DIAGNOSIS AND MANAGEMENT OF SPEECH AND SWALLOWING IMPAIRMENTS IN MULTIPLE SCLEROSIS

1. Katherine Parsons, MA, CCC-SLP VAMC Washington, DC DIAGNOSIS AND MANAGEMENT OF SPEECH AND SWALLOWING IMPAIRMENTS IN MULTIPLE SCLEROSIS

2. BACKGROUND INFORMATION chronic degenerative disease of the CNS linked to the autoimmune system Environmental trigger (e.g., a virus) in a genetically susceptible individual

3. DEMOGRAPHICS OF MS 5-10% of organic neurological disease The most common progressive neurological disorder of young adults Median age of onset is 30 years (unusual before 20 and after 60) More common in women

4. Demyelinization and Glial Proliferation Define axon – it remains in tact Define demyelinization – destruction of myelin sheaths Death of oligodendrocytes (cells that produce myelin) Glia proliferation Myelin sheath degenerates Microglia cells transport broken up myelin to the regional perivascular space Formation of dense plaques or patches of demelinization at haphazard sites in the white matter of brain or spinal cord

5. SYMPTOMS Motor weakness Fatigue Parasthesias Oculovisual disturbances Gait dysfunction Speech and swallowing deficits Impairment of bowel and bladder

6. SUBTYPES OF MS Relapsing-remitting MS (RR MS) Secondary Progressive MS (SP MS) Progressive Relapsing MS (PR MS) Primary Progressive MS (PP MS)

7. CLINICAL COURSE OF MS Initial intermittent neurological relapses and remissions Followed by permanent neurological deficits Enter progressive phase of the disease Late stage symptoms: nystagmus, scanning speech, intention tremor

8. Speech is a highly complex process which depends on finely controlled and coordinated muscles Impairment can affect not only communication but also psychosocial status SPEECH

10. Cerebellar involvement • Basal Ganglia involvement • Brainstem involvement- • Cranial nerves: • V-Trigeminal • VII-Facial • IX-Glossopharyngeal • XII-Hypoglossal Neurological substrates of speech

11. slurred, or imprecise speech (articulation) low volume or weak voice due to respiration problems (respiration) difficulty with resonance and pitch control abnormally long pauses between words or syllables of words – this is called ‘scanned speech’ Impairments with MS

12. Respiratory control Strengthen muscles Overarticulation and slowed speech rate Emphasize intonation patterns ‘Speech conservation’ i.e. make the most important points first when energy levels are highest Avoiding competing with background noise Management of Dysarthria

13. V: muscles of mastication (masseter, buccinator), velum, mylohyoid, anterior belly of digastric muscles VII: lips, post. belly of digastric muscles,stylohyoid, taste for the anterior tongue IX: sensation and motor functions for tongue and pharynx CRANIAL NERVES INVOLVED IN SWALLOWING

14. X: Pharyngeal branch- sensation and motor functions for velum and pharynx Superior laryngeal branch-motor functions for cricothyroid, part of inferior pharyngeal constrictor + sensation for base of tongue and supraglottic area of larynx Recurrent laryngeal-intrinsic laryngeal muscles + muscles of trachea, esophagus CRANIAL NERVES INVOLVED IN SWALLOWING

15. XI: cranial branch-fibers to pharyngeal and superior branches of X + uvula and levator veli palatini spinal branch: sternocleidomastoid and trapezius XII: external and internal muscles of tongue CRANIAL NERVES INVOLVED IN SWALLOWING

16. Difficulty chewing Coughing while eating or immediately after Excessive saliva or drooling Choking Food sticking in the throat A weak, soft voice Difficulty manipulating food in mouth Aspiration vomiting Potential swallowing problems

17. Lesions in the part of the brain that controls swallowing (primarily in the brainstem) Lesions in the nerves that provide feedback to the brain Dry mouth (possibly medication induced) causes of swallowing problems

18. Patient Caregivers Nursing, including CNAs Speech-language pathologist Nutritionist Occupational therapist Physician DYSPHAGIA TEAM

19. Different consistencies Oral transit: speed, bolus manipulation Swallowing initiation Laryngeal rise Vocal quality: wet/dry, throat clearing, cough, choke Multiple swallows BEDSIDE SWALLOWING EVALUATION

20. Oral preparatory Oral voluntary Pharyngeal Esophageal 4 PHASES OF SWALLOWING

22. Labial seal Lingual movement Buccal muscles Sensory feedback Consistency/size of bolus ORAL PREPARATORY PHASE

23. Tongue begins posterior propulsion of bolus Bolus squeezes against hard palate Labial seal ensures against leakage and maintains pressure Tension in buccal muscles prevent particles separating from main bolus < 1 sec. transit ORAL PHASE

25. Elevation and retraction of velum with closure of velopharyngeal port Initiation of pharyngeal peristalsis Elevation and closure of larynx: epiglottis, false vocal folds, true vocal folds Relaxation of cricopharyngeal sphincter <1sec. for transit PHARYNGEAL PHASE

26. ORAL AND PHARYNGEAL PHASES

27. PHARYNGEAL/ESOPHAGEAL PHASES

28. Peristaltic wave in pharynx continues into esophagus Cricopharyngeal sphincter opens to allow bolus transit 8-20 secs. for transit to esophageogastric sphincter ESOPHAGEAL PHASE

29. Changes in Swallowing with MS: Sensation changes Muscles weaken and lose range of motion Mastication muscles lose tension, strength Lingual mass decreases leading to decreased pressure and speed so swallow initiation delayed because of a longer oral transit Epiglottis slower in closing off airway Cricopharyngeus muscle and pharyngeal constrictors weaken so there is more residual left in the pharynx after a swallow

30. Flexible fiberoptic tube threaded thru nose Direct visualization of structures Can be completed at bedside Results can be recorded Disadvantage: Actual swallow NOT visualized FEES: FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING

31. “Gold standard” Different consistencies Radiographic study-direct visualization Assess effectiveness of various positions Assess effectiveness of various techniques MODIFIED BARIUM SWALLOW STUDY

32. Treatment of Swallowing Disorders Therapies designed to heighten sensory input (i.e., thermal tactile stimulation) to improve triggering of the pharyngeal swallow Compensatory strategies (i.e., posture and sensory enhancements) are important for persons with cognitive impairments such as dementia The Heimlich Maneuver

33. Sit upright Eat slowly Don’t talk with food in mouth Thicken liquids (if indicated) Avoid high choking foods Eat small meals more frequently (2/2 fatigue) Alternate liquids and solids Use postural strategies (if indicated) Take a symptom inventory Creating a safe eating environment

34. OTHER DEFICITS: COGNITIVE IMPAIRMENTS Between 34 and 65% of people with MS have some sort of cognitive impairment Dysfunction correlates with more permanent destruction of brain tissue; worse in people with progressive forms of MS Common cognitive problems: Problems with abstract conceptualization Short-term memory deficits Attention difficulties Slower speed of information processing

35. Depression and MS have a complicated relationship One can aggravate the other Depression has many of the same symptoms as MS Many people with MS initially get misdiagnoses as depressed Also, many people with confirmed MS have depression that goes undiagnosed OTHER DEFICITS: PSYCHOSOCIAL

36. CAREGIVER EDUCATION