Communication & Swallowing in MS: what works?

Melissa LoucasSpeech & Language Therapist/Clinical

Tutor, University of Reading

Outline

• Characteristics

• Identifying changes

• Intervening

Referrals to SLT

• Hartelius (1994) 2 % (Sweden)

• Yorkston (2003) 11% (USA)

• Your teams?– Influencing factors

• Patient characteristics• resources

SPEECH CHARACTERISITCS

Speech changes

• Dysarthria and dysphonia

Prosody

What can speech sound likeMost common: mixed spastic-ataxic (Hartelius et al 2000)

• Aesthenic voice• Strained voice• Disrupted prosody• Imprecise articulation• Slowed speech rate

How common are speech changes?• Patient report

– Beukelman (1985) 23%– Hartelius (1994) 44%– Yorkston (2003) 40%

• Clinical findings– Darley et al (1972) 41% – Hartelius et al (2000) 51% prevalence– Bauer et al (2013) 47%

• Instrumental & subclinical– Hartelius (2000) 62%– Feij’o (2004) 70%– Dogan (2007) 60%

Predictors of dysarthria?

• Types of MS– Progressive>RRMS severity

• MS severity (EDSS scores)– More severe speech in higher EDSS– But onset of changes not correlated with EDSS

• Disease duration– Not usually independently correlated

Other communication changes:Communication?• Naming• Word definition• Word fluency• Sentence repetition• Verbal explanation &

reasoning• High level comprehension• Murdoch and Lethlan (2000)• >50 normal language ability

• Self-report: 62% Klugman & Rose (2002)

Cognition?• memory• attention • speed of information

processing • executive functions

– (Fraser & Stark, 2003; Pierson & Griffith, 2006; Shevil & Finlayson, 2006).

• Kujaja (1996) unimpaired language in unimpaired cog

So we know that…..

• More severe speech and communication changes more likely if other MS symptoms are more severe

• But is this the best time to work on speech?

IMPACT

Non-linear relationships

• Impairment • Impact– Roles? (Hartelius

1994)– Communicative

participation (Yorkston 2001; Bringfelt 2006; Yorkston 2014)

– VHI scores (Bauer et al 2013)

VHIJacobson et al 1997

• 30 item validated questionnaire • physical, emotional and impact on function of

voice changes

So we know that….

• Speech and communication changes impact each person differently

• There are tools to look at impact BUT• are they routinely accessed?• Do they capture the lived experience of

someone with MS?

PARTICIPATION IN LIFE

Restricted communicative participation associated with

– Fatigue – Mobility– Bladder control– Visual difficulties– Cognitive /thinking difficulties– Depression– Social support– Employment status– Speech usage– Education levels

o Qualitative e.g. Yorkston 2001; Bringfelt et al 2006, o Quantitative Baylor et al 2010; Yorkston 2013

Communicative Participation

• https://www.youtube.com/watch?v=BrBoB22HLXs

• Baylor, Yorkston et al 2013:– Communicative Participation Item Bank– how much your condition interferes with your

participation in that situation– Convert scores to logit scale (0 = calibrations

sample) or T scores (50 = calibration sample)

So we know that….

• Communicative participation is bigger than speech and language

• It needs an MDT approach to help

• There is a published tool to explore it

SLT INTERVENTIONS

Speech impairment

Speaker compensations

Intelligibility of acoustic signal

Signal Independent Information

Supplemented intelligibility

Naturalness

PARTICIPATION

Preferred roles

Listener attitudes

Physical & social envir

Yorkston 2008 (conference hand out)

Interventions for dysarthria:o Improving intelligibility

• Articulatory accuracy • Rate control (Yorkston & Beukelman 1981)• volume (Sapir et al 2001; Tjaden et al 2014)• Feedback and Self monitoring

oSpeaker adjustmentsoSpeech supplementation / augmentative oListener adjustments

Principles of Motor Learning

• Usage• Specificity• Intensity• Salience• Feedback• Blocked vs. random

e.g. Ludlow et al 2008

So we know that…

• There is limited evidence for effectiveness of communication interventions in MS

• BUT• Can operate at all/any levels of participation• Need to consider overall MS profile

CASES: WHAT MIGHT INTERVENTION LOOK LIKE?

