Ask the expert: speech problems

Some people with MS may experience problems with their speech. This can include slurred speech, poor voice quality and difficulty remembering words. These problems can be frustrating and, at times, can result in distressing experiences.

We spoke to speech and language therapist, Suzanne Buckley to find out what causes these problems and learn about some of the practical strategies that can help.

Suzanne: Speech is a wonderful thing; it's our most human characteristic and it is, without a doubt, the most highly skilled activity that we do. And we do it without even thinking! Speech involves the precise and rapid co-ordination of more than 80 different muscles, many of them paired. And your brain does all of this by sending and receiving 1,400 motor commands per second! These motor commands help to coordinate the muscle movements involved in speaking.

To help us understand the speech system and be able to explain it to people experiencing difficulties, we often like to break it down into five distinct parts:

• Respiration – This is the air from our lungs, without which we'd only be mouthing the words.
• Phonation – This happens when air from the lungs vibrates your vocal cords to produce sound. Without this vibration you would be whispering.
• Articulation – This is when we shape the air coming through into consonants and vowels depending on the shape of your lips, tongue and opening jaw. Without shape, you'd just be saying ‘ahhh'.
• Resonance – This is when we can control the nasal tone of each sound by raising or lowering the velum (or soft palate) – this is the soft part of the roof of your mouth, right at the back. Without some nasal tones, you would sound stuffed up or conversely, you would sound hypernasal. This is when air escapes through your nose while speaking when you don't want it to (hypernasality).
• Prosody – This helps convey meaning or emotion by changing the stress, intonation (the rise and fall of your voice during speech) or melody of what we say. Without variation in tone, you might sound like a robot.

If one part of this system is disrupted because of MS nerve damage, it can result in a speech impairment or voice disorder. Knowing which one or ones are impaired will help your therapist determine how or what to treat to help improve the problem.

Your speech could also be impaired not because of dysarthria, but because of other muscles in your body. For example, if you find it difficult to keep your head upright, this may affect your ability to take in an adequate breath to speak. 

Suzanne: The most common type of difficulty that we see is a motor speech difficulty called dysarthria which can cause speech to sound slurred, too quiet or too fast. By speaking loudly, slowly and clearly, which can be learned and practised, this can help improve how well you're understood by others.

Dysarthria can occur in around 50% of people with MS, but we rarely see it when people are first diagnosed. There are many different types and combinations of dysarthria so it's important that your speech and language therapist explains to you what's happening so that you can focus on the specific aspect of your speech that is the most unclear. For example, if lingual sounds – the sounds that your tongue makes like 'l' or ‘n' – are reduced in clarity, practising and focusing on those specific sounds and speech movements can make a huge difference.

Suzanne: Techniques such as speaking slowly, over-exaggerating your speech and good posture can all be hugely beneficial to you being heard and not feeling as though you are endlessly repeating yourself. Often, we tell people to imagine being on stage, giving a performance. By thinking this way, it automatically makes you THINK BIG. You then project your voice through good posture and breath support, and slow your speech down for the best clarity.

It's important, though, that the person you're talking to understands that they too have a role to play. They can help by doing simple things such as facing you, reducing any background noise like the TV or radio, repeating back the bits that they heard so you don't have to repeat from the beginning. These little tweaks can contribute to overall improvements.

Suzanne: Difficulty with word finding is more of a cognitive language difficulty rather than a speech difficulty. To explain the difference, speech is HOW you say something, so your physical ability to move, co-ordinate and control movements. Whereas language is WHAT you say, through words or symbols which can be written, spoken or expressed with gestures or body language.

It's not that you've not remembered the word, or that the word is 'lost'; it is more about struggling to retrieve it. It's that tip of the tongue feeling we've all experienced where it's almost there, but something's blocking it from being found.

These difficulties can be hugely frustrating and for some reason it tends to be objects, people or places that are the tricky ones. I often hear people describe how, when they're particularly stressed or under pressure because they're feeling an intense need to get their message out, this has a detrimental effect on finding the right word at the right time.

It's easy for me to say, but by reducing the pressure when you are faced with a situation where a particular word can't be found, you will be better able to manage this. If it has taken more than a few seconds to find the word, your brain has effectively taken you down a path with a brick wall at the end. You need to reverse back up the path and find a different route. This can be done by talking around the word, describing where you might find it, what it looks like, anything that you can do to work around that word block. You may also be lucky and the person you're talking to might be able to help you to find it.

Psychological techniques such as owning what's happening to you and normalising it can help you to feel more in control. By saying with complete and unapologetic transparency, "I sometimes experience difficulties finding the right words because of my MS" will give you ownership of the situation and that will help boost your confidence. 

Suzanne: There is a wealth of assistive technology out there that can enhance learning, working and day-to-day interactions for people with communication difficulties. For some who have more persistent difficulty with face-to-face communication, having a therapist who is skilled in alternative and augmentative communication (AAC) can be a big help. Ask your therapist how confident they are in AAC. If it's an area of specialism that they don't have, there are organisations you can turn to for advice, such as Communication Matters, Ace Centre or the Assistive Technology Industry Association, who are all experts in the field.

For anyone who lives in England and who has complex physical difficulties as well as speech difficulties, there are specialised services that are commissioned by NHS England to help you. They can fund high-tech communication devices as well as fund the communication software and the mounting system that you might need (e.g., poles that connect a communication device to a wheelchair or a floor mount). If you are eligible for their service, you do not need to pay but you need to be referred by your speech and language therapist. If you aren't eligible, there are other funding routes such as charitable funds or your local NHS services.

Suzanne Buckley is a speech and language therapist working in the Neurological Rehabilitation Centre at the Royal Free London NHS Foundation Trust.