- Speech & Swallowing
- What difficulties might be experienced?
- MS and Speech
- MS and Swallowing
- Final Thoughts
- Why Do I Choke On My Saliva?
- Hard to swallow, easy to choke
- When a weak cough is a bad sign
- Nearly half of residents of long-term care facilities vulnerable to pneumonia
- Treatment for Swallowing Problems
- MS and Trouble Swallowing
- The normal swallowing process
- Symptoms of trouble swallowing
- How common is it among people with MS?
- What you can do
- Bite, Chew, Swallow: How to Deal With Dysphagia When You Have MS
- What Goes Wrong With Swallowing
- Faulty Timing
- Weak Swallowing Muscles
- Figuring Out the Problem
- Improving Swallowing
- Posture Changes
- Changing the Consistency of Food and Liquid
- Strengthening Exercises for Better Swallowing
- Neurological conditions: MS, Parkinson’s disease, ALS
- Numbers affected in the UK, and the world, showing the proportion with swallowing difficulties, dysphagia:
- MS – Multiple Sclerosis
- ALS – Amyotrophic Lateral Sclerosis
- Training with IQoro® – a complement to rehabilitation
Speech & Swallowing
People with MS often have trouble with swallowing (dysphagia) and speech (dysarthria) due to the nerves in the brain and spinal cord that make these tasks happen becoming damaged. These difficulties are more common in those with advanced MS, but can occur at any stage. Speech and swallowing problems also vary in severity but treatments and techniques can help you improve speech and make swallowing easier.
It is important to discuss any concerns with your health professional as food or liquids in the lungs can cause pneumonia or abscesses, or a person may be at risk for malnutrition or dehydration if food is not reaching the stomach. A person can also inhale small amounts of food or liquids without being aware of it. This is called silent aspiration.
What difficulties might be experienced?
You may notice:
- Possible changes in swallowing
- Coughing when eating or drinking
- Food sticking in the throat or mouth
- Difficulty swallowing medications
- Sniffing or sneezing during meals
- Food or drink travelling up into the nasal passages
- Reduced consumption of food or liquid
- Time required to finish meals notably increases
- Difficulty controlling saliva
As each person’s experience will be different, individual management strategies are essential. It is better to seek assessment sooner rather than later, to ensure effective management. It is important to see a Speech and Language Therapist if any of the following occur:
- Possible changes in speech
- Slurred speech
- Overly nasal speech
- Voice changes (e.g. reduced volume or poor pitch control)
- Experiencing fatigue after talking
- Problems with vocabulary (“finding the words”)
- Speech slows down, or requires more effort
Early intervention is vital as problems with swallowing can also result in weight loss, poor nutrition, dehydration and chest infections.
MS and Speech
Difficulties with speech are fairly common with MS. Speech changes may begin with a slight slurring of speech, with a later weakening of the muscles of the mouth and throat. There are many areas in the brain, and brainstem, that control speech patters and when lesions appear and damage certain areas changes to speech patterns occur. Changes may stem from mild to severe making it difficult for people to speak and be understood. Not only can clarity of speech be impacted but also and non-verbal communication such as facial expressions. Additionally, you may have trouble ‘finding the right words’, as lesions on the brain affect the ways the brain finds words. A Speech and Language Therapist can help you focus on breathing techniques, learn energy conservation and find strategies to improve the volume and pace of your speech. Dysarthrias are commonly associated with other symptoms caused by lesions in the brainstem which may include tremor, head shaking or incoordination.
Common issues that occur:
- Scanning speech: the normal “melody” or speech pattern is disrupted, with abnormally long pauses between words or individual syllables of words.
- Slurring: a common occurrence resulting from the weakness and/or incoordination of the muscles of the tongue, lips, cheeks and mouth.
- Nasal speech: the persons speech sounds like having a cold or nasal obstruction.
Alternative communication methods
If speech becomes too difficult, other ways of communicating may be easier. There are many options available, such as: using pen and paper; pointing to pictures or written words; or using electronic communication devices. If communication technologies become necessary, a Speech and Language Therapist can discuss which technology is most appropriate and teach the best use of aids that can support or substitute speech. Your GP should be able to refer you for a review. Carers, family and friends should be taught about these technologies as well, as they will be communicating with you via the alternative system.
MS and Swallowing
MS can damage the nerve fibres in the brain that control swallowing, or damage the nerves in the muscles that execute this function. As a result, chewing and readying food for swallowing may become difficult. Triggering a swallow and clearing food from the mouth may become harder and coughing may be weaker. Some food and fluid loss from between the lips may also occur. It is important that you, your carers and family members are alert to the possibility of swallowing problems, so that advice regarding management can be sought early. Modifications to the texture of your food and drink may increase food intake and safety. Other factors also play a part, such as posture and the eating environment. A Speech and Language Therapist will need to assess your situation before recommending specific management strategies.
Changing what you eat
- Water may be the most difficult item to swallow. However, use a commercial thickener for this and any other thin liquids, Check with your local chemists for availability and recommendations.
- Be wary of using ice cubes or gelatines, as they melt into liquid before they can reach the back of the mouth.
- Smoothies can be an easy way to consume nutritious food.
- Chop, mince or blend meat and other coarse food and moisten with broths, juices, gravies or soups.
