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  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

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