Maureen
• 60yrs MS since 2004 – no details on medical
history
• Referred to SLT ‘ frequent coughing on food
and saliva
• April2014 Clinical bedside eval – inconclusive
as absent cough and already chesty referred
for VF
• Vf- not done till july as had chest infection

56. Case example 2 Maureen
• VF- prolonged oral prep
• delayed swallow trigger
• poor clearance of pharynx
• trace silent aspiration of thin liquids
• Recommendations: stage 1 , puree , safe
swallow instructions
• Outcome: declined thickener, having puree
• 1 chest infection in a year

57. Maureen -Communication
• Requested communication review as having trouble
making her needs known to carers and husband
• Ax : severe dysarthrophonia, output v slow and
effortful , occasional words are intelligible only
• Consider low tech communication aid – use of low tech
essential as precursor to high tech
• Alphabet chart – able to point but tremor is a problem,
visual neglect, head support
• Agreed on combination of pictures/letters /words
tailored to her needs
• Complex high tech AAC can be provided by regional
specialist centres eg Cambridge CASEE

58. Case example 3 Helen
• 48 yr old Primary Progressive MS
• Lived with children and twice daily carers
• Ist contact July 2015: In-patient admission with
chest infection – medical discussion re CAP vs asp
pneumonia
• Ref to SLT ‘mild swallowing problem’
• Bedside evaluation: mild dysarthria, parameters
of OP sw not abnormal ,
• Recs: Normal fluids and diet

59. Case 3 Helen
• Nov 2015- IP admission frequent RTIs and UTIs
• SLT r/v poor voluntary cough, mild to mod dysarthria, bedside eval
not sufficient to determine aspiration , referred for VF
• VF Jan 2016 : reduced oral control, 1/3 silent trace aspiration on
thin, delayed reflex
• Stage 1 and soft diet
• Feb2016 : Readmitted with L basal consolidation, H declined
thickener and wanted to see VF
• March 2016: OP appt showed VF – declined again
• Jul 2016 adm with SOB , sats 80%, had recently choked on chicken ,
s/b physio – used cough assist improved sats
• Rec: stage 1 and soft diet
• Sept 2016: OP , on stage 1 , no chest infection for 1/12 , putting on
wt , in NH

60. References
• 1.Guan XL , Wang H , Huang HS , Meng L . Prevalence of dysphagia
in Multiple sclerosis: a systematic review and meta-analysis Neurol
Sci 2015 May 36(5) 671-81
• 2.Bergamaschi, R ,Crivelli P et al J Neurol Sci 2008 Jun The DYMUS
Questionnaire for the assessment of dysphagia in multiple sclerosis
• 3.Speyer R, et al Effects of therapy in oropharyngeal dysphagia by
SLTs : a systematic review Dysphagia 2010:25(1)
40-65
• 4.NPSA,RCSLT,BDA, National Nurses Nutrition Group, Hospital
Caterers Assocation. Dysphagia Diet Descriptors 2011
• 5.Duika L Burgess Watson, Lewis et al Altered Eating: a definition
and framework for assessment and intervention

61. Useful Publications/ resources
• MS society swallowing and Speech difficulties
leaflets
• https://www.mssociety.org.uk/ms-
resources/swallowing-difficulties-booklet
• Communication aid provision:
• Guidance for Commissioning AAC Services and
Equipment NHS England March 2016
• http://www.communicationmatters.org.uk/pa
ge/aac-commissioning-england