- It may be necessary to avoid large chunks of any solid food, as they can lodge in your airway.
- Try nut butters instead of individual nuts (providing your tongue is able to move the sticky food around your mouth).
- Try food that is warmer or colder than the body.
- Add herbs, stocks and sauces to food that may be bland.
- Chew each mouthful at least 30 times, slowing down your eating, breathe, think about how it tastes and feels.
For maximum enjoyment, try and vary your diet as much as possible. A dietician can match food preferences with adequate nutrition and the textures required for safe swallowing.
Changing how you eat
- Sit upright and lean slightly forward when eating or drinking, and stay upright for half an hour after finishing.
- Keep the chin parallel with the table or slightly tucked down, as this ensures the mouth and throat are in a good position for handling food.
- Take one small bit at a time. Clear your mouth before your next bite.
- Never wash food down with liquid; moisten the food instead.
- Choose soft, moist foods and thick, cold liquids first, as they are the easiest to swallow. Dry solids and thin liquids are more difficult, and require closer attention for safe swallowing.
- Begin a meal with something cold, e.g. a sorbet or smoothie.
- Consider avoiding thin liquids altogether when fatigued. Thus, consume thin items in the morning and thick ones in the evening.
- If your eating seems to slow down, pause and switch to something icy, as the sensation can help trigger the swallowing action.
- With solids, swallow at least two times per mouthful-the first time to send the food down, followed by a dry swallow to clear any residual particles.
- With liquids, especially hot, thin liquids, swallow, then clear your throat, then swallow again before taking more liquid.
- Voluntarily coughing during the meal may help to clear your throat.
Changing the eating environment
Distractions during mealtimes can make managing problems more difficult, especially if you have to pay particular attention to a therapy technique.
Some suggestions that may make mealtimes easier are:
- Quieten your self and your surroundings during a meal. It’s always a good idea to make mealtimes a calm part of the day and to save discussion of “hot” or contentious topics for other times.
- Limit conversations during mealtimes to yes/no questions that can be answered by a nod of the head. In this way, you avoid being rushed to finish your mouthful and respond.
- If you like to watch television, or if eating at a social gathering, try to eat food with ‘safe’ meal textures to reduce the need for intense concentration on the act of swallowing. This will make your meal more enjoyable.
Swallowing difficulties may affect how you take any medications. It may be better to take tablets whole with pureed food or smoothies rather than water. Alternatively, check with a pharmacist if it is acceptable to cut or crush the tablets, or whether the medication comes in liquid form. Note: It is essential to discuss any changes to how you take your medications with your pharmacist.
You should be aware that:
- Some medications increase saliva production, so be sure to discuss this issue with your GP if you think this may be the case.
- Some patches and medications may be useful for reducing saliva production. However, they can reduce all other body fluids, which creates other problems. You should consult your GP and SLT about using these medications.
Sometimes swallowing problems may mean eating becomes too difficult and alternative feeding methods (i.e. a tube) will be suggested. An Speech and Language Therapist can describe the various options in your case to help you and your support team make the best decision.
Associated Difficulties – Excessive Saliva
Some people may find they have more saliva in their mouths than they can manage. This is not the result of increased saliva production, but of lip, cheek and tongue weakness and less frequent swallowing. This can cause drooling.
The following strategies have been found to be useful:
- Sealing lips firmly
- Swallowing more frequently
- Sipping drinks regularly
- Sucking sugar-free lozenges (if your SLT says it is safe to do so)
- Swallowing reminders (e.g. a timer set to ‘ding’ every so often)
- Swallowing before talking
Other potential remedies include:
- Soft collar: may help to keep the head in an upright position and stop saliva falling out of the mouth.
- Suctioning machine: particularly if the swallow is very difficult to ‘trigger’. However, check with a physiotherapist first.
Xerostomia (dry mouth)
Xerostomia is caused by a lack of saliva in the mouth. Saliva production commonly decreases as a result of dehydration, as a side effect of certain medications, or because the saliva glands are not functioning correctly. It is uncomfortable and can make chewing, swallowing and speaking difficult.
Some strategies for coping with a dry mouth include:
- Clean your mouth and tongue with toothpaste (or a baking soda solution) on a very soft toothbrush.
- Use mouthwash to cleanse and relieve dryness (e.g. dissolve 1/4 teaspoon baking soda with 1/4 teaspoon salt in warm water.).
- If able to swallow easily, take regular sips of fluid throughout the day. Avoid coffee or tea, as these are diuretics.
- Remember to keep your mouth closed when not speaking or eating as breathing through the mouth dries it out.
- Use over-the-counter medications, such as artificial saliva, or saliva stimulants. There are also medications available on prescription from a GP.
Xerostomia alters the acid balance in the mouth, and makes teeth susceptible to cavities. Thus, it is very important to stay vigilant about oral health – including checking for ulcers and tooth decay. If using a mouthwash, it is important to avoid those with alcohol as this can damage the lining of the mouth. Also, dry mouth can affect the lips and skin around the mouth. Lip balm can be used to prevent cracking, but should be nonpetroleum based to avoid skin reactions and dryness.
