Written by: Kendra Wormald / Medical Rehabilitation / August 02, 2023 / 10 minutes read

This piece serves as a contribution to the series investigating neurodegenerative conditions from the perspective and scope of a Speech-Language Pathologist.

1. Definition 

2. Prevalence

3. Cause 

4. Symptomatology

5. What Can Be Done?

Multiple Sclerosis (MS) is a chronic and typically progressive autoimmune disease where damage to nerve cell sheaths occurs in the brain and spinal cord (MS Society, 2023).

Myelin sheath serves as a protective covering of nerves and facilitates the transmission of nerve impulses through nerve fibres. In MS, the myelin sheath is mistakenly attacked by the immune system, leading to demyelination. If scar tissue (sclerosis) replaces the myelin, nerve impulses may become disrupted to varying degrees (Mayo Clinic, 2022). This gives MS its name, Multiple Sclerosis  meaning ‘many scars’.

With 90,000 Canadians living with MS, Canada has one of the highest rates of this disease occurring. On average, roughly 12 Canadians are diagnosed with MS everyday, often between the ages of 20-50. There are on average 2.8 billion people worldwide with MS (MS Society, 2023).

There are several possible causes of MS such as autoimmune diseases, infectious agents, such as viruses, environmental and genetic factors. There are roughly 200 genes identified as contributors to the overall risk of developing MS (MS Society, 2023).

Contributing Factors:
(My-MS.org, 20014, National MS Society, 2023, MS Canada, 2023) 

Age: Onset typically occurs around 20 to 40 years of age

Sex: Women are more than 3x more likely than men to have relapsing-remitting MS
where symptoms get worse, followed by recovery in a cyclical pattern.

Family: If a family member has had MS, you are more likely to develop the disease

Infections: A variety of  viruses are linked to MS, such as Epstein-Barr, the virus causing infectious mononucleosis.

Race: Those with Northern European descent are more likely to develop MS. People of Asian, African or Native American descent have the lowest risk.

Climate: MS is far more common in countries with temperate climates. Your birth month may also impact your likelihood of developing MS.

Vitamin D: Low levels may result in MS.

Obesity: This link has been found more so in females, specifically childhood and adolescent obesity.

Genes: A gene on chromosome 6p21 has been found to be associated with multiple sclerosis.

Autoimmune Diseases: Increased risk if you have disorders such as thyroid disease, pernicious anemia, psoriasis, type 1 diabetes or inflammatory bowel disease.

Smoking: Smokers who experience initial symptoms of MS are more likely for a second events confirming relapsing-remitting MS to occur 

(National MS Society, 2023, NHS, 2022, John Hopkins Medicine, 2023, MS Society, 2023)

Without the protective layer of the myelin sheath, communication between cells is disrupted, leading to the body not receiving instruction necessary to perform basic tasks such as speaking, walking, learning, and seeing. MS can also have a significant impact on energy levels, sleep and quality of life (National MS Society, 2013). The following outlines symptoms related to the scope of a Speech-Language Pathologist. For a more comprehensive list of symptoms, see here.

Cognition: Approximately 50% of people with MS will develop problems with cognition. MS may lead to atrophy of the brain, decreasing its size and optimal functioning

• Memory or Recall: This is the most frequently reported problem. Memory loss tends to present as difficulty recalling more recent events and trouble with new learning. 

• Processing Speed: Both recall and verbal fluency will be interrupted as they require rapid information processing. 

• Abstract reasoning/ Problem Solving: Problems with analyzing, identifying and rationalizing problems may occur in addition to difficulty with planning and sequencing

• Visual-Spatial Abilities: Reduced ability to recognize, draw or assemble objects

Speech 

• Verbal Fluency: Frequent occurrence of ‘tip of the tongue’ phenomenon where word finding becomes difficulty 

• Dysarthria: Disrupted muscle coordination paired with muscle weakness may lead to slurred speech overall resulting in reduced speech intelligibility. ‘ Scanning dysarthria’ is often found in MS, whereby speech is slurred and monotonous. This may present as, Mispronunciation of words, failing to complete words and sentences and long pauses between words or syllables  

• Dysphonia: Impairment of the voice presenting as hoarseness, raspy speech or changes in pitch and difficulty controlling volume. 

Swallowing 

• Dysphagia: Often occurring at more severe stages. Nerve disruption may affect the coordination and strength of automatic movements throughout different phases of swallowing. This may lead to aspiration, or food going ‘the wrong way’ and ending up in the lungs, potentially causing further health concerns. Food may feel stuck in the throat, a choking sensation, unexplained recurrent lung infections (pneumonia), malnutrition and coughing while eating/drinking.

• Chewing (mastication): Muscle coordination, strength and fatigue may make chewing challenging. Numbness can make it difficult to feel and manipulate food and liquid in the mouth

(National MS Society, 2023, NHS, 2022, John Hopkins Medicine, 2023, MS Society, 2023)

A Speech-language Pathologist will offer support depending on the severity and individual experience of Multiple Sclerosis. An SLP may suggest the following strategies to aid with speech, swallowing and communication: 

Cognition: 

• Using exercises to retrain discrete cognitive processes such as attention

• Using internal memory strategies or spaced retrieval training to solidify memories

• Compensatory strategies: 

• Where memory is weak, write it down 

• New learning supported by increased time 

• Store important things in one spot 

• Plan most challenging cognitive tasks for your best time in the day 

• Use mental pictures to aid memory 

• Key wording used by communication partner 

• When struggling to find a word don't continue to try to find it, shift attention to something else

Voice: 

• Amplification system or Augmentative Alternative Communication 

• Ensure focus is on abdominal breathing v.s. short shallow breaths.
  To learn more about Breath in communication, see here  

• Straw Phonation (SOVT): Narrowing or partial occlusion at the mouth (“oo”, straw phonation, lip trills, fist at mouth, cup with water) 

• Resonant Voice Therapy: Voice has forward focus → voice should feel easy and should feel vibration in face

• Vocal Function Exercises:  Series of systematic vocal manipulations designed to strengthen and balance the laryngeal musculature

• Manual Therapy: Any type of physical manipulation or touch to neck/laryngeal area

• Strategies: Slow speech rate, shorten breath groups if respiration support is compromised, exaggerated articulation, repetition, awareness of message breakdown, energy conservation 

• Vocal Hygiene 

Swallowing: 

Three different approaches: 

• Strength training = targets specific muscles or muscle groups and considers load, intensity and dosage 

• Skill-based training = Focuses on specificity of practice (skills must be directly relevant to desire motos task), challenge (task should continue to challenge the patient) and feedback (patient should have feedback about performance)

• Compensatory Strategies: Compensate for the swallowing problem; they do not change swallowing physiology, but rather external factors to improve swallowing function. Examples: 

     - Sit upright at a 90° angle during and for at least 30 minutes after eating

                       - Minimize distractions.
                      - Avoid watching TV, reading or speaking while eating/ drinking

                       - Eat slowly, and take small bites, ensuring your food is fully chewed 

                       - Swallow multiple time to clear residue 

                       - A change in diet texture may be necessary 

A Speech-Language Pathologist will work with you to devise a plan to support you within their scope of practice. Intervention will change as the disease progresses, where you may need more and less support in the areas mentioned above.

To speak with a psychotherapist or one of the speech-language pathologists at Well Said: Toronto Speech Therapy, schedule an initial consultation by clicking the link below or calling (647) 795-5277.