Presentation by Melissa Loucas

1. Communication & Swallowing in
MS: what works?
Melissa Loucas
Speech & Language Therapist/Clinical
Tutor, University of Reading

2. Outline
• Characteristics
• Identifying changes
• Intervening

3. Referrals to SLT
• Hartelius (1994) 2 % (Sweden)
• Yorkston (2003) 11% (USA)
• Your teams?
– Influencing factors
• Patient characteristics
• resources

4. SPEECH CHARACTERISITCS

5. Speech changes
• Dysarthria and dysphonia
Prosody

6. What can speech sound like
Most common: mixed spastic-
ataxic (Hartelius et al 2000)
• Aesthenic voice
• Strained voice
• Disrupted prosody
• Imprecise articulation
• Slowed speech rate

7. How common are speech changes?
• Patient report
– Beukelman (1985) 23%
– Hartelius (1994) 44%
– Yorkston (2003) 40%
• Clinical findings
– Darley et al (1972) 41%
– Hartelius et al (2000) 51% prevalence
– Bauer et al (2013) 47%
• Instrumental & subclinical
– Hartelius (2000) 62%
– Feij’o (2004) 70%
– Dogan (2007) 60%

8. Predictors of dysarthria?
• Types of MS
– Progressive>RRMS severity
• MS severity (EDSS scores)
– More severe speech in higher EDSS
– But onset of changes not correlated with EDSS
• Disease duration
– Not usually independently correlated

9. Other communication changes:
Communication?
• Naming
• Word definition
• Word fluency
• Sentence repetition
• Verbal explanation &
reasoning
• High level comprehension
• Murdoch and Lethlan (2000)
• >50 normal language ability
• Self-report: 62% Klugman &
Rose (2002)
Cognition?
• memory
• attention
• speed of information
processing
• executive functions
– (Fraser & Stark, 2003; Pierson
& Griffith, 2006; Shevil &
Finlayson, 2006).
• Kujaja (1996) unimpaired
language in unimpaired cog

10. So we know that…..
• More severe speech and communication
changes more likely if other MS symptoms are
more severe
• But is this the best time to work on speech?

11. IMPACT

12. Non-linear relationships
• Impairment • Impact
– Roles? (Hartelius
1994)
– Communicative
participation
(Yorkston 2001;
Bringfelt 2006;
Yorkston 2014)
– VHI scores (Bauer et
al 2013)

13. VHI
Jacobson et al 1997
• 30 item validated questionnaire
• physical, emotional and impact on function of
voice changes

14. So we know that….
• Speech and communication changes impact
each person differently
• There are tools to look at impact
BUT
• are they routinely accessed?
• Do they capture the lived experience of
someone with MS?

15. PARTICIPATION IN LIFE

16. Restricted communicative
participation associated with
– Fatigue
– Mobility
– Bladder control
– Visual difficulties
– Cognitive /thinking difficulties
– Depression
– Social support
– Employment status
– Speech usage
– Education levels
o Qualitative e.g. Yorkston 2001; Bringfelt et al 2006,
o Quantitative Baylor et al 2010; Yorkston 2013

18. Communicative Participation
• https://www.youtube.com/watch?v=BrBoB22
HLXs
• Baylor, Yorkston et al 2013:
– Communicative Participation Item Bank
– how much your condition interferes with your
participation in that situation
– Convert scores to logit scale (0 = calibrations
sample) or T scores (50 = calibration sample)

19. So we know that….
• Communicative participation is bigger than
speech and language
• It needs an MDT approach to help
• There is a published tool to explore it

20. SLT INTERVENTIONS

21. Speech
impairment
Speaker
compensati
ons
Intelligibility
of acoustic
signal
Signal
Independent
Information
Supplemented
intelligibility
Naturalness
PARTICIPATION
Preferred
roles
Listener
attitudes
Physical &
social envir
Yorkston 2008 (conference hand out)

22. Interventions for dysarthria:
oImproving intelligibility
• Articulatory accuracy
• Rate control (Yorkston & Beukelman 1981)
• volume (Sapir et al 2001; Tjaden et al 2014)
• Feedback and Self monitoring
oSpeaker adjustments
oSpeech supplementation / augmentative
oListener adjustments

23. Principles of Motor Learning
• Usage
• Specificity
• Intensity
• Salience
• Feedback
• Blocked vs. random
e.g. Ludlow et al 2008

