Welcome to today's Webinar: Speech and Swallowing in Multiple

 
 
Welcome to today's Webinar: Speech and Swallowing in Multiple
Speech and Swallowing in Multiple Sclerosis                        Tuesday, 21 May 2019
Webinar




                     Welcome to today’s Webinar:

                Speech and Swallowing in Multiple
                           Sclerosis
                           Your Presenter is Kate Morris

                      Your Facilitator is Ms Nicola Graham




           Handouts



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             This contains a copy of the slides presented
             today.




                                                            Multiple Sclerosis Limited




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Welcome to today's Webinar: Speech and Swallowing in Multiple
Speech and Swallowing in Multiple Sclerosis                                                           Tuesday, 21 May 2019
Webinar




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Welcome to today's Webinar: Speech and Swallowing in Multiple
Speech and Swallowing in Multiple Sclerosis                Tuesday, 21 May 2019
Webinar




           Acknowledgement


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                                                    Multiple Sclerosis Limited




                    Welcome to today’s Webinar:

                Speech and Swallowing in Multiple
                           Sclerosis
                        Your Presenter is Kate Morris

                     Your Facilitator is Ms Nicola Graham




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Welcome to today's Webinar: Speech and Swallowing in Multiple
Speech and Swallowing in Multiple Sclerosis                                Tuesday, 21 May 2019
Webinar




           Introduction to Presenter


                                  Kate Morris

                                  •   Graduated 1999 from University of Newcastle.
                                  •   19 years working in a variety of settings across
                                      NSW including private/public hospitals, aged car
                                      facilities, community, home, schools.
                                  •   Strong background working with adults with
                                      neurological conditions.
                                  •   Currently at Everyday Independence where I
                                      continue to work with this caseload. Team leader of
                                      interdisciplinary team including speech
                                      pathologists, physiotherapists and occupational
                                      therapists.




                                                                    Multiple Sclerosis Limited




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             This presentation has been prepared and is
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             The views presented are not necessarily the views
               of Multiple Sclerosis Limited.

             Individuals are encouraged to seek further advice
               regarding the relevance of the information
               presented for their situation.
                                                                    Multiple Sclerosis Limited




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Welcome to today's Webinar: Speech and Swallowing in Multiple
Speech and Swallowing in Multiple Sclerosis                                           Tuesday, 21 May 2019
Webinar




               Multiple Sclerosis – Speech, Swallowing and the Role of
               the Speech Pathologist

               Click to edit Master title style




               Kate Morris
               Speech Pathologist/Team Leader (Newcastle/Hunter New England Region)
               Everyday Independence
               katem@everydayind.com.au
               May 2019




              Outline

               -   Speech Pathology and MS
               -   Why is speech/voice important?
               -   Normal speech and voice production
               -   Speech difficulties in MS and typical speech changes
               -   Why is swallowing important?
               -   Swallowing difficulties in MS and typical swallowing changes
               -   When might someone be referred for speech pathology assessment?
               -   What is involved in speech pathology assessment?
               -   What is involved in the management of speech difficulties?
               -   Speech strategies
               -   What is involved in the management of swallowing difficulties?
               -   Safe swallowing strategies and oral hygiene
               -   The interdisciplinary team
               -   Questions?




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Speech and Swallowing in Multiple Sclerosis                                              Tuesday, 21 May 2019
Webinar




              Speech Pathology and Multiple Sclerosis

               •   The demyelinating lesions caused by MS may result in spasticity, weakness,
                   slowness and/or incoordination of the lips, tongue, mandible, soft palate, vocal
                   cords and diaphragm. There can be varying degrees of motor, sensory and
                   cognitive impairments which can affect speech and swallowing.

               •   Speech and swallowing difficulties can have a negative impact on the person’s
                   quality of life and independence.

               •   Although speech and swallowing difficulties are common in MS, referral rates to
                   speech pathology tend to be low.

               •   Providing therapy for speech, swallowing and cognitive difficulties may not
                   improve the person to premorbid baseline, but can be helpful in re-establishing
                   functional daily activities and independence as much as possible.




              Why is speech and having a voice important?

