CONTENTSIntroduction ---------------------------------------3Involving a ---------------------------------4Speech difficulties ---------------------5Alternative communication methodsSwallowing difficulties --------------6Implications for eating and drinkingAssociated --------------------------------- 10Excessive salivaXerstomia (Dry mouth)Final ------------------------------------------ 12Sources of support and --------- 13Contact --------------------------------------- 14

AUTHORAdapted from text by Lynn Curnow (SLT), with support from Gaylea Fritsch(Senior SLT, Counties Manakau) and Denise Diedrichs (Senior SLT, WestCoast).ACKNOWLEDGEMENTSThe MS Society of New Zealand would like to thank the author, our advisors,and the Information Series Review Team.MS and Speech & Swallowing published in 2006 by the Multiple SclerosisSociety of NZ with the support of the James Searle Say Foundation.Reprinted in 2007.Multiple Sclerosis Society of New Zealand IncorporatedPO Box 32124Christchurch 8147NEW ZEALANDPhoneEmailWebsite0800 MS LINE or 0800 675 [email protected] Multiple Sclerosis Society of NZ Inc 2007ISSN: 1176-4473ISBN: 978-0-908982-08-0

INTRODUCTIONMultiple sclerosis sometimes causes problems with speakingand swallowing, although not usually until someone has had thecondition for some time. Fortunately, there are treatments andtechniques available to manage these problems.A Speech and Language Therapist (SLT) is the key healthprofessional for identifying solutions to these problems.You can ask your GP to refer you to an SLT, or contact your districthealth board. An SLT will liaise with your GP or consultant to identifythe most effective approach to managing any difficulties, and maycall upon dietitians and neurologists for help as well.This booklet offers an overview of the problems with speechand swallowing in MS and helps those with these difficulties tounderstand more.You should be read this booklet in conjunction with assistance andadvice from medical professionals.MS and Speech & Swallowing Page 3

INVOLVING A PROFESSIONALIt is important to see a Speech and Language Therapist if any of thefollowing 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.As each person’s experience will be different, individual managementstrategies are essential. It is better to seek assessment sooner ratherthan later to ensure effective management.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.Other possible changes due to problems with swallowing includeweight loss, poor nutrition, dehydration and chest infections.Page 4 MS and Speech & Swallowing

SPEECH DIFFICULTIES(Dysarthria)Speech changes may begin with a slight slurring of speech, with alater weakening of the muscles of the mouth and throat. This mayaffect the clarity of speech and non-verbal communication such asfacial expressions.Additionally, you may have trouble ‘finding the right words’, as lesionson the brain affect the ways the brain finds words.A Speech and Language Therapist can help you focus on breathingtechniques, learn energy conservation and find strategies to improvethe volume and pace of your speech.ALTERNATIVE COMMUNICATION METHODSIf speech becomes too difficult, other ways of communicating maybe easier. There are many options available, such as: using penand paper; pointing to pictures or written words; or using electroniccommunication devices.If communication technologies become necessary, an SLT candiscuss which technology is most appropriate and teach the bestuse of aids that can support or substitute speech. Carers, family andfriends should be taught about these technologies as well, as theywill be communicating with you via the alternative system. They mayalso need to help with things like setting up, charging batteries andproviding low-level maintenance.MS and Speech & Swallowing Page 5

SWALLOWING DIFFICULTIES(Dysphagia)MS can damage the nerve fibres in the brain that control swallowing,or damage the nerves in the muscles that execute this function. As aresult, chewing and readying food for swallowing may become difficult.Triggering a swallow and clearing food from the mouth may becomeharder and coughing may be weaker. Some food and fluid loss frombetween the lips may also occur.It is important that you, your carers and family members are alertto the possibility of swallowing problems, so that advice regardingmanagement can be sought early.Modifications to the texture of your food and drink may increase foodintake and safety. Other factors also play a part, such as posture andthe eating environment.A Speech and Language Therapist will need to assess your situationbefore recommending specific management strategies.TIPS FOR EASIER EATING & DRINKINGChanging what you eat Water may be the most difficult item to swallow. However,use a commercial thickener for this and any other thin liquids(e.g.‘ThickenUp’ is available at most chemists.) Be wary of using ice cubes or gelatines, as they melt intoliquid before they can reach the back of the mouth. Smoothies can be an easy way to consume nutritious food.Page 6 MS and Speech & Swallowing

Chop, mince or blend meat and other coarse food andmoisten with broths, juices, gravies or soups. It may be neccesary to avoid large chunks of any solid food,as they can lodge in your airway. Try nut butters instead of individual nuts (providing yourtongue 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.For maximum enjoyment, try and vary your diet as much aspossible. 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 drinkingand 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 positionfor handling food. Take one small bite at a time. Clear your mouth before youtake the next bite. Never wash food down with liquid; moisten the food instead. Choose soft, moist foods and thick, cold liquids first, asthey are the easiest to swallow. Dry solids and thin liquidsare more difficult, and require closer attention for safeswallowing. Begin a meal with something cold, e.g. a sorbet or smoothie. Consider avoiding thin liquids altogether when fatigued.MS and Speech & Swallowing Page 7