Because MS brings ongoing changes to functional abilities, regular monitoring and reviews are essential. Sometimes this will involve full reassessment, but may simply require informal discussions with you and those involved in your care. As with any other MS-related issues, managing speech and swallowing impairments works best when you, your family and carers, and other support services take a positive and collaborative approach.
For more information please view our MSNZ Information Series booklet: Multiple Sclerosis Speech and Swallowing
Why Do I Choke On My Saliva?
Why do I sometimes choke on my saliva? Does it mean that something is wrong?
Choking and coughing from inhaling our own saliva has happened to most of us. And in most cases, the embarrassment while red-faced, spluttering and trying to catch a breath is the worst thing to worry about.
If you’re otherwise healthy, the most common cause of choking on saliva is just being in a rush. We are all automatically swallowing our saliva all day. But actions such as talking too quickly, laughing too hard or turning your head quickly while swallowing can cause the normal automatic swallowing to turn into an inhalation—with the obvious result. You’ve probably already figured out the helpful tip here: Slow down!
On the other hand, your mouth may be too dry. Normally, salivary glands produce two to four pints of saliva daily. If you have dry mouth, not only do you not produce enough saliva but the saliva you do produce is thick and stringy—and easier to choke on.
Dry mouth can be caused by a number of things, including dehydration, mouth breathing, antihistamines, blood pressure drugs and certain other medications.
What helps: Mouthwashes and oral rinses made especially for dry mouth help stimulate the flow of saliva. Good brands to try are Biotene and ACT. Chewing gum also can get your salivary juices flowing. Sipping water frequently throughout the day also helps. Ask your doctor whether a medication you’re taking causes dry mouth and, if so, whether switching to an alternative makes sense.
Another cause of thick saliva is having too much mucus in your nasal passages, possibly because of postnasal drip from a cold or allergies. Using a saline nasal spray, a neti pot or a pulsating water nasal irrigation device can thin mucus and open clogged sinuses—as can drinking hot beverages.
If these remedies don’t help, or you if you seem to be choking on saliva frequently—especially if choking happens not just from saliva but also when you try to swallow foods or drinks—you should talk to your regular doctor or an otolaryngologist to rule out another health problem. There are many conditions ranging from mild to serious that can affect swallowing—examples include Sjögren’s syndrome, an autoimmune disorder that causes the mouth and eyes to dry out…Parkinson’s disease, which weakens muscles including those in the throat…and gastroesophageal reflux disease (GERD), which can cause choking when stomach acid backs up into the throat.
Recall that last time you had something “go down the wrong pipe”? You spent the next several minutes coughing, choking and feeling like something bad was in your throat.
It may seem strange to say this, but count yourself lucky.
Your brain was making you do the right things to keep what you drank or ate out of your lungs. The path for air to enter our lungs, the larynx (or voice box), is very close to the upper esophageal sphincter, the entry point for food and liquids to our esophagus. This close anatomical relationship of these two entry points means the brain must coordinate breathing, eating and drinking to ensure the lungs get only air and the esophagus gets only food or liquids. This coordination happens unconsciously, so we never really think about it until we get food or liquid in our airway.
As it turns out, millions of people with brain diseases, including those with Alzheimer’s, Parkinson’s, Lou Gehrig’s disease, stroke, multiple sclerosis and traumatic brain injury, have impaired swallowing. As a result, they are unable to protect their lungs in the way that a healthy person can.
The result is that millions of brain disease patients are at risk for inhaling food and saliva into the lungs, leading to death by pneumonia or even choking.
Detecting and treating impaired swallowing is important, particularly as the nation’s nearly 70 million baby boomers continue to age. Impaired swallowing is associated with many conditions of the elderly, and it is often severely underreported. Clinicians may not detect it or may see it as a side effect of another condition.
As a neuroscientist who has studied brain diseases, I know of no pharmaceutical companies that have drug discovery programs aimed at restoring weakened swallow and cough. And yet, it’s a major problem.
Hard to swallow, easy to choke
An important part of swallowing is complete closure of the larynx while food is moving through the throat. Disordered swallowing, or dysphagia, limits the ability of the muscles in the mouth and throat to move liquid or food into and through the esophagus and on to the stomach.
This inability to protect the airways and lungs increases the risk of pneumonia or choking.
In addition, many people with brain disorders experience reduced coughing, or a weakened ability to activate breathing muscles to generate airflows that eject material from the lungs. Weakened cough is caused by problems with nerves in our lungs that detect foreign material or with the brain driving the respiratory muscles.
Disordered swallowing can also be caused by problems with nerves in the neck. For example, people who have had cancer of the head or neck often undergo extensive surgery to remove the diseased tissue. This process can inadvertently damage nerves that are important for swallowing.
Sometimes, the swallowing impairment, rather than the primary brain disease, actually leads to death. When swallowing is impaired, it is more likely that material will enter the lungs and trachea during eating or drinking. This is known as aspiration. Aspirated food or drink “seeds” the lungs with material that is coated with pathogens from the mouth. These pathogens are not normally present in the lungs and can cause chronic inflammation and serious bouts of pneumonia.
When a weak cough is a bad sign
In patients with acute stroke, severe swallow and cough impairments occur at the same time. Our research has shown that the risk of aspiration due to swallow impairment can be predicted by weakened cough in patients with stroke or Parkinson’s disease. These findings indicate that brain diseases can lead to multiple impairments in how we protect our airways.
