communication and swallowing impairment in ms: 'a view from everyday clinical practice' -...

Management of Communication and Swallowing Impairment in MS:

‘a view from everyday clinical practice‘

Maggie GriffithPrincipal Speech and Language Therapist.

Herts Community NHS Trust

Session Aims

• Increase knowledge base of swallowing mechanics and impairment

• Understand SLT’s scope of practice and interventions

• Consider impact of interventions• Gain practical advice for patients • Experience for yourself texture modification

Overview

• Normal swallowing mechanics• Dysphagia in MS – prevalence and risk• Swallow impairments in MS signs and

symptoms • Assessment and management • Impact of swallowing interventions• Communication impairments• Case Histories

Swallowing

• Upper aerodigestive tract has dual functions via the same anatomic pathway

• Swallowing depends on configuration of structures that change respiratory path to a digestive one and then reconfigures back to a respiratory one

• Complex process with multiple modalities including motor, sensory and psychological components

• More than 40 muscles involved• Speed of swallowing 600-1000ms – healthy

Normal swallow

Normal biscuit swallow

Normal Liquid swallow

Oro-pharyngeal swallow stages

• Has voluntary and reflex elements• Pre-oral –ability to take sip from cup or food from spoon/ fork and

transfer into front of the mouth• Oral – formation of bolus ie gathering it up and containing it

between tongue and palate• Includes mastication – break down food and mix with saliva ,

moving it from one side to the other using the tongue , forming cohesive bolus

• Action of soft palate and tongue prevent loss over back of tongue prior to swallow trigger

• Transfer of bolus posteriorly towards faucial arches where swallow reflex initiated

Oro-pharyngeal swallow stages 2

Tongue base moves downwards to drop bolus into the vallecular space and palate raises to prevent reflux into nasopharynxTongue base contacts posterior pharyngeal wall and both constrict to propel bolus down towards oesophagus Simultaneously the hyoid bone is pulled up and forwards elevating the larynx with it Larynx closes at 3 levels Upper oesophageal sphincter relaxes and allows passage of bolus – beginning of oesophageal phaseLarynx descends to normal position and airway is open

Neuroanatomy of Swallowing

• Motor nuclei and pattern generators for reflex are located in the brainstem – nucleus tractus solitarius and nucleus ambiguous- major contribution of cranial nerves

• Cortical control in precentral and inferior frontal gyrus and regions adjacent to sylvian fissure and lateral precentral cortex - required for voluntary control and some parts of pharyngeal phase

Overview

• Normal swallowing mechanics• Dysphagia in MS – prevalence and risk• Swallow impairments in MS signs and symptoms • Assessment and management • Impact of swallowing interventions• Communication impairments• Alternative and augmentative communication• Case Histories

Prevalence

• Systematic review in 2015 Guan 1 et al confirmed that more than 1/3 of people with MS have swallowing difficulties

• Study by Astero Constantinou at Trinity Dublin (unpublished)• Examined a representative sample with wide age range and

disease progression• Mild dysphagia 46%, very small percentage had severe

problem• Males with more than 15 yrs of disease at highest risk had

more severe dysphagia • Being female 82% less risk of dysphagia

Overview


Impairment

• 53% oral phase impairment-prolonged preparation of the bolus , prolonged mastication, reduced lingual coordination, delayed initiation of pharyngeal swallow

• 68% Pharyngeal phase impairment – reduced tongue base retraction, poor laryngeal elevation and closure resulting in penetration into larynx

Why is it important to manage dysphagia in Neuromuscular Disease?

• Reduce risk of respiratory infection• Maintain nutritional and hydration needs • Preserve quality of life and psychosocial

benefit of eating and drinking

Mild impairment- signs and symptoms

• I can’t drink continuously• I can’t take large amounts• It takes me ages to eat a meal • Sometimes I seem to forget to swallow • Weight loss • Appetite loss • I cough on food and drink occasionally

Severe impairment

• Can be difficult to detect if cough reflex impaired

• Food sticking in throat• Poor ability to chew• Nasal regurgitation• Frequent for chest infections• Dehydration and malnutrition • Frequent coughing and choking

What is aspiration ?

