Katherine Parsons, MA, CCC-SLP

VAMC Washington, DC

BACKGROUND INFORMATION

chronic degenerative disease of the

CNS
linked to the autoimmune system
Environmental trigger (e.g., a virus) in
a genetically susceptible individual

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

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

SYMPTOMS

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

SUBTYPES OF MS

Relapsing-remitting MS (RR MS)

Secondary Progressive MS (SP MS)
Progressive Relapsing MS (PR MS)
Primary Progressive MS (PP MS)

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

Speech is a highly complex process

which depends on finely controlled and
coordinated muscles

Impairment can affect not only

communication but also psychosocial
status

Cerebellar involvement
Basal Ganglia involvement
Brainstem involvement

Cranial nerves:

V-Trigeminal
VII-Facial
IX-Glossopharyngeal
XII-Hypoglossal

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

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

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

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

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

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

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)

Patient
Caregivers
Nursing, including CNAs
Speech-language pathologist
Nutritionist
Occupational therapist
Physician

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

Oral preparatory
Oral voluntary
Pharyngeal
Esophageal

Labial seal
Lingual movement
Buccal muscles
Sensory feedback
Consistency/size of bolus

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

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

Peristaltic wave in pharynx continues

into esophagus
Cricopharyngeal sphincter opens to
allow bolus transit
8-20 secs. for transit to
esophageogastric sphincter

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

Flexible fiberoptic tube threaded thru

nose
Direct visualization of structures
Can be completed at bedside
Results can be recorded
Disadvantage: Actual swallow NOT
visualized

Gold standard
Different consistencies
Radiographic study-direct visualization
Assess effectiveness of various
positions
Assess effectiveness of various
techniques

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

Sit upright
Eat slowly
Dont 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

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

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