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Speech & Swallowing Symptoms
Speech and voice problems occur in around 25 to 40% of those with multiple sclerosis (MS), particularly during relapses or periods of extreme fatigue. The problems are basically of two types:
Dysarthria - refers to a speech disorder, caused by neuromuscular impairment, which results in disturbances in motor control of the speech mechanism. The demyelinating lesions caused by MS may result in spasticity, weakness, slowness, and/or ataxic incoordination of the lips, tongue, mandible, soft palate, vocal cords, and diaphragm. Therefore, articulation, speaking rate, intelligibility, and natural flow of speech in conversation are the areas most likely to be affected in those with MS.
Dysphonia - refers to a voice disorder, often accompanies dysarthria because the same muscles, structures, and neural pathways are used for both speech and voice production. Therefore, voice quality, nasal resonance, pitch control, loudness, and emphasis may also be affected in those with MS.

Speech disorders are fairly common in MS. Speech patterns are controlled by many areas in the brain, especially the brainstem. Lesions in different parts of the brain can cause several types of changes in normal speech patterns. They range from mild difficulties to severe problems that make it difficult to speak and be understood.

Like other symptoms of MS, speech or swallowing difficulties are both due to an area of damaged nerves that normally aid in performing these tasks. Difficulty in swallowing, can occur among people with MS. It occurs more frequently in advanced cases, but it can occur at any stage.
Dysphagia - referring to the difficulty in swallowing.

Speech

Dysarthria is a speech diagnostic term that can be used to classify various types of neuromuscular speech disturbances. Dysarthria results from notable degrees of one or more abnormalities involving speech musculature, including weakness, paralysis, incoordination, sensory deprivation, exaggerated reflex patterns, uncontrollable movement activities, and excess or reduced tone.

Basically, speech is the muscles in your lips, tongue, vocal cords, and diaphragm working together to help you speak clearly. With dysarthria, the part of your brain that controls them doesn't work well and it's difficult for you to move those muscles the right way. When speaking, people may not be able to understand you very well. Some people with dysarthria have only minor speech problems while others have a lot of trouble getting their words out.

Dysarthria can make your speech:
Flat
Higher or lower pitched than usual
Jerky
Mumbled
Slow or fast
Slurred
Soft, like a whisper
Strained

Dysarthria affects around 40 to 50% of those with MS and is the most common communication disorder with this disease. It's usually mild; however, symptom severity reflects the extent of nerve damage.

The dysarthrias are considered motor speech disorders because speaking difficulties are largely due to breakdowns in movement control of one or more muscle groups that compose the speech mechanism. The name of each dysarthria subtype is partially derived from the basic characteristics of the overlying movement disturbances. Normal speech production involves the integration and coordination of five primary physiological subsystems.

So basically, the normal processes of speech and voice production are overlapping and require the following fve processes to work together smoothly and rapidly:
Respiration: (Breath support) Using the diaphragm to quickly fill the lungs fully, followed by slow, controlled exhalation for speech.
Phonation: (Voice production) Using the vocal cords and air flow to produce voice of varying pitch, loudness, and quality.
Articulation: (Pronunciation of words) Coordinating quick, precise movements of the lips, tongue, mandible, and soft palate for clarity of speech.
Resonation: (Nasal versus oral voice quality) Raising and lowering the soft palate to direct the voice to resonate in the oral and/or nasal cavities to further affect voice quality.
Prosody: (Rate, rhythm, and inflection patterns of speech) Combining all elements for a natural flow of conversational speech, with adequate loudness, emphasis, and melodic line to enhance meaning.

Locating the damaged areas responsible for the speech problem is often difficult. Many areas in the brain, especially the brainstem, control speech patterns. Thus, lesions in different parts of the brain can cause several types of changes in normal speech patterns. They range from mild difficulties to severe problems that make it difficult to speak and be understood.

There are three types of dysarthria associated with MS:

Spastic - Due to muscle stiffness or tightness. Caused by bilateral lesions of corticobulbar tracts.
- Harsh, strained voice quality
- Pitch breaks
- Imprecise articulation
- Slow rate of speech
- Reduced breath support and/or control
- Reduced or mono-loudness
- Short phrases, reduced stress
- Hypernasality

Ataxic - Due to loss of muscle movement control. Caused by bilateral or generalized lesions of the cerebellum.
- Vocal tremor
- Irregular articulation breakdown
- Dysrhythmic rapid alternating movements of the tongue, lips, and mandible
- Scanning speech
- Variable loudness
- Prolonged phonemes and intervals

Mixed - Due to features of both the spastic and ataxic types.
- Impaired loudness control
- Harsh or hypernasal voice quality
- Impaired articulation
- Impaired emphasis
- Impaired pitch control

Differential diagnosis depends on the extent and location of MS lesions, and the specifc speech, voice, and accompanying physical signs that result. Mixed dysarthria is most common in MS, because multiple neurological systems are typically involved. In mixed dysarthria, nerve damage may involve your brain's white matter and/or cerebellum, your brainstem, and/or your spinal cord.