• Bolus moves below the vocal folds or glottis = aspiration

• If bolus enters larynx but does not go below vocal cords it is termed ‘laryngeal penetration’

• What causes aspiration pneumonia ? • -infected saliva• -orally ingested material • -gastroesophageal contents

Aspiration

Aspiration Pneumonia

• Not all patients who aspirate material into their lungs will develop aspiration pneumonia

• Strong cough can eject matter from larynx and then even if it enters lungs it can trigger a secondary cough

• Immune response from cells in lungs absorb and transport foreign materials out of the lungs

• No studies to link amount and type of aspirant to development of pneumonia

Aspiration Pneumonia

• A predictive tool would make decisions around risk feeding much easier

• Risk factors identified ( in elderly) • - heart failure and COPD • -multiple medications esp sedatives• -dependence for feeding inc enteral feeding • -poor oral hygiene• Suctioning • bdebound

Overview


Investigating swallow problems

• Screening :

• Swallow specific questionnaires – EAT -10 (89% sensitivity) , Sydney Swallow Questionnaire- visual analogue scale , and Swallowing Disturbance Scale (79.7% sensitivity)

• Specific questionnaire for MS • DYsphagia in Multiple Sclerosis or

DYMUS• (Bergamaschi et al 2008)(2)

• Swallow screening tests – locally agreed

• Clinical assessment :

• Referral to SLT on identification of OD ( oro-pharyngeal dysphagia)

• Clinical (bedside =) swallow exam – only 60% reliable at detecting aspiration

• Use of cervical auscultation – no robust evidence to support it

• Pulse Oximetry-uses oxygen desaturation as a possible marker of aspiration but only one study supports its use

• Objective assessment : videofluoroscopy ( modified barium swallow ), feess- endoscopic evaluation of swallow – mainly looks at the pharyngeal phase

• Cough reflex testing

FEESS- endoscopic view

DYMUS

• Do you have difficulties swallowing solid food (such as• meat. bread. and the like)?• Do you have difficulties swallowing liquid (such as water,• milk, and the like)?• Do you have a globus sensation in your throat during• swallowing?• Do you have food sticking in your throat?• Do you cough or do you have a choking sensation after solid• ingestion?• Do you cough or do you have a choking sensation after• liquid ingestion?• Do you need to swallow more and more times before• completely swallowing solid food?• Do you need to cut food in small pieces before swallowing?• Do you need to take more and more sips before completely• swallowing liquid?• Do you have weight loss?

Aims of SLT working in Dysphagia

• Unique role in assessment diagnosis and management of OD • Overall aims• Detailed and accurate assessment –leading to accurate diagnosis –

this can assist with medical diagnosis • Maximising safety with regard to reducing or preventing aspiration• Balancing safety with quality of life and accounting for individual’s

preferences • Working with MDT ( esp Dietitians) to optimise Nutrition and

hydration • Stimulating improved swallowing with oral motor/sensory

exercises, swallow techniques and positioning

Swallowing Interventions

• Counselling and reassurance – demystify the swallow mechanism – explode myths eg I will choke to death on a liquid

• Show people their videofluoroscopy study –gives reassurance in mild cases and informed decision making in more severe cases

• Swallow manoeuvres- designed to maximise airway protection and optimise swallow biomechanics

Swallowing Interventions

• Swallow Rehab training specific muscular groups eg suprahyoids , tongue

• Different levels of evidence eg Shaker exercise or chin tuck against resistance- Level A (3)

• Expiratory muscle strength training • Electrical Stimulation (NMES ) – not endorsed

by RCSLT due to lack of quality evidence and therefore safety not ensured

Swallowing safely

• Posture – optimum sitting upright with chin tucked down • Allow plenty of time for E and D • Concentrate – avoid distractions • Smaller amounts and slow pacing • Masticate thoroughly before swallowing • Don’t talk while E and D • Manage fatigue – use snacks and have bigger meal

earlier in the day • Avoid mixing liquid and food in the same mouthful

Texture Modification-Fluids

• Why ? Slows down transit of fluid to allow more time to successfully coordinate swallowing . Can prevent aspiration .