• Andy:– Self-employed businessman; ataxic dysarthria with

work & social impact– Self-monitoring– Rate control with articulatory accuracy for key salient

phrases– Fatigue awareness– Alternative communication choices (email,

answerphone)– disclosure

• Stuart: – Retired, chronic progressive MS, wheelchair

dependent– Aesthenic voice; participation & QoL issues– phonatory strength training; self-monitoring;

stepped progression supported through therapy– Care-giver education– Amplification for specific circumstances

• Cherry– 18 years old; primary progressive MS; self-image &

social impact– Prosodic break downs (elongations, intra-word

pauses); degraded voice quality; articulatory imprecision

– Rate control; normalisation– Visual-acoustic feedback, targeted phrases– Disclosure to new college mates

Swallowing

CharacteristicsPredictorsScreeningInterventions

SWALLOWING CHARACTERISTICS

Swallowing changes:

BUT:

Swallowing symptoms:

Chewing n=184

Swallowing solids n=187

Swallowing liquids n=182

Chokes on food or drink n=188

Solids or fluids?

De Pauw et al 2002

Objective changes

De Pauw et al 2002

How common are swallowing changes?• Self-report: 33%

– Hartelius 1994

• Screening Test: 31.7 %• Poorjavad 2010

• Clinical interview: 31 %– Solaro 2013;

• Clinical & instrumental examination(FEES):34 %– Calcagno 2002;

• Higher on instrumental assessment?• Tassorelli et al 2008; Wiesner et al 2002

• Fernandes et al 2013• Meta-analysis Guan et al 2015: 36% vs 81%

Predictors of dysphagia?

• Types of MS

• MS severity (EDSS scores)

• Disease duration

So we know that

• Dysphagia is more likely in more severe MS

• But is this the best time to work on swallowing?

IDENTIFYING SWALLOW CHANGES

Screening Tools: DYMUS

Bergamaschi et al 2008

Screening Tests

• TWST- Hughes & Wiles (1996)

• TOMASS (Huckerbee, 2014 Conference)

• V-VST (Clave 2008)

SLT Assessment

• Clinical

o Case historyo Oro-motor examo Oral trialsoMeal time

observationo QoL

• Instrumental

o VFo FEES

https://www.youtube.com/watch?v=G1Enx7lHrrg

So we know that…

• There are a range of ways to assess swallowing

• But • What do your teams use to identify?• Do you know what models your SLTs use?

SLT INTERVENTION

Compensatory Interventions

– Postural– Speed & amount– Food/drink consistencies

• Calcagno et al 2002– Self-awareness

• Yorkston et al 2004– Sensory

• Rosenbeck 1996; Bullow et al 2003

MDT

• Independent feeding (Langmore et al 1998)• Cognition• Physical abilities• Alternative feeding (Vessey 2008)

Rehabilitative Interventions

• EMST

• Cough efficiency– Chiara 2006

• Reduced Penetration-Aspiration scores (PD)– Troche et al 2010

Rehabilitative

• Electrical stimulation– Intraluminal stimulation– 5Hz– 20 patients with MS &

aspiration– Improvement in

swallowing over sham– Restivo et al 2013

BotoxRestivo et al 2011:• 14 patients with

hypertonic UES dysfunction

• 10 unit botox each side CP under EMG control

• Improvements for 18 weeks

When to support?

• Emerging evidence with other conditions for early interventions

• Most research looks at ‘permanent’ symptoms as inclusion criteria– How to support dysphagia ‘relapse’?

So we know that….

• Range of interventions to use though limited evidence (especially in MS) embedded in MDT

• But

• Emerging evidence for early interventions in other conditions & specialist techniques

Your team working:

Collaborative intervention

Specialist Assessm

ent

Identification

References• Bauer V, Aleric Z, Jancic E, Knezevicc B, Prpicc D, Kacavendac A Subjective and perceptual analysis of voice quality and

relationship with neurological disfunction in multiple sclerosis patients Clinical Neurology and Neurosurgery 115S (2013) S17–S20

• Baylor C, Yorkston K, Bamer A, Britton D, Amtmann D Variables associated with communicative participation in peoplewith multiple sclerosis: A regression analysis Am J Speech Lang Pathol. 2010 May ; 19(2): 143–153

• Baylor C, Yorkston K , Eadie T, Kim J, Chung H, Amtmann D The Communicative Participation Item Bank (CPIB): Item bank calibration and development of a disorder-generic short formJ Speech Lang Hear Res. 2013 Aug; 56(4): 1190–1208

• Beukelman, D. R., Kraft, G. H., & Freal, J. Expressive communication disorders in persons with multiple sclerosis. Archives of Physical Medicine and Rehabilitation (1985) 66 675–677

• Bergamaschi R The DYMUS questionnaire for the assessment of dysphagia in multiple sclerosis Journal of the Neurological Sciences 269 (2008) 49-53

• Bringfelt PA, Hartelius L, Runmarker B Communication Problems in Multiple Sclerosis: 9-Year Follow-Up Int J MS Care 2006;8:130–140.

