Some people with MS may experience problems with their ability to swallow. This can include feeling as though food is stuck in your throat and finding it difficult to chew and swallow. 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.
How can MS affect swallowing in someone with MS? What can go wrong?
Suzanne: The act of swallowing is a complex one that involves more than 30 muscles and nerves working together to propel food and drink from your mouth to your stomach. These nerves are both motor and sensory so not only do they move the muscles, they also provide the sensory feedback (the size, texture and temperature of food) we need when we swallow. As with the complex speech system, if one component of the swallowing system is disrupted by MS damage, it can result in difficulties with swallowing food or drink or both. A swallowing difficulty is also called dysphagia.
Because MS can affect scattered and diverse areas of the nervous system, problems with swallowing can vary from individual to individual. It's relatively rare in those who are able to walk. If you're experiencing changes or have concerns with your swallowing, it's important that a full clinical swallow assessment is done by a qualified speech and language therapist.
This assessment helps the therapist to pinpoint the difficulty and work out an individualised treatment plan which may include:
- neuromuscular electrode stimulation or skill training – electrodes are placed on the neck and provide small electrical currents to activate the nerves and muscles used in swallowing; alternatively, in strength and skill training, the electrodes are used to give you feedback on your muscle activity whilst you swallow (biofeedback), this can be used alongside swallowing exercises to make you more aware of what's happening in your body when you swallow
- compensatory strategies – such as holding food or drink in your mouth and when you're ready, swallowing as hard as you can
- food and drink modifications – such as different textured foods or thicker drinks
- swallowing exercises.
If your swallow has been affected by a relapse, it's important to contact your GP who can refer you for a swallow assessment because the implications of food or drink going down ‘the wrong way' can affect your overall health.
Are there any exercises that can help someone who has a swallowing delay and struggles to swallow small tablets?
Suzanne: Not all problems with swallowing are down to weakness, which make certain exercises redundant. For example, if it's because of a motor planning difficulty, where the swallow movements happen in an uncoordinated way, then muscle strengthening exercises may not be appropriate.
If someone is experiencing a delay to triggering a swallow, there are compensatory strategies that could be tried, such as a three second preparation. This is a simple strategy of mentally preparing yourself to swallow while counting to three, and when you reach three, you swallow.
Simple sensory tricks to wake up the sensory nerves can really help a delayed swallow trigger. This can be as simple as drinking ice cold or fizzy drinks or strong flavours like sour lemon or ginger as a flavour enhancer – all of these can help to stimulate that sensory reflex.
Difficulty with swallowing tablets is a really common problem. It can be helped by talking to your speech and language therapist or a pharmacist about whether you can, for example, take the tablet with a spoonful of yoghurt instead of washing it down with water. The pharmacist may also be able to provide a liquid form of the medication or could advise you on whether the tablets might be safe to crush and put on a spoonful of yoghurt.
Is posture important when it comes to managing swallowing problems?
Suzanne: Posture is hugely important – this is why commonly, when we see people with complex swallow and physical disabilities, we ensure we see them as part of a multi-disciplinary team. I would see people with my physiotherapy or occupational therapy colleagues who can give me and my patient ideas on how to maximise good posture.
This could be as simple as sitting up at the table with the seat in a good position, up against your back, and making sure that your head is in a nice neutral position and you're not lifting your chin up. All of these things can be a huge help. An occupational therapist and physiotherapist can also look at whether more supportive seating is required, for example moulded cushions.
Are there any foods you should avoid if you have difficulty swallowing?
Suzanne: When people experience difficulties, often the food types that are the first to become difficult are the dry, crumbly textures or the chewy textures like meat. Particularly with dry, crumbly foods, you can accidentally inhale bits before you've prepared for the swallow. We often tell people to avoid the high risk foods like nuts or salads, or foods that have a skin or a husk. Your speech and language therapist will be able to offer you more advice on this.
What would you say to someone who's becoming increasingly worried about choking because of their swallowing difficulties?
Suzanne: It can be a frightening thing and for those who have experienced it, I can imagine it to be something you would never want to happen again. Thankfully, it is extremely rare and if, after having seen your GP or your speech and language therapist, you are still experiencing anxiety around this, then please go back to those same health professionals and talk it through with them. There can be so many things that can be done or explained or advised that can help alleviate those concerns for you.
Suzanne Buckley is a speech and language therapist working in the Neurological Rehabilitation Centre at the Royal Free London NHS Foundation Trust.