• Stage 1 syrup -should pour like single cream• Stage 2 custard – should easily drop off spoon

but not pour • Stage 3 pudding – stays on spoon

Texture modification- Food

• SLT determines safe textures of fluids and foods for a given individual

• National descriptors of food from BDA , RCSLT,Nutrition Nurses, Hospital Caterers Assoc.(4)

• B=thin puree• C=thick puree• D=pre-mashed E=Fork mashable

Use of Thickener

• 2 main types- Xanthan gum based and maize starch • XG mixed differently liquid added to drink rather

than the other way round• Better compliance due to improved mouth feel ,

resistant to amylase • Standardised dosage • Mixing instructions are crucial – should not increase

in thickness after 1 min – if it does then it has been mixed incorrectly

PEG Feeding Decisions

• Ethical , moral and legal dilemmas- ‘right choice vs prudence’

• Human right to nutrition• Mental Capacity – can be very difficult to

establish with severe communication disability• Risks of PEG insertion – morbidity and

mortality• Provision of information essential• Need to be sensitive to diversity of opinions

Overview


Impact of altered eating : QoL and psychological burden

• Definition of altered eating by Duika Burgess Watson – reasearch at Durham University funded by NIHR(4)

• ‘any change of state of physical, emotional and social interactions around food that has a negative impact on health and well being ‘

• Accounts of food hedonics ‘ie flavour and texture’ very limited – the science of deliciousness

• V ltd research into how to improve appetite

Flavour

• Flavour comes from combined sensory input :smell , trigeminal nerve stimulation, temperature , texture, visual cues

Olfaction triggers powerful memories( retronasal olfaction stimulates the olfactory bulb associated with emotional memory) – research has shown that triggering smell memories can stimulate appetite even if they are not food smells

Consequences of altered eating

• Is putting someone on a modified diet a form of sensory deprivation ?

• Eating together strengthens family bonds- communal aspect of food

• Need to balance attention to physical anatomical and functional aspect with cognitive, cultural /social and emotional aspects of dysphagia

PEG Feeding Decisions

• Ethical , moral and legal dilemmas• Human right to nutrition• Mental Capacity – can be very difficult to

establish with severe communication disability• Risks of PEG insertion – morbidity and

mortality• Provision of information essential• Need to be sensitive to diversity of opinions

Overview


How is speech affected ?

• Mechanics of speech production • Respiration• Voice ( phonation)• Resonance• Articulation• Prosody-loudness, pitch patterns ( intonation) • Signals meaning and emotions

How it sounds

• Spastic –ataxic dysarthria ( slurred speech )• Voice sounds weak and strained ( absent in

severe ) • Pitch v variable • Articulation imprecise • Slow rate of speech

Communication Changes

Language • Naming• Word fluency • Verbal explanation and

reasoning • High level comprehension • Study by Klugman and Rose

2002 62% self reported these changes

Cognitive factors • Memory• Info processing speed• concentration

Communicative Participation

• Taking part in life situations• Affected by more than just speech and

language impairment eg fatigue, ataxia and spasticity, and vision

• Baylor , Yorkston et al 2013 – Communicative Participation Item Bank – tries to combine qualitative and quantitative information. Takes account of experience of people with the communication disorder

Interventions

• Improving compensation even when intelligibilty is 100%

• Voice quality and prosodic aspects such as intonation and loudness

• Once speech is severely affected it becomes very difficult to modify and use of AAC can be introduced

• Goals will depend on individual

Overview

• Normal swallowing mechanics• Dysphagia in MS – prevalence and risk• Swallow impairments in MS signs and symptoms • Assessment and management • Impact of swallowing interventions• Communication impairments• Alternative and augmentative communication• Case Examples

Case Example 1

• AB 45 year old• Referral stated ‘coughing and choking on food

and fluids daily’ No history of chest infections• Background secondary MS since 18 yrs –

ataxia onset a t 40yrs• Patient reported symptoms – liquids go down

the wrong way , choking on saliva, no problems with food

Case Example 1

• Clinical swallow assessment : NAD • No able to detect v subtle problems with bolus

control• Intervention: Reassurance and safety

instructions -specifically chin tuck • Referred for VF to get objective view of

baseline , and refine any therapeutic interventions. VF was within limits of normal

