This document provides an overview of communication and swallowing issues in multiple sclerosis (MS), including characteristics, identification, and interventions. It summarizes that speech and swallowing changes are common in MS, affecting over 30% of patients, and are more likely with increased disease severity and progression. A variety of screening tools and assessments are available to identify speech and swallowing issues. Interventions can target impairment, compensation, and participation, and involve speech language therapy as well as a multidisciplinary approach. Early intervention may provide benefits, though evidence for treatments is still limited.

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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