               •   Being able to read to our children
               •   Being able to talk on the phone
               •   Being able to participate in meetings at work
               •   Being able to have a conversation with our friends
               •   Being able to express an opinion or feeling
               •   Being able to ask for directions




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Speech and Swallowing in Multiple Sclerosis                                             Tuesday, 21 May 2019
Webinar




              Normal Speech and Voice Production

               Normal speech and voice production requires these processes to work together
               smoothly and rapidly:

               •   Respiration – how we control our breathing for speech

               •   Phonation – how we use our vocal cords to produce voice

               •   Resonance – how we direct our airflow for speech

               •   Articulation – how we coordinate our muscles for clear speech

               •   Prosody – how natural our speech sounds




              Speech Difficulties in MS

               •   Approximately 40% of people with MS may have speech problems at some
                   time. This may occur due to lesions (or damaged areas) in the part of the brain
                   responsible for muscle control of the lips, tongue, soft palate, vocal cords or
                   diaphragm.

               •   Symptoms and severity can depend on the the extent and location of the MS
                   lesions.

               •   Speech problems are more prevalent as the disease progresses.

               •   Speech problems are more prevalent in those with mobility issues.




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Speech and Swallowing in Multiple Sclerosis                                               Tuesday, 21 May 2019
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              Typical speech changes in MS

               •   Dysarthia is a speech disorder that can occur in MS. It is caused by
                   neuromuscular impairment which results in disturbances in motor control of the
                   speech mechanism. Dysarthria can often be described as spastic, ataxic or
                   mixed and this based on what symptoms are present.

               This can lead to problems such as
               - slurred speech,
               - imprecise articulation,
               - reduced loudness or difficulties controlling volume,
               - slower rate of speech,
               - monotone or lack of intonation, “scanning speech”
               - dysfluency.

               People may have one, some or all of these symptoms.
               These speech difficulties can often lead to difficulties being understood and
               difficulties participating in conversations.




              Typical speech changes in MS cont…

               •   Dysphonia is a difficulty with your voice and often occurs alongside dysarthria
                   as the same muscles, structures and neural pathways are used for both speech
                   and voice production.

               This can lead to problems such as
               - changes in voice quality .g hoarseness, harshness, breathiness
               - changes in resonance e.g hypernasality.

               •   People with MS may also have cognitive or language difficulties e.g difficulties
                   finding words, difficulties with memory, concentration and problem solving.




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Speech and Swallowing in Multiple Sclerosis                                             Tuesday, 21 May 2019
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              Why is swallowing important?

               •   Being able to have coffee with friends
               •   Being able to attend family celebrations and events eg birthdays, weddings,
                   anniversaries
               •   Being able to participate in family dinners
               •   Being able to eat and drink the same things as everyone else




              Normal Swallowing

               There are many different processes involved in swallowing, many without
               conscious thought.

               -   Food enters mouth. It can take some effort to even get to this point!
               -   Tongue and teeth grind the food, food mixes with saliva to make a “ball” or
                   bolus and tongue sends it backwards (we consciously control this phase)
               -   Soft palate raises to block off nasal passages, tongue pushes bolus out of the
                   mouth and into the throat (now becomes involuntary).
               -   Epiglottis and vocal cords move to close the airway that leads to the lungs
                   (stops food going down the wrong way).
               -   Throat muscles squeeze together to push bolus down further towards the
                   stomach (oesophagus).
               -   Muscles in the oesophagus contract and push the food into the stomach.
               -   Once the bolus reaches the stomach it opens to let it in and then closes again
                   to prevent food coming back up (reflux).




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Speech and Swallowing in Multiple Sclerosis                                                 Tuesday, 21 May 2019
Webinar




              Swallowing Difficulties in MS

               •   The same muscles and organs involved in speech are also involved in
                   swallowing. 30-40% of people with MS experience difficulties with swallowing
                   (dysphagia) at some time. These problems can come and go and range from
                   mild to severe. Some people may have difficulties swallowing during a relapse
                   and these may resolve as they recover.
               •   MS can cause dysphagia if there is damage to any part of the brain that
                   controls swallowing or damage to the connections between the brain and the
                   spinal cord (the brainstem). Messages in the brainstem control movements of
                   the body so damage to this area can lead to a combination of symptoms
                   affecting muscles used in swallowing.
               •   People who are more physically impaired are more likely to have swallowing
                   difficulties due to the role the brainstem plays in mobility and swallowing.
               •   Swallowing difficulties are easier to manage if they are picked up early. Often
                   you can still enjoy a normal diet by using compensatory strategies or making
                   minor modifications to texture.
               •   Your needs and difficulties may change over time so you may need to be
                   reviewed regularly by the speech pathologist.