• Calcagno P, Ruoppolo G, Grasso MG, De Vincentiis M, Paolucci S. Dysphagia in multiple sclerosis - prevalence and prognostic factors. Acta Neurol. Scand. [2002]

• Bülow M, Olsson R, Ekberg O. Videoradio-graphic analysis of how carbonated thin liquids and thickened liquids affect the physiology of swallowing in subjects with aspiration on thin liquids. Acta Radiologica. 2003;44:366–372

• Chiara T, Martin D, Davenport P, Bolser D. Expiratory muscle strength training in persons with multiple sclerosis having mild to moderate disability: effect on maximal expiratory pressure, pulmonary function, and maximal voluntary cough. Arch Phys Med Rehabil 2006;87:468–473

• Chiara, T., Martin, D., Sapienza, C. Expiratory muscle strength training: speech production outcomes in patients with multiple sclerosis. Neurorehabil Neural Repair. 2007;21:239–249

• Clave P, Arreola V, Romea M, Medina L, Palomera E, Serra-Prat M. Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration. Clin Nut 2008; 27: 806–15

• Darley FL, Brown JR, Goldstein NP Dysarthria in multiple sclerosis. J Speech Hear Res. 1972 Jun;15(2):229-45.• De Pauw A, Dejaeger E, D'hooghe B, Carton H Dysphagia in multiple sclerosis Clinical neurology and neurosurgery

2002 Sep;104(4):345-51• Dogan M, Midi I, Yazici MA, et al. Objective and subjective evaluation of voice quality in multiple sclerosis. J Voice

2007;21(6):735–40.

• Enderby P et al Therapy Outcome Measures for Rehabilitation Professionals Speech and Language Therapy, Physiotherapy, Occupational Therapy, 2nd Edn 2006

• Fernandes AM1, Duprat Ade C, Eckley CA, Silva Ld, Ferreira RB, Tilbery CP. Oropharyngeal dysphagia in patients with multiple sclerosis: do the disease classification scales reflect dysphagia severity? Braz J Otorhinolaryngol. 2013 Aug;79(4):460-5.

• Feij’o AV, Parente MA, Behlau M, et al. Acoustic analysis of voice in multiple sclerosis patients. J Voice 2004;18(3):341–7.• Guan XL1, Wang H, Huang HS, Meng L. Prevalence of dysphagia in multiple sclerosis: a systematic review and meta-analysis.

Neurol Sci. 2015 May;36(5):671-81. Epub 2015 Feb 3• Hamdan AL, Farhat S, Saadeh R, et al. Voice-related quality of life in patients with multiple sclerosis. Autoimmune Dis

2012:143813.• Hartelius L1, Svensson P. Speech and swallowing symptoms associated with Parkinson's disease and multiple sclerosis: a

survey Folia Phoniatr Logop. 1994;46(1):9-17• Hartelius L1, Runmarker B, Andersen O. Prevalence and characteristics of dysarthria in a multiple-sclerosis incidence cohort:

relation to neurological data. Folia Phoniatr Logop. 2000 Jul-Aug;52(4):160-77.• Huckabee, M.L., McIntosh, T. and Apperley, O. (2014) Quantitative Assessment of Oral Phase Efficiency: TOMASS Norms and

Preliminary Validation. Nashville, TN, USA: Dysphagia Research Society Annual Scientific Meeting, 5-8 Mar 2014. In Dysphagia 29 763. (Conference Contributions - Abstracts)

• Jacobson, B.H., Johnson, A., Grywalski, C., Silbergleit, A., Jacobson, G., Benninger, M.S., & Newman, C.W. (1997). The Voice Handicap Index (VHI): development and validation. American Journal of Speech Language Pathology, 6, 66-70

• Klugman TM, Rose E “Perceptions of the impact of speech, language, swallowing and hearing difficulties on quality of life in a group of South African persons with multiple sclerosis Folia phoniatrica et logopaedica 2002: 54 2001-221

• Kujala P, Portin R, Ruutiainen J Language functions in incipient cognitive decline in multiple sclerosis Journal of the neurological sciences, 1996

• Langmore et al Predictors of Aspiration Pneumonia: How Important Is Dysphagia? Dysphagia 1998; 13, 69-81• Ludlow CL, Hoit J, Kent R, Ramig LO, Shrivastav R, Strand E, Yorkston K & Sapienza CA (2008) “Translating Principles of

Neural Plasticity into Research on Speech Motor Control Recovery and Rehabilitation” JSLHR 51 (supplement 240-258)• MacKenzie C & Green J Cognitive linguistic deficit and speech intelligibility in chronic progressive multiple sclerosis Iny.