Another way of thinking about this problem is that the nervous system has many tools, or reflexes, that it uses to perform certain tasks. Each reflex has a specific function, and the brain coordinates the time of occurrence of each to optimize the result.
For example, a cough can eject material out of the airways into the throat and out of the mouth. Swallows frequently occur just after coughs to move material that was deposited into the throat into the esophagus and then the stomach. The result is that lungs were cleared by coughing, and swallowing moved any remaining material out of the throat to prevent aspiration.
Nearly half of residents of long-term care facilities vulnerable to pneumonia
Patient in a care facility. Via . From www..com
Simultaneous impairments of cough and swallow lead to high aspiration risk. This high risk is due to seeding of the lower airways with harmful pathogens that increase the risk of pneumonia. Mortality rates of aspiration pneumonia have been reported of over 60 percent, leading to a US$4.4 billion medical burden from hospitalized patients alone in 1997. Aspiration pneumonia costs as much as $17,000 per hospital admission. Further, this type of pneumonia can occur in as many as half of long-term care residents.
When members of our research team talk to their friends about airway protection and its consequences, everyone seems to have a story. Most center around an older relative who had a brain disorder and the difficulties this person had eating. Often their relative choked when eating or had to eat special thick foods. These are signs of impaired swallow, cough and aspiration.
Speech pathologists specialize in diagnosing and treating swallowing disorders. They often recommend thick foods that are easier to swallow and less likely to penetrate the airways during swallowing. This clinical approach is the most well-accepted.
Some companies market devices that apply a weak electrical current to the neck to improve swallowing. The long-term benefit of these devices is controversial. Further, these therapies have not been shown to enhance a weakened cough reflex.
There are no drugs for the treatment of impaired swallow or cough. It appears that the pharmaceutical industry has not yet recognized the importance of prevention of aspiration in patients with neurological disease in disease outcome.
A team in Japan has promoted a comprehensive protocol using sensory stimuli such as menthol and capsaicin, the pungent ingredient in red peppers, to help elderly people who have serious impairments in swallowing. Their preliminary results show impressive improvements in reducing aspiration pneumonias in these patients.
There is a promising approach based on strengthening breathing muscles that has been shown to improve swallow and cough function in patients with Parkinson’s disease and stroke. This approach is called “expiratory muscle strength training,” and it is easy for health care professionals and most patients to perform. The extent to which this method can prevent pneumonia in at-risk patients is unknown at this time.
In short, while there are some promising approaches, there are no widely accepted therapies for restoring weakened swallow and cough in patients at significant risk of aspiration. Continued research on the fundamental neurological mechanisms of coughing and swallowing will provide a foundation for new therapies to reduce the occurrence and severity of aspiration pneumonia.
Treatment for Swallowing Problems
A speech therapist can also help with swallowing problems. She might suggest changes in diet, positioning of your head, or exercises that can help. In very severe cases, feeding tubes can deliver nutrients and fluids directly into the stomach.
Along with therapy, there are things you can do to make swallowing easier:
- Sit upright at a 90-degree angle, tilt your head slightly forward, or stay sitting or standing upright for 45 to 60 minutes after you eat.
- Stay focused on the tasks of eating and drinking. Keep distractions away. Don’t talk with food in your mouth.
- Go slowly. Aim to eat about 1/2 teaspoon of your food at a time.
- You may need to swallow two or three times per bite or sip. If food or liquid catches in your throat, cough gently or clear your throat, and swallow again before you take a breath.
- Concentrate on swallowing often. Try alternating a bite of food with a sip of liquid.
- Try different temperatures and textures of liquids. For example, you can make drinks colder or try carbonated beverages.
- Drink plenty of fluids. Suck on popsicles, ice chips, or lemon-flavored water to get your mouth to make more saliva, which will help you swallow more often.
- If chewing is hard for you, stay away from foods that need a lot of jaw power.
- If thin liquids make you cough, try thickening them. You can also substitute thin liquids with thicker ones — nectars for juices and cream soups for plain broths, for instance.
- When you take medication, crush your pills and mix them with applesauce or pudding. Ask your pharmacist to let you know which pills you shouldn’t crush and which medicines you can buy in a liquid form.
Different techniques help with different problems, which is why it is important to have the advice of a health professional to help find what suits you. They may suggest some of the following techniques for you, your family or carers:
Keep a good, upright posture when eating and drinking. A physiotherapist can help with this. Stay upright for at least 30 minutes after a meal. You may also want to read MS Essentials Factsheet: Posture and movement 1 – an introduction and MS Essentials Factsheet: Posture and movement 2 – moving well with MS.
Eat in a relaxed atmosphere. Swallowing can be easier if you’re relaxed. Being relaxed might help you concentrate on your swallowing, or help your swallowing muscles work as best as they can. Some people find it best to eat in a quiet atmosphere, without radio, TV or conversation for distraction.
Don’t rush a meal. If the swallowing process is not in perfect working order, allowing it the time to deal with each swallow in turn can be helpful.
Chewing well helps get the food ready for swallowing, mixing it well with your saliva.