Case Example 1

• Review – c/o speech feels out of control and slurred and after a while talking ‘hearing dulls’

• Features noted on informal assessment • -100% intelligibility• -Articulation speed slows on multisyllabic words• -reduced pitch variation • Effortful and incoordinated breathing pattern in

speech • Mild ataxic dysarthrophonia

Therapy Aims

• Reduce level of neck tension to allow greater control of speech mechanism

• Improve coordination of breathing thereby reducing vocal tract tension

• Methods; neck and shoulder stretches with relaxation; strap muscle stretches ,hierarchical approach to coordination of phonation and respiration ( Accent Method )

• Mixed outcome for communication:• Understood and able to practise and apply

techniques- positive about feeling able to control speech better

• Not talking much – issues with depression and high cognitive demand of speaking

• Agreed discharge and ability to self refer

Case example 2 Maureen

• 60yrs MS since 2004 – no details on medical history

• Referred to SLT ‘ frequent coughing on food and saliva

• April2014 Clinical bedside eval – inconclusive as absent cough and already chesty referred for VF

• Vf- not done till july as had chest infection

Case example 2 Maureen

• VF- prolonged oral prep • delayed swallow trigger • poor clearance of pharynx• trace silent aspiration of thin liquids• Recommendations: stage 1 , puree , safe

swallow instructions• Outcome: declined thickener, having puree • 1 chest infection in a year

Maureen -Communication

• Requested communication review as having trouble making her needs known to carers and husband

• Ax : severe dysarthrophonia, output v slow and effortful , occasional words are intelligible only

• Consider low tech communication aid – use of low tech essential as precursor to high tech

• Alphabet chart – able to point but tremor is a problem, visual neglect, head support

• Agreed on combination of pictures/letters /words tailored to her needs

• Complex high tech AAC can be provided by regional specialist centres eg Cambridge CASEE

Case example 3 Helen

• 48 yr old Primary Progressive MS• Lived with children and twice daily carers• Ist contact July 2015: In-patient admission with

chest infection – medical discussion re CAP vs asp pneumonia

• Ref to SLT ‘mild swallowing problem’• Bedside evaluation: mild dysarthria, parameters of

OP sw not abnormal , • Recs: Normal fluids and diet

Case 3 Helen

• Nov 2015- IP admission frequent RTIs and UTIs• SLT r/v poor voluntary cough, mild to mod dysarthria, bedside eval not

sufficient to determine aspiration , referred for VF • VF Jan 2016 : reduced oral control, 1/3 silent trace aspiration on thin, delayed

reflex• Stage 1 and soft diet• Feb2016 : Readmitted with L basal consolidation, H declined thickener and

wanted to see VF • March 2016: OP appt showed VF – declined again • Jul 2016 adm with SOB , sats 80%, had recently choked on chicken , s/b physio

– used cough assist improved sats • Rec: stage 1 and soft diet • Sept 2016: OP , on stage 1 , no chest infection for 1/12 , putting on wt , in NH

References

• 1.Guan XL , 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

• 2.Bergamaschi, R ,Crivelli P et al J Neurol Sci 2008 Jun The DYMUS Questionnaire for the assessment of dysphagia in multiple sclerosis

• 3.Speyer R, et al Effects of therapy in oropharyngeal dysphagia by SLTs : a systematic review Dysphagia 2010:25(1)

40-65• 4.NPSA,RCSLT,BDA, National Nurses Nutrition Group, Hospital Caterers

Assocation. Dysphagia Diet Descriptors 2011• 5.Duika L Burgess Watson, Lewis et al Altered Eating: a definition and

framework for assessment and intervention

Useful Publications/ resources

• MS society swallowing and Speech difficulties leaflets

• https://www.mssociety.org.uk/ms-resources/swallowing-difficulties-booklet

• Communication aid provision:• Guidance for Commissioning AAC Services and

Equipment NHS England March 2016 • http://

www.communicationmatters.org.uk/page/aac-commissioning-england

https://www.mssociety.org.uk/ms-resources/swallowing-difficulties-booklet



http://www.communicationmatters.org.uk/page/aac-commissioning-england



communication and swallowing impairment in ms: 'a view from everyday clinical practice' -...

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