Journal Lang.Comm,Dis (2009) 44 (4) 401-420• McHorney CA, Robbins J, Lomax K, Rosenbek JC, Chignell K, Kramer AE, et al. The SWAL-QOL and SWAL-

CARE outcomes tool for oropharyngeal dysphagia in adults: III. Documentation of reliability and validity. Dysphagia. 2002;17:97–114

• Murdoch, B. E. and Lethlean, J. (2000). Language disorders in multiple sclerosis. In Bruce E. Murdoch and Deborah G. Theodoros (Ed.), Speech and language disorders in multiple sclerosis (pp. 109-130) London: Whurr.

• Poorjavad M1, Derakhshandeh F, Etemadifar M, Soleymani B, Minagar A, Maghzi AH. Oropharyngeal dysphagia in multiple sclerosis. Mult Scler. 2010 Mar;16(3):362-5

• Restivo DA et al Botulinum toxin improves dysphagia associated with multiple sclerosis European Journal of Neurology 2011 18 486-490

• Restivio et al Brain Stimulation May 2013 (6) 418-423 Pharyngeal Electrical Stimulation for Dysphagia Associated with Multiple Sclerosis: A Pilot Study

• Rosenbek JC, Roecker EB, Wood JL, Robbins J. Thermal application reduces the duration of stage transition in dysphagia after stroke. Dysphagia. 1996;11:225–233

• Sapir S, Pawlas A, Ramig LO, Seeley E, Fox C, Corboy J Effects of intensive phonatory-respiratory treatment (LSVT) on voice in two individuals with multiple sclerosis Journal of Medical Speech-Language Pathology, Vol. 9, No. 2. (2001), pp. 141-151

• Solaro C et al Prevalence of patient-reported dysphagia in multiple sclerosis patients:An Italian multicenter study (using the DYMUS questionnaire) Journal of the Neurological Sciences 331 (2013) 94-7

• Tassorelli C, Bergamaschi R, Buscone S, Bartolo M, Furnari A, Crivelli P, et al.Dysphagia in multiple sclerosis: From pathogenesis to diagnosis. Neurol Sci 2008;29(Suppl. 4): S360–3.

• Thomas FJ, Wiles CM. Dysphagia and nutritional status in multiple sclerosis. J Neurol 1999; 246: 677–82.• Tjaden K, Sussman JE, Wilding GE “impact of clear, loud and slow speech on scaled intelligibility and speech severity in

Parkinson’s Disease and Multiple Sclerosis” Journal of Speech Language and Hearing Research 2014: 57 (3) 779-92• Troche M, Okun M et al Aspiration and swallowing in Parkinson disease and rehabilitation with EMST Neurology 2010 23; 75

(21) 1912-1919• Vessey S, Lelie P & Exley C (2008) A Pilot Study Exploring the Factors that Influence the Decision to have PEG Feeding in

Patients with Progressive Conditions Dysphagia 23 (3)• Wiesner W, Wetzel SG, Kappos L, Hoshi MM, Witte U, Radue EW, et al. Swallowing abnormalities in multiple sclerosis:

correlation between videofluoroscopy and subjective symptoms. Eur Radiol 2002;12:789–92• Yamout B, Fuleihan N, Hajj T, et al. Vocal symptoms and acoustic changes in relation to the expanded disability status scale,

duration and stage of disease in patients with multiple sclerosis. Eur Arch Otorhinolaryngol 2009;266(11):1759–65• Yorkston KM & Beukelman D Treatment Sequences Based on Intelligibility and Prosodic Considerations Journal of Speech

and Hearing Disorders, 1981, Vol. 46, 398-404.• Yorkston KM, Klasner ER, Bowen JD, Eade DM, Gibbons LE, Johnson KL, Kraft GH Characteristics of multiple sclerosis as a

function of the severity of speech disorders Journal of Medical Speech Language Pathology 2002 11(2) 73-84 .• Yorkston, K., Klasner, E. R., & Swanson, K. M. Communication in context: A qualitative study of the experiences of individuals

with multiple sclerosis. American Journal of Speech-Language Pathology 2001 10(2), 126–137.• Yorkston KM , Miller RM, Strand EA Management of Speech and Swallowing in Degenerative Diseases 2 nd Edtn 2004 Pro-Ed

Austin, Texas• Yorkston KM, Baylor C, Amtmann D Communicative participation restrictions in multiple sclerosis: Associated variables and

correlation with social functioning Journal of Communication Disorders 52 (2014) 196–206