Complete Guide To Speech Therapy for Multiple Sclerosis

Multiple sclerosis is an unpredictable neurological disorder that can impact swallowing, communication, cognition, and more. How can speech therapy best help these patients?

The complete guide to speech therapy for multiple sclerosis covers:

• Assessments and screens
• Signs and symptoms in your scope of practice
• Evidence-based treatments for dysphagia, communication, and cognition
• Who and when to refer out

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Speech Therapy For Multiple Sclerosis

In multiple sclerosis (MS), the immune system attacks the myelin covering the nerve fibers of the central nervous system. Over time, this leads to a variety of impairments.

MS is unpredictable and progresses very differently in each person. This means that you’ll assess and periodically screen your patients for a wide range of disorders.

More Popular Articles

• Speech Therapy Goal Bank
• Complete Guide to Informal Assessments

Speech Therapy Assessments for MS

Possible areas of assessment:

• Clinical bedside swallowing assessment
• Instrumental swallowing assessment
• Cognitive-linguistic assessment
• Motor Speech Assessment
• Voice & Resonance Assessment

See The Evaluation Pack for print-and-go assessment forms. And read What Do I Assess First? for help deciding what assessment to choose.

Evidence-Based Speech Therapy Screens for Multiple Sclerosis

Fatigue & Energy Conservation Screens:

• Fatigue Severity Scale
• Modified Fatigue Impact Scale

Swallowing Screens:

• Yale Swallow Protocol
• EAT-10
• Xerostomia Questionnaire

Cognitive Screens:

• The Montreal Cognitive Assessment
• The Brief International Cognitive Assessment for Multiple Sclerosis
• Symbol Digit Modalities Test

(Rosca, 2020; Corfield, 2018; Kalb, 2018)

Common ST-Related Signs & Symptoms in MS

• Dysarthria: Slurred speech, impaired prosody, respiratory weakness
• Voice: Dysphonia
• Resonance: Hypernasality
• Language: Difficulties with expression, comprehension, fluency, abstract language
• Cognition: Difficulties with memory, attention, executive functioning, information processing, visual processing
• Dysphagia: Slow or delayed swallows, muscle weakness or discoordination

(The France Foundation, 2015)

When To Refer Out 

Refer out to your talented healthcare team if you see the following symptoms in your patients with MS:

• Optometry/Ophthalmology/Certified Vision Therapist: Eye pain, vision loss, blurred vision, double vision (Aravich, n.d.)
• Occupational Therapy: Help with energy conservation, ADLs, IADLs
• Physical Therapy: Impaired mobility
• Dietician: Weight loss, malnutrition
• Mental Health Specialist: Depression, anxiety
• Primary Care Physician: Reflux, spasticity, urinary issues, etc.
• Neurologist: Overall management of MS, including medications

(National Multiple Sclerosis Society, n.d., 2)

Managing Fatigue During Your Session

About 80% of patients with MS experience fatigue (National Multiple Sclerosis Society, n.d., 1).

When planning treatments, make energy conservation your main focus.

Watch for signs of fatigue during your sessions. Fatigue can worsen deficits in motor speech, voice, swallowing, and cognition.

Teach the compensatory strategies covered below and use the Fatigue Severity Scale or the Modified Fatigue Impact Scale as needed.

What About Exercises For Multiple Sclerosis?

There are evidence-based multiple sclerosis exercises that can help your patients meet their speech therapy goals, including safer swallows and a louder voice. You’ll find these below.

But never push a patient with MS to the point of fatigue. Remember, your main focus is energy conservation.

General physical exercise (cardio, resistance, and flexibility) can improve MS symptoms, including difficulties with cognition, fatigue, and respiratory function (Kalb, 2018; Halabchi, 2017). Refer patients to their doctor for medical clearance and to physical therapy to design a safe exercise program.

Cognition

About half of people with MS have a cognitive deficit, although it’s typically mild-moderate in severity (Newsome, 2017).

Use compensatory cognitive or memory strategies as needed to support your speech therapy treatments. Examples are writing down information, adding external aides, and giving more cues.

You’ll find cognitive treatment ideas below.

Dysarthria in Multiple Sclerosis

Dysarthria and dysphonia are the most common communication disorders in the muscular sclerosis population (25-40% of patients).

• Dysarthria in MS can impact all speech subsystems (respiration, phonation, resonance, articulation, prosody)
• It often shows up later in the disease or when very fatigued

(National Multiple Sclerosis Society, n.d. 1)

Learn more about the types of dysarthria and how to treat them.

Types of Dysarthria in MS

Spastic, ataxic, or mixed dysarthria are most common in MS.

Here are the symptoms of each:

Spastic Dysarthria:

• Hypertonia
• Slow rate
• Strained vocal quality
• Pitch breaks

Ataxic Dysarthria:

• Reduced muscle coordination
• Excess and equal stress
• Distorted vowels
• Lack of coordination in jaw, face, and tongue

Mixed Dysarthria. Combinations of dysarthria types (e.g., spastic–ataxic, flaccid–spastic):

• Slow speech
• Prosody disrupted
• Hypernasality
• Strained voice

How To Treat Dysarthria in MS

To treat dysarthria in MS, focus on the speech subsystem that affects each patient’s intelligibility the most.