              Typical swallowing changes with MS

               •   Slow oral preparation e.g difficulties chewing food
               •   Food sticking in the throat
               •   Difficulties initiating a swallow or increased effort in swallowing
               •   Coughing during and after eating and drinking, or choking on foods
               •   Difficulties managing saliva eg dribbling
               •   Dry mouth (sometimes side effect of medications) which can lead to tooth
                   decay, gum disease and discomfort
               •   Food or drink coming back up
               •   Excess saliva or dribbling

               These difficulties if left untreated may lead to more serious difficulties e.g
               aspiration pneumonia, malnutrition or dehydration.




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Speech and Swallowing in Multiple Sclerosis                                               Tuesday, 21 May 2019
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              Other factors to consider

               •    Symptoms can fluctuate throughout the day and can be impacted upon by
                    stress, fatigue, heat and pain.
               •    Distracting environments and lapse in attention may also contribute to
                    difficulties.
               •    Often swallowing difficulties are overlooked until a choking episode occurs.
               •    Difficulties at mealtimes can be compounded by difficulties feeding self due to
                    hand tremor.
               •    Some people who experience cognitive changes may also have difficulties
                    swallowing due to impaired judgement eg take bites that are too big or choose
                    foods which are difficult to chew and swallow.
               •    Sensory difficulties eg lack of feeling cold or pain may also interfere with
                    swallowing.




                   When might someone be referred to speech
                   pathology?

               •    When speech problems begin interfering with everyday communication eg if the
                    person is being asked to repeat words, it’s harder to carry on conversations
                    because the speech is unclear or too quiet, if the person can’t talk fast enough
                    to keep up with their thoughts.
               •    When symptoms of dysphagia are observed e.g if the person is experiencing
                    frequent chest infections or losing weight, the person is taking a long time to
                    eat meals, the person is reporting coughing when eating, the person is
                    describing difficulties chewing or swallowing




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Speech and Swallowing in Multiple Sclerosis                                             Tuesday, 21 May 2019
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              What is involved in speech pathology
              assessment?

               The Speech Pathologist will talk to you about your goals - what is important to you,
               what is working and what is not working, look at your strengths and areas of
               difficulty, what are the barriers you have to living an everyday life.

               Assessment of Speech:
               • Discuss your concerns – can people understand you? Hear you?
               • Examination of the person’s oral muscles that are used for speech (lips,
                 tongue, soft palate) and assessment of how you control their movement eg
                 range, rate, strength and coordination.
               • Assessment of breath support and control
               • Assessment of voice quality
               • Assessment of how clear the person’s speech sounds




              Speech Pathology Assessment cont…

               Swallowing:
               • Discuss your concerns – which foods/drinks are you having? Which ones are
                 difficult? Have you lost weight? Have you had chest infections?
               • Examination of oral muscles used for chewing and swallowing
               • Observation of person eating and drinking various foods and drinks.
               • Assessment of initiation of the swallow, movements of the muscles during
                 swallowing and observe for signs of difficulty.
               • Sometimes a speech pathologist might refer you for a videofluroscopy (also
                 called a modified barium swallow) if they need further information about your
                 swallow. This is a moving x-ray of the swallowing process and allows us to see
                 problems happening inside the body.




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Speech and Swallowing in Multiple Sclerosis                                             Tuesday, 21 May 2019
Webinar



              What is involved in the management of speech
              difficulties?

               In mild to moderate cases, the speech pathologist may:
               - Offer strategies and exercises to assist in strengthening function.
               - Teach and demonstrate strategies to help make speech clearer and more
                  natural e.g slowing down, overarticulating, phrasing and pausing.
               - Teach and demonstrate strategies/exercises targeting loudness and breath
                  control.
               - Assist you to learn the skill of self monitoring.
               - There is some emerging evidence that speech can be improved by a course of
                  LSVT (Lee Silverman Voice Treatment).
               - In some cases, medication or Botox injections have been used to improve
                  voice.

               In severe cases when a person is unable to communicate functionally or their
               safety and wellbeing is affected, the speech pathologist may introduce
               augmentative forms of communication e.g alphabet boards, iPads or other high
               tech devices. This is relatively uncommon.




              Speech Strategies

               It is important to remember that MS can affect each person differently and no two
               people are the same. These strategies may or may not be helpful to you and if
               unsure, please see your speech pathologist!

               •   Speak loudly and slowly.
               •   Minimise background noise.
               •   Face your listener.
               •   Separate words with little pauses.
               •   Exaggerate your speech sounds/overarticulate.
               •   Take a deep breath before starting to speak. Let air out slowly as you speak.
               •   Ask your communication partners to let you know if they are having difficulty
                   understanding you.
               •   Work on your self monitoring.
               •   Consider aids such as voice amplifiers, alphabet boards, picture cards or
                   speech generating devices.