Thus, consume thin items in the morning and thick ones in theevening. If your eating seems to slow down, pause and switch tosomething icy, as the sensation can help trigger the swallowingaction. With solids, swallow at least two times per mouthful—the firsttime to send the food down, followed by a dry swallow to clearany residual particles. With liquids, especially hot, thin liquids, swallow, then clearyour throat; then swallow again before taking more liquid. Voluntarily coughing during the meal may help to clear yourthroat.Changing your eating environment Distractions during mealtimes can make managing problemsmore difficult, especially if you have to pay particular attentionto a therapy technique. Some suggestions that may makemealtimes easier are: Quieten yourself and your surroundings during a meal. It’salways a good idea to make mealtimes a calm part of the dayand to save discussion of “hot” or contentious topics for othertimes. Limit conversations during mealtimes to yes/no questions thatcan be answered by a nod of the head. In this way, you avoidbeing 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 forintense concentration on the act of swallowing. This will makeyour meal more enjoyable.Page 8 MS and Speech & Swallowing

Taking medicationsSwallowing difficulties may affect how you take any medications. Itmay be better to take tablets whole with pureed food or smoothies rather than water. Alternatively, check with a pharmacist if it isacceptable to cut or crush the tablets, or whether the medicationcomes in a liquid form.Note: It is essential to discuss any changes to how you take yourmedications with your pharmacist.Alternative solutionsSometimes swallowing problems may mean eating becomes too difficult and alternative feeding methods (i.e. a tube) will besuggested. An Speech and Language Therapist can describe thevarious options in your case to help you and your support team makethe best decision.MS and Speech & Swallowing Page 9

ASSOCIATED DIFFICULTIESEXCESSIVE SALIVASome people may find they have more saliva in their mouths than theycan manage. This is not the result of increased saliva production, butof lip, cheek and tongue weakness and less frequent swallowing. Thiscan 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). Swallowing reminders (e.g. a timer set to ‘ding’every so often). Swallowing before talking.Also, a soft collar may help to keep your head in an upright positionand stop saliva falling out of your mouth. Another alternative is to usea suctioning machine, particularly if your swallow is very difficult to‘trigger’. However, check with a physiotherapist first.Some medication can increase saliva production, so be sure todiscuss this issue with your GP if you think this may be the case.Some patches and medications may be useful for reducing salivaproduction. However, they can reduce all other body fluids, whichcreates other problems. You should consult your GP or SLT aboutusing these medications.Page 10 MS and Speech & Swallowing

XEROSTOMIA (DRY MOUTH)Xerostomia is caused by a lack of saliva in the mouth. Salivaproduction commonly decreases as a result of dehydration, as a sideeffect of certain medications, or because the saliva glands are notfunctioning 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 bakingsoda solution) using a very soft toothbrush. Use mouthwash to cleanse and relieve dryness (e.g.dissolve 1/4 teaspoon baking soda with 1/4 teaspoon saltin warm water.). If you can swallow easily, take regular sips of fluidthroughout the day. Avoid coffee or tea, as these arediuretics. Remember to keep your mouth closed when not speakingor 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 availableon prescription from a GP.Xerostomia alters the acid balance in the mouth, and makes teethsusceptible to cavities. Thus, it is very important to stay vigilantabout oral health – including checking for ulcers and tooth decay. Ifyou use a mouthwash, it is important to avoid those with alcohol asthis can damage the lining of your mouth.Also, dry mouth can affect your lips and skin around your mouth.Use lip balm to prevent cracking, but this should be non-petroleumbased to avoid skin reactions and dryness.MS and Speech & Swallowing Page 11

FINAL THOUGHTSAs with any other MS-related issues, managing speech andswallowing impairments works best when you, your family andcarers and other support services take a positive and collaborativeapproach.Because MS brings ongoing changes to your functional abilities,regular monitoring and reviews are essential too. Sometimes this willinvolve a full reassessment, but may usually simply require informaldiscussions with you and those involved in your care.Page 12 MS and Speech & Swallowing

SOURCES OF SUPPORTAND INFORMATIONTHE MS SOCIETY OF NEW ZEALANDWe can put you in contact with a regional Field Worker. They arrangesocial groups, exercise classes, support meetings and referrals withintheir regions. Some people with MS find support groups helpful asan occasion where they can share their experiences and learn howothers deal with MS. Contact details for your nearest regional societyare located over the page.INTERNET RESOURCESThe Internet provides a great deal of information about MS, butthe quality and accuracy of the information can vary. Some usefulwebsites are:MS SocietiesMS Society of New ZealandMS International FederationAustraliaUnited KingdomUnited What Everyone Keeps Asking—about disabilitywebsite 0800 17 1981MS and Speech & Swallowing Page 13

CONTACT DETAILSTHE MS SOCIETY OF NZWe are available to help you with your queries and give youinformation and guidance.MSNZPO Box 32124 Christchurch 8147 NEW ZEALANDPhone0800 MS LINE or 0800 675 ONAL MS SOCIETIESNorthland09 438 3945Manawatu06 357 3188Auckland & North Shore09 845 5921Wellington04 388 8127Waikato07 834 4740Marlborough03 578 4058Bay of Plenty07 571 6898Nelson03 544 6386Rotorua07 346 1830West Coast03 768 7007Gisborne06 868 8842Canterbury03 366 285706 835 8542 South Canterbury03 687 7375Hawkes BayPage 14Taranaki06 751 2330Otago03 455 5894Wanganui06 345 2336Southland03 218 3975 MS and Speech & Swallowing

ISSN: 1176-4473ISBN: 978-0-908982-08-0

Multiple sclerosis sometimes causes problems with speaking and swallowing, although not usually until someone has had the condition for some time. Fortunately, there are treatments and techniques available to manage these problems. A Speech and Language Therapist (SLT) is the key health