Alternate liquid with solid
For some people, swallowing problems mean that food gets stuck, or travels only very slowly towards the stomach.
Drinking between mouthfuls can help keep the food moist and wash it down.
Avoid speaking whilst eating
The two different processes can interfere with each other and could increase the chance of choking.
Adapt the food you choose
There are ways of adapting the food you like to suit you better. If very thin liquids are likely to go down the wrong way, thickeners could make them easier to swallow. You might try eating softened foods, or moistening dry foods, perhaps with a sauce. Speech and language therapists can suggest ways to get the right consistency for you.
Get nutritional advice
To make sure you get the nutrition you need, a dietitian can help you plan what you eat. For example, if you find it uncomfortable to eat larger meals, then smaller, more frequent meals and milky drinks might help you get enough calories.
Nutritional supplements are helpful for some people.
> Find out more about diet and MS
MS and Trouble Swallowing
Multiple sclerosis (MS) is a chronic, progressive condition that affects the central nervous system. As MS causes damage to the nerves, it can cause a disruption in how a person moves, thinks, and feels. One of the symptoms MS can cause is difficulty swallowing, which is referred to medically as “dysphagia.”
The normal swallowing process
There are several things that occur during a normal swallow reflex. When things are working properly, this happens without much thought, but when difficulties arise, it can be helpful to understand how the process normally functions. Experts have categorized the swallowing process into three phases:
- Oral phase – in the oral phase, food is chewed and combined with saliva to form a bolus. The tongue helps move the food around the mouth for chewing and moves the bolus to the back of the mouth.
- Pharyngeal phase – in the pharyngeal phase, the vocal folds close and the epiglottis covers the larynx (the entrance to the lungs) to keep food and liquid out.
- Esophageal phase – in the esophageal phase, the bolus moves into the esophagus, the tube that connects the mouth to the stomach.1
Symptoms of trouble swallowing
Dysphagia is characterized by being unable to swallow, having food get stuck in your throat, coughing while swallowing, or a choking sensation. Disturbances to any of the three phases can cause difficulty swallowing.1,3
If an obstruction of food causes choking, immediate attention is required. Fast action can save the life of a person who is choking. Abdominal thrusts, also called the Heimlich Maneuver, can be done by another person or by yourself to force air up the windpipe and expel the lodged food or object.4
How common is it among people with MS?
It’s difficult to give an exact estimate on how many people with MS experience dysphagia. As with many features of MS, each person experiences symptoms uniquely. One study that measured how people with MS swallowed found that 43% of them experienced abnormal swallowing, although almost half didn’t complain of it.2
In our Multiple Sclerosis In America 2017 survey, 24% of survey respondents noted they were currently experiencing trouble swallowing at the time of the questionnaire, and 57% said they had experienced trouble swallowing at some point. Dysphagia that occurs with MS may be occasional, or it may happen frequently or almost all the time.
What you can do
If you’re experiencing trouble swallowing, it’s important to speak to your doctor about it. Your doctor needs to understand all your symptoms to provide you with the best approach for managing your symptoms, and you may also receive a referral to a Speech Language Pathologist. Despite their title, Speech Language Pathologists can assess, diagnose, and treat swallowing disorders, in addition to their expertise in speech and language disorders.5
In addition to getting professional help, some people find that eating slowly, sitting up straight while eating and drinking, and chewing food thoroughly can help reduce the risk of choking.3
Bite, Chew, Swallow: How to Deal With Dysphagia When You Have MS
Suddenly being unable to swallow is scary, to say the least.
“When dysphagia — trouble swallowing — strikes, I can feel my adrenal glands kick in, my eyes widen, and a feeling of genuine panic for my life arise,” says Trevis Gleason, 50, a former chef who blogs for Everyday Health about living with multiple sclerosis (MS).
“I’ve even had to have someone perform the abdominal thrust maneuver when I went into a full choke,” he says.
While Gleason experiences swallowing issues only occasionally, dysphagia can be a persistent problem for some people with MS.
What Goes Wrong With Swallowing
The reasons swallowing problems arise are complex because swallowing itself is complex.
“There are 17 components that work together during the two-second period in which swallowing occurs,” says Martin B. Brodsky, PhD, assistant professor and speech-language pathologist in the department of physical medicine and rehabilitation at Johns Hopkins University School of Medicine in Baltimore.
Of the 12 cranial nerves in the brain, Dr. Brodsky says, half are devoted to swallowing, and these 6 cranial nerves control upward of 30 pairs of muscles.
In a properly executed swallow, the airway is closed tightly before the swallow is initiated and food or liquid enters the throat. Once the swallow is complete, and the food or beverage is gone, the airway opens back up.
Swallowing issues related to multiple sclerosis are usually due to problems in the timing, or coordination, of a swallow or to weakness in the muscles used to swallow.
When the timing of a swallow is off, food or liquid in the mouth drips down into the throat before the swallow is initiated and the airway is closed off.
“Because you haven’t initiated the swallow in a timely manner,” Brodsky says, “you now have the opportunity for the food to drop into the airway, and you can have coughing or choking before the swallow begins.”