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Speech and Swallowing in Multiple Sclerosis                                            Tuesday, 21 May 2019
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              What is involved in the management of
              swallowing difficulties?

               The speech pathologist may:
               • Offer advice regarding appropriate diet textures, diet modifications
               • Suggest exercises or strategies which assist with safe swallowing
               • Monitoring and managing symptoms early may prevent more serious problems
                 such as aspiration pneumonia, malnutrition or dehydration.

               •   In later stages, weakness and fatigue may lead to inadequate oral intake and
                   alternative feeding options may need to be considered.




              Safe Swallowing strategies

               It is important to remember that MS can affect each person differently and no two
               people are the same. These strategies may or may not be helpful to you and if
               unsure, please see your speech pathologist!

               •   Always sit upright for meals, preferably at the dining table.
               •   Take small mouthfuls of food or drink at a time.
               •   Chew carefully.
               •   Make sure you have cleared your mouth before putting any more food in.
               •   Concentrate. Minimise distractions while eating.
               •   Avoid talking whilst eating.
               •   If you feel yourself getting tired when eating, stop and have a rest.
               •   Keep your chin down rather than throwing your head back.
               •   Think about swallowing – bring swallow under voluntary control.
               •   Eat often – smaller more frequent meals may be easier than larger meals.
               •   Remain upright after you have eaten for at least 20 minutes.




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Speech and Swallowing in Multiple Sclerosis                                               Tuesday, 21 May 2019
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              Safe swallowing strategies continued…

               •   Drink lots of fluids and keep hydrated.
               •   If you have muscle weakness, you may need to place food in the back of your
                   mouth.
               •   Choose foods carefully. Consider textures, taste, temperature of foods. Avoid
                   foods which are difficult eg those that are hard or have tough skins, those that
                   fall apart in your mouth and dry, sticky foods.
               •   Don’t sacrifice nutrition! Monitor your weight.
               •   Take your time and don’t rush your meal.
               •   Try to remain relaxed when eating. Anxiety can often make swallowing worse.
               •   Alternating mouthfuls of food and fluid can sometimes help with the sensation
                   of food getting stuck in the throat.
               •   Do an extra swallow (two swallows per mouthful of food).
               •   If you are needing to clear your throat, or notice coughing or a gurgly voice
                   during mealtimes, you may be at risk of food/drink going down the wrong way.




              Oral Hygiene

               Home Oral Care Program
               Use toothbrushes with built up handles; consider electric toothbrushes and flossing
               devices
               Brush twice daily
               Sit to brush and floss if standing is tiring
               Floss at bedtime without fail
               Allow family member or personal carer to assist with brushing or flossing
               Manage tremors by wearing weighted gloves
               Use products such as Biotene to help manage xerostomia
               Avoid caffeine, alcohol, tobacco, use humidifier at night to help with xerostomia
               Use fluoridated toothpaste
               Use tongue scraper or brush to clean the tongue daily
               Eat a well-balanced diet without excessive sweets
               Replace toothbrush every 3-4 months




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Speech and Swallowing in Multiple Sclerosis                                         Tuesday, 21 May 2019
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              Other important members of the team and how
              we work together

               •   Physiotherapist – posture and trunk control
               •   Occupational Therapist – feeding, adaptive equipment
               •   Dietitian - nutrition
               •   Medical team eg GP, neurologist, nurses
               •   Support workers and carers
               •   Family members




              References

               MS Essentials – Speech and Swallowing
               Dysarthria in Multiple Sclerosis – A Resource for HealthCare Professionals
               (National MS Society)
               Management of Speech and Swallowing in Degenerative Diseases, Yorkston,
               Miller, Strand, 2004
               MS Website and Fact Sheets




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Speech and Swallowing in Multiple Sclerosis          Tuesday, 21 May 2019
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Speech and Swallowing in Multiple Sclerosis                                   Tuesday, 21 May 2019
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Speech and Swallowing in Multiple Sclerosis                                  Tuesday, 21 May 2019
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Speech and Swallowing in Multiple Sclerosis                                            Tuesday, 21 May 2019
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Speech and Swallowing in Multiple Sclerosis                                            Tuesday, 21 May 2019
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Speech and Swallowing in Multiple Sclerosis               Tuesday, 21 May 2019
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