Dysarthia evaluation in MS has traditionally included both informal and formal measures of a variety of oral-motor, speech, and voice functions, with comparison to referenced norms. Formal articulation tests are not commonly used because MS-related dysarthria tends to have an irregular pattern of breakdown that is not necessarily based on misarticulation of specifc speech sounds. Rather, measures of oral reading rate in phonetically balanced passages are standard.

Different types of dysarthria, related to the type of speech produced:
Clipped - speech where words are slurred over and uncompleted
Cerebellar - varying from jerky or scanning speech to explosive
Explosive - speech uttered with more force than necessary
Scanning - slurring, monotonous speech
Staccato - speech in which each syllable is uttered separately

One pattern of speech that is commonly associated with MS is called "scanning" speech. This type of speech produces speech in which the normal "melody" or speech pattern is disrupted, with abnormally long pauses between words or individual syllables of words. People with MS may also slur words as a result of weak tongue, lip, and mouth muscles. Other speech problems include explosive dysarthrias, or nasal speech, which can sound as though the person has a cold or nasal obstruction.

Speech-language therapy is the only treatment for dysarthria. How much your speech may improve depends on the location of the damage caused by the demyelinated lesions.

Dysphonia is an impairment with the voice or difficulty speaking. This can include hoarseness, raspy speech or a change in pitch when the person tries to talk. In MS, dysphonia often means that the person has trouble controlling the volume of speech, meaning that they speak too softly to be heard or more loudly than is appropriate. Dysphonia should be differentiated from dysphasia or aphasia, both of which refer to problems understanding or communicating spoken or written words.

Dysphonia is considered a form of dysarthria because these conditions involve the same muscles, structures, and nerve pathways used in speaking. Difficulties produced by speech problems:
Slurring words from weak weak tongue, lip, and mouth muscles
Mispronunciation of words
Monotonous tone of voice
Failure to complete words
Long pauses between words or syllables

Other people struggle with understanding language or find that they "lose words" mid-sentence, or switch words or syllables when speaking. These difficulties are probably related to the cognitive symptoms and again will be discussed later in the Cognitive Issues section.

A speech therapist (or speech and language pathologist) help people with MS improve speech patterns, enunciation, and oral communication in general. Treatment for speech problems like muscle stiffness that make it difficult to speak, can usually be helped with medications.

A speech therapist might also suggest:
Exercises to strengthen or relax your vocal cords or improve how you move your jaw, tongue, and lips
Strategies other than speech that can help you communicate with others. You might focus on using shorter words and phrases or ways to simplify words, sentences, or sounds.
Practice controlling your breath so it can help you speak longer sentences in one breath or accent specific words.

Other ways to manage your speech problems:
Don’t feel rushed or pressured when you’re trying to talk. If you feel comfortable, it may help to let the other person know you have a speech problem.
Try to talk with someone face-to-face whenever possible. Your facial expressions and gestures can help you get your point across.
If a conversation goes on too long, ask if you can take a break.
Try to relax. If you can keep a positive attitude, it might put you and the other person at ease so you won’t feel anxious about understanding each other.

Swallowing

Dysphagia is the difficulty in swallowing, and can occur among many with MS. While this is more frequent to occur in advanced cases of the disease, it can occur at any stage. This may cause a person may cough after drinking liquids, or choke while eating certain foods, particularly those with crumbly textures.

Some symptoms of a swallowing problem are:
Coughing or choking when eating
Feeling like food is lodged in the throat
Unexplained recurrent lung infections (pneumonia)
Otherwise unexplained malnutrition or dehydration

When swallowing difficulties are present, food or liquids that you eat may be inhaled into the trachea (windpipe) instead of going down the esophagus and into the stomach. Once in the lungs, the inhaled food or liquids can cause pneumonia or abscesses. Because the food or drink isn't reaching the stomach, a person may also be at risk for malnutrition or dehydration.

A speech therapist or pathologist can usually treat swallowing problems. Treatment typically consists of changes in diet, positioning of the head, exercises, or stimulation designed to improve swallowing. In very severe cases that don't respond to these measures, feeding tubes may be inserted directly into the stomach to provide the necessary fluids and nutrition.

Along with therapy, there are things you can do to make swallowing easier:
Sit upright at a 90° angle, tilt your head slightly forward.
Stay focused on the tasks of eating and drinking. Keep distractions away and don't talk with food in your mouth.
Eat slowly and take small bites at a time.
You may need to swallow multiple times for every bite or sip.
Concentrate on swallowing often. Try alternating a bite of food with a sip of liquid.
Drink plenty of fluids to stay hydrated.
If chewing is hard for you from lack of strength, eat softer foods.