RELATED: Speech Therapy Can Improve MS Symptoms
Weak Swallowing Muscles
When the muscles involved in swallowing are weak, the swallow may be initiated properly and the airway may close, so it’s protected, but not all the food or liquid goes down. That means that when the swallow is complete and the airway opens back up, a residue of leftover food and drink is left in the throat.
“This is the reason most patients with MS have problems,” says Brodsky. “Over time, that residue builds up, and eventually there may be a tipping point. The areas within the throat that are capable of keeping the person safe under most circumstances are filled.”
When food or liquid enters the airway, it’s called aspiration. If the person cannot cough out the material that was breathed in, it can lead to a potentially life-threatening lung infection known as aspiration pneumonia. In fact, aspiration pneumonia is one of the leading causes of death in MS (although swallowing problems are just one of many risk factors for developing it).
Figuring Out the Problem
To determine why swallowing difficulties are occurring, a speech-language pathologist will conduct one or a combination of the following exams:
Oral Motor Exam In this exam, the speech-language pathologist takes a look at the person’s mouth, how he is swallowing, and the way his tongue moves and listens to how his voice sounds.
“We may say, ‘Stick out your tongue, lift it up, push it down, move it left to right, put your tongue against your cheek,’ etc. We also test strength and sensation,” says Brodsky.
Instrumental Evaluation Two tests using instruments are performed to look at the physiology of swallowing:
Videofluoroscopy is a moving X-ray that looks at the digestive tract from the lips down to the stomach. During the exam, patients are given different consistencies of foods and liquids to swallow to see which they can handle more easily. “We care more about how thick food is, such as water versus pudding, more so than how smooth or rough it is,” says Brodsky.
Fiberoptic endoscopic evaluation of swallowing involves inserting a tiny camera through the nose to the back of throat so the speech-language pathologist can see the throat during swallowing. “We can’t see the oral cavity using the camera, so anything that’s going on with chewing or the tongue or where the food is in the mouth we won’t see. But I can see if the food or liquid has dropped past the tongue in the mouth before the person swallows, and see why they are aspirating,” says Brodsky.
Once a cause is determined, a speech-language pathologist considers what approach might help to improve swallowing. But Brodsky says there is no such thing as a one-size-fits-all solution, and a combination of approaches is often used.
“For some patients, a head turn works. For others, it may be a maneuver and a posture change. And sometimes when you think you’ve fixed one problem, you may have inadvertently created another,” he says.
Adjusting one’s thinking can also be a challenge, adds Gleason.
“There is an apparent dichotomy between what we think we should do, and what we must do to minimize choking risks — for instance, tilting the head down rather than back to open the esophagus feels unnatural, or thickening very thin foods so that they are recognizable to the senses when we think we should thin things to make them go down easier,” he says. “It’s not hard to learn. What’s difficult is to replace the innate reactions with learned behaviors I know could save my life.”
Changes in posture while swallowing can change the direction of or control the flow of liquids and foods.
“This is something patients can do with their body, typically their head, such as turn their head or tuck their chin,” says Brodsky. “But it’s different for everyone, and takes trial and error during an instrumental evaluation to see what helps.”
Posture changes have helped Gleason somewhat. “Putting my chin to my chest can help to open the esophagus while closing off the airway a bit. This can help me sometimes,” he says, adding “though I must say that being that conscious of the right action in the moment can be tough.”
Maneuvers are specific techniques to change the timing of swallowing, keep the airway closed, or help move food and liquids out of the mouth and into the throat. Which maneuvers are recommended depend on what’s going wrong in a particular person’s swallow.
An example of a maneuver is to hold one’s breath before and during a swallow.
“When functioning properly, as we swallow, we are forced to hold our breath because the airway closes when we swallow,” Brodsky explains. “So before a patient swallows, I can ask him to take in some air, hold it, then swallow. When you voluntarily hold your breath, your vocal cords close, and therefore your lower airway is protected and food or drink won’t drip into it.”
Changing the Consistency of Food and Liquid
Changing the volume or consistency of foods and liquids can sometimes make them safer to consume.
“For example, I can give you a teaspoon of water, a tablespoon of cream soup, or a bite of a graham cracker,” says Brodsky. “Not only are these all different consistencies, but they are different volumes. Smaller is often better, but not always, depending on the patient.”
While the speech-language pathologist helps patients determine which consistencies and volumes are safest for them, a dietitian can help ensure the food is providing proper amounts of carbohydrates, protein, fats, and other nutrients, as well as help improve the tolerability and likability of food.
“Most of the patients I see never see a dietitian,” says Brodsky. “The patients are manipulating the consistency of their own food, not its nutritional content. However, the dietitian can come into play where nutrition is a concern.”
Strengthening Exercises for Better Swallowing
A variety of exercises may also help to improve swallowing.
“Simply turning your head or doing a maneuver does not improve physiology,” says Brodsky. “We don’t want patients doing this the rest of their lives.”
The good news, he says, is since MS responds well to exercise — and swallowing is about muscle coordination — patients can push to fatigue, rest, and then continue with the exercises. The specific exercises that will help vary from person to person, so ask your physician or speech-language pathologist to show you the ones that will help you.
In addition, if swallowing problems arise during an MS relapse, “Chances are, the impairments we find during the exam will improve to the point where they may not have to do the head turn for a while until the next exacerbation of MS,” Brodsky says.