24. So we know that…
• There is limited evidence for effectiveness of
communication interventions in MS
• BUT
• Can operate at all/any levels of participation
• Need to consider overall MS profile

25. CASES: WHAT MIGHT
INTERVENTION LOOK LIKE?

26. • Andy:
– Self-employed businessman; ataxic dysarthria
with work & social impact
– Self-monitoring
– Rate control with articulatory accuracy for key
salient phrases
– Fatigue awareness
– Alternative communication choices (email,
answerphone)
– disclosure

27. • Stuart:
– Retired, chronic progressive MS, wheelchair
dependent
– Aesthenic voice; participation & QoL issues
– phonatory strength training; self-monitoring;
stepped progression supported through therapy
– Care-giver education
– Amplification for specific circumstances

28. • Cherry
– 18 years old; primary progressive MS; self-image
& social impact
– Prosodic break downs (elongations, intra-word
pauses); degraded voice quality; articulatory
imprecision
– Rate control; normalisation
– Visual-acoustic feedback, targeted phrases
– Disclosure to new college mates

29. Swallowing
Characteristics
Predictors
Screening
Interventions

30. SWALLOWING CHARACTERISTICS

31. Swallowing changes:

32. BUT:

33. Swallowing symptoms:
Chewing
n=184
Swallowing solids n=187
Swallowing
liquids n=182
Chokes on food
or drink n=188

34. Solids or fluids?
De Pauw et al 2002

35. Objective changes

36. De Pauw et al
2002

37. How common are swallowing
changes?
• Self-report: 33%
– Hartelius 1994
• Screening Test: 31.7 %
• Poorjavad 2010
• Clinical interview: 31 %
– Solaro 2013;
• Clinical & instrumental examination(FEES):34 %
– Calcagno 2002;
• Higher on instrumental assessment?
• Tassorelli et al 2008; Wiesner et al 2002
• Fernandes et al 2013
• Meta-analysis Guan et al 2015: 36% vs 81%

38. Predictors of dysphagia?
• Types of MS
• MS severity (EDSS scores)
• Disease duration

39. So we know that
• Dysphagia is more likely in more severe MS
• But is this the best time to work on
swallowing?

40. IDENTIFYING SWALLOW CHANGES

41. Screening Tools: DYMUS
Bergamaschi et al 2008

42. Screening Tests
• TWST- Hughes & Wiles (1996)
• TOMASS (Huckerbee, 2014 Conference)
• V-VST (Clave 2008)

43. SLT Assessment
• Clinical
o Case history
o Oro-motor exam
o Oral trials
o Meal time
observation
o QoL
• Instrumental
o VF
o FEES
https://www.youtube.com/w
atch?v=G1Enx7lHrrg

44. So we know that…
• There are a range of ways to assess
swallowing
• But
• What do your teams use to identify?
• Do you know what models your SLTs use?

45. SLT INTERVENTION

46. Compensatory Interventions
– Postural
– Speed & amount
– Food/drink consistencies
• Calcagno et al 2002
– Self-awareness
• Yorkston et al 2004
– Sensory
• Rosenbeck 1996; Bullow et al 2003

47. MDT
• Independent feeding (Langmore et al 1998)
• Cognition
• Physical abilities
• Alternative feeding (Vessey 2008)

48. Rehabilitative Interventions
• EMST
• Cough efficiency
– Chiara 2006
• Reduced Penetration-
Aspiration scores (PD)
– Troche et al 2010

49. Rehabilitative
• Electrical stimulation
– Intraluminal stimulation
– 5Hz
– 20 patients with MS &
aspiration
– Improvement in
swallowing over sham
– Restivo et al 2013

50. Botox
Restivo et al 2011:
• 14 patients with
hypertonic UES
dysfunction
• 10 unit botox
each side CP
under EMG
control
• Improvements
for 18 weeks

51. When to support?
• Emerging evidence with other conditions for
early interventions
• Most research looks at ‘permanent’ symptoms
as inclusion criteria
– How to support dysphagia ‘relapse’?

52. So we know that….
• Range of interventions to use though limited
evidence (especially in MS) embedded in MDT
• But
• Emerging evidence for early interventions in
other conditions & specialist techniques

53. Your team working:
Collaborative
intervention
Specialist
Assessment
Identification

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