MS Dysarthria Treatments:

1. Communication partner training
2. Breath support exercises
3. Clear speech strategies
4. Respiratory muscle strength training
5. LSVT LOUD®
6. Other dysarthria treatment (articulation, phonation, etc.)
7. AAC

1. Communication Partner Training

Teach communication partners the following tips:

• Choose the right environment
  • Decrease background noise
  • Make sure there’s enough light
  • Correct any hearing or vision loss
• Give your full attention
  • Sit close enough to see each other
  • Listen and watch the entire time the person is speaking
• Confirm the topic
  • Check that you and the speaker are on the same topic
  • “Are we still talking about…?”
• Use keywords
  • Refer back to words the speaker said to try to create a full narrative
  • “You said ‘dinner.’ Were you talking about dinner with your family next week?”
• Encourage writing, drawing, or gesturing
• Repeat each word
  • If the speaker is especially hard to understand, repeat each word they say. Confirm that each word is correct before moving on to the next word
• Set ground rules
  • To avoid frustration, have a set number of times the speaker tries to say something before they take a break or use AAC

2. Breath Support Exercises

If your patient has poor respiratory support, such as running out of breath while speaking, help them build up breath support. This may improve dysarthria.

Teach them how to gradually build breath support for speech. You may start with controlled breathing and then add voiceless sounds then longer and more complex utterances as they improve.

Read How To Build Breath Support for Speech for a step-by-step guide.

3. Clear Speech Strategies

Clear speech strategies are compensatory tactics for improving intelligibility.

Here’s how to do them:

1. Talk BIG by over-articulating
2. Talk LOUD by increasing your volume
3. Talk SHORT by using short phrases

4. Respiratory Muscle Strength Training

Inspiratory and expiratory muscle strength training (IMST and EMST) are evidence-based exercises for multiple sclerosis.

IMST has been shown to improve respiratory strength and dyspnea in patients with MS (Martin-Sanchez, 2020). And EMST may modestly improve communication (Antonsson, 2023).

Again, focus on energy conservation and never push a patient with MS to the point of fatigue.

Learn how to do Expiratory Muscle Strength Training.

5. LSVT LOUD

LSVT LOUD is an intensive program that increases breath support and vocal intensity. Consider it for your patients with MS who have reduced breath support, vocal intensity, or intelligibility.

A randomized control trial found that LSVT LOUD improved vocal intensity in patients with MS. The results weren’t maintained at a 15-month follow-up, implying that people with MS need maintenance treatment (Cirpiatico, 2021).

6. Dysarthria Treatments

If deficits in articulation or phonation are the main cause of your patient’s reduced intelligibility, consider dysarthria treatments that target them.

7. AAC

Augmentative and alternative communication (AAC) is any way of communicating besides talking.

AAC can supplement or even replace talking. By not having to repeat themselves or talk too loudly, AAC can help patients with MS conserve energy.

Consider adding AAC if your patient is willing plus physically and cognitively able to use it when they need it.

Here are examples of ‘Everyday AAC’ (using what’s already available or easily available to your patient):

• Nodding, shrugging, gestures
• Pointing
• Fingerspelling (tracing letters in the air or on a table)
• Writing (felt-tip pen and paper, whiteboard, boogie board™, Buddha Board™, etc.)
• Texting
• Alphabet board
• Needs board
• Code board
• Typing on a tablet, computer, etc.
• Text-to-speech apps or narrator programs on at-home devices (cell phone, computer)

See the AAC Pack for premade handouts and printable boards.

Voice Disorders in Multiple Sclerosis

Dysphonia often co-occurs with dysarthria in patients with MS.

Symptoms of dysphonia in MS include decreased loudness, impaired pitch control, breathiness, hypernasality, and impaired vocal quality (The France Foundation, 2015).

Dysphonia may also worsen with fatigue.

How To Treat Dysphonia in MS

MS Dysphonia Treatments:

1. Resonance therapy
2. Breath support exercises
3. Vocal hygiene
4. Other voice treatments – phonation, pitch, focus
5. Communication partner training
6. AAC

1. Resonance Therapy

If your assessment uncovers a resonance impairment that can be treated by speech therapy—and you think resonance significantly impairs your patient’s ability to communicate effectively—then treat that!

Remember to keep resonance therapy functional.

Consider Resonant Voice Therapy, an evidence-based dysphonia treatment, or other resonance treatments.

2. Breath Support Exercises

Respiratory muscle strength is significantly reduced in some patients with multiple sclerosis (Gosselink, 2000). This can result in a weak, breathy, or hypernasal voice.

Consider breath support exercises and respiratory muscle strength training for these patients.

3. Vocal Hygiene

If appropriate, make a vocal hygiene program for your patient with multiple sclerosis.

For example, teach vocal hygiene if their dysphonia is worsened by environmental irritants or vocal abuse.

Download the evidence-based Vocal Hygiene Checklist:

Dysphagia in Multiple Sclerosis

Studies