But “some MS patients may not get back to baseline” after a flare, “so what we are trying to do is maintain and keep swallowing issues from getting worse.”
Neurological conditions: MS, Parkinson’s disease, ALS
- MS – Multiple Sclerosis
- ALS – Amyotrophic Lateral Sclerosis
- Training and rehabilitation
Neurological conditions like MS, Parkinson’s and ALS can all, more or less, cause reduced ability to use the face’s and mouth’s functions like being able to eat, chew, swallow, speak and smile.
In this section we briefly describe MS, Parkinson’s, ALS and the usual symptoms for their diagnosis. MS, Parkinson’s and ALS differ symptom-wise but have similar problems and requirements for treatment. Later, we will show how exercise with IQoro can function as a complement to traditional physiotherapy to maintain the health of the body’s, face’s and mouth’s functions as long as possible. IQoro is a new and unique neuromuscular treatment method that requires just 30 seconds’ exercise, three times per day.
Neurological conditions: MS, Parkinson’s disease, ALS
Neurological sicknesses affect the central nervous system: both the brain and the spine and also those nerves out in the body – the peripheral nerve system – which sends, for example, signals to and from our fingers and the central nervous system. Also affected are those nerves that control our inner organs, the autonomic nerve system, which cannot be controlled voluntarily. In summary, all of these nerve systems can be affected to different degrees depending upon which neurological condition is present.
In all of these neurological sickness groups there will exist symptoms of dysphagia, eating-, chewing- and swallowing difficulties to different degrees depending upon the exact condition and its severity.
There is a large range of medical conditions that are classed as neurological diseases, or that affect the central nervous system.
- Sicknesses where functionality is impaired or ceases to exist in cells, tissue or organs: degenerative diseases like for example Alzheimer’s or Parkinson’s disease.
- Multiple sclerosis (MS).
- Stroke. Read more about stroke here.
- Cerebral palsy (CP). Read more about cerebral palsy here.
- Tumours, including brain tumours and tumours in the spine and peripheral nervous system. Read more about ’cancer of the face, mouth, head and neck’ here.
- External trauma or injuries to the brain, spine or peripheral nerves. Read more about injuries to the head or neck region here.
- Infections in the brain like encephalitis and meningitis, for example as caused by lyme disease.
Certain of these sicknesses arise spontaneously through injuries but others occur in bouts or are degenerative. In the rest of this document we cover only MS, Parkinson’s and ALS.
Numbers affected in the UK, and the world, showing the proportion with swallowing difficulties, dysphagia:
The NHS say that it’s estimated that there are more than 100,000 people diagnosed with MS in the UK.
It’s most commonly diagnosed in people in their 20s and 30s, although it can develop at any age. It’s about two to three times more common in women than men.
Of these 100 00 sufferers, the MS society estimates that 30-40% of people with MS may experience swallowing problems. https://www.mssociety.org.uk/search#resultType=list&q=Dysphagia&sort=relevance&page=1&results=20
In Sweden there are 17,000 – 18,000 people affected, with approximately 500 new sufferers each year.
Is the most common neurological sickness amongst moderately older women in the world, of which approx 50% are in Europe. Most common amongst populations in Europe and North America – and very uncommon in large parts of Asia and Africa.
In the UK, the NHS says https://www.nhs.uk/conditions/parkinsons-disease/ that It’s thought around 1 in 500 people are affected by Parkinson’s disease, which means there are an estimated 127,000 people in the UK with the condition.
Most people with Parkinson’s start to develop symptoms when they’re over 50, although around 1 in 20 people with the condition first experience symptoms when they’re under 40.
Men are slightly more likely to get Parkinson’s disease than women.
In Europe there are between 4.06 – 7.89 victims per 100,000 of the population and 1.47 – 2.43 new sufferers / 100,000 each year. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049265/ More men than women are affected.
In the UK this translates to approx. 950 to 1600 new cases every year, and a population of 2600 to 5100 sufferers.
Of these, dysphagia emerges in more than 80% of patients during the advanced phases of the disease https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359548/
MS – Multiple Sclerosis
MS is a sickness of the central nervous system caused by inflammation and scarring of the nerves. This prevents the nerve signals being transmitted properly, which then affects various functions. Because various areas of the central nervous system can be affected, the symptoms strike different parts of the body. The sickness exists in several different forms.
MS often comes in bouts with periods of sickness. Over the years the symptoms can give problems even during the periods between attacks. The symptoms vary greatly from person to person.
Common symptoms of MS
- Become weaker, or have poorer control over certain muscles.
- Sensory symptoms, parasthesias: numbness, tingling, pins and needles.
- Impaired balance.
- Eyesight disturbances
- Swallowing difficulties – dysphagia – in 33% of those affected
In Sweden there are approximately 18,000 people with the sickness and 500 new cases each year. The sickness is the most common reason for neurological injuries in the moderately old in the world, of whom roughly half are in Europe. The disease usually strikes between 16 and 55 years of age, and occurs twice as often in women as in men.
There are a range of different options to minimise the effects of then sickness and an important part of treatment is physiotherapy and personal training to strengthen and keep the affected muscles in good shape.
Parkinson’s is a relatively common progressive neurological sickness that affects primarily older men. There are, however, cases of 20-year-olds being affected. In Sweden, there are approximately 20,000 sufferers and around 2,000 new patients are diagnosed each year. The disaese is caused when cells in a part of the brain break down, and affect the manufacture of dopamine, which impairs the ability to control the body’s movements and causes them to be slower.
Usual symptoms of Parkinson’s
Each person with Parkinson’s has individual symptoms, some have shaking and others have muscle stiffness as the primary symptom. The common symptoms, however, are:
- Shaking of the hand (tremors) – the first symptom in 75% of cases with, for example, trembling whilst resting, the thumb moving towards the index finger in an uncontrolled motion.
- Trembling in the body, starting first on one side, but in time affecting both sides.
- Stiff muscles.
- Walking becomes shambling.
- Reduced facial mobility.
- Monotonous voice.
- Swallowing difficulties – dysphagia – in 41% of those affected.
In Parkinson’s too, physiotherapy is an important part of rehabilitation to reduce the symptoms and improve everyday life.
ALS – Amyotrophic Lateral Sclerosis
In Sweden, there are approximately 700 sufferers and about 200 new cases are diagnosed each year. Two of three victims are men. The sickness usually appears between 45 and 60 years old, but younger cases occur too. Swallowing difficulties – dysphagia – are a common symptom in various types of ALS and affect 40 – 90% of sufferers.
There are five varieties of ALS: Classic ALS – Amyotrophic Lateral Sclerosis, progressive bulbar palsy, pseudobulbar palsy, progressive spinal muscular atrophy, and primary lateral sclerosis. Symptoms of these five variants are slightly different but, in most cases, end in almost total paralysis.
Usual symptoms of ALS – speech and swallowing difficulties
1. Classic ALS – amyotrophic lateral sclerosis
- Weakening of the muscles in the arms and legs – appear as first symptoms.
- Chewing difficulties.
- Speech difficulties.
- Difficulty with facial expressions.
- Swallowing difficulties – dysphagia.
2. Progressive bulbar palsy
- Speech and swallowing difficulties, dysphagia – appear as first symptoms.
- A complete inability to speak and swallow – occurs later.
- Problems with arms and legs – in the next phase.
3. Pseudobulbar palsy
- Speech and swallowing difficulties – dysphagia – increasing severity.
- Facial mobility affected.
- Uncontrolled crying and laughing.
4. Progressive spinal muscular atrophy
- Weakness and withering in the musculature in the arms and legs, increasing severity.
- Reduced mobility, gradual deterioration.
- Note: speech and swallowing functions are never affected.
5. Primary lateral sclerosis
- Paralysis in the body combined with stiffness in the musculature, spasticity, slowed mobility and gradual deterioration.
- Speech difficulties.
- Swallowing difficulties.
- Slow progression of the disease over many years.
Training with IQoro® – a complement to rehabilitation
IQoro is a new and unique neuromuscular treatment method that requires just 30 seconds’ exercise, three times per day. Exercising with IQoro can contribute to retaining and maintaining as much as possible of the normal functions for an extended period. This is possible because IQoro activates the internal involuntary muscles in the same way that traditional physiotherapy strengthens arms and legs. Training with IQoro therefore it makes a positive difference in the ability to continue to eat via the mouth, chew, use facial expressions and to form sounds (speak) for an extended time.
IQoro is unique in being able to effectively activate the involuntary musculature from the face, oral cavity, pharynx, and the esophagus, down to the diaphragm. The treatment is a good complement to physiotherapy as only a short exercise period is required – one and a half minutes per day, and that the training has no negative side effects except for possible exercise stiffness in the early days. IQoro cannot, of course, treat the underlying disease.
See here how you train with IQoro
Optimise the conditions for successful PEG feeding
Even in those cases where the PEG (Percutaneous Endoscopic Gastrostomy) is unavoidable, it is still of great importance to maintain the muscle functions which are involved in the entire swallowing process: from mouth to stomach. This is to optimise the stomach’s ability to receive normal amounts of nutrient and to avoid long, drawn-out mealtimes – which can take longer than 30 minutes via a PEG.
Training with IQoro before being fed via a PEG, and stimulating the taste function – perhaps with a net of varying tastes and consistencies in the mouth – during the PEG session, contribute to stimulating and maintaining the muscle functions that are involved in the swallowing process. Taken together, these actions can improve the conditions for PEG continuing to work.
See here how you train with IQoro
IQoro® acts on the entire swallowing process
Research shows that IQoro acts on, and regenerates, the entire swallowing process. It stimulates the sensory nerves in the mouth, and by doing this, reaches the brain’s control system for the swallowing process, which is closely linked to the control systems for other bodily functions, including breathing, the ability to form sounds (speech), facial expression, postural control , stomach and intestine functions, and more. This explains why exercising with IQoro can have a positive effect on so many different bodily functions.
It is not scientifically proven that IQoro has an effect on MS, Parkinson’s or ALS sufferers. However, it is highly credible that IQoro can work as a complement, because the majority of research supporting use of the device has been carried out on stroke patients who are also, of course, suffering from a neurological disease. As well as this, there is clinical experience of treatment of people with the above conditions and over 20 years’ of research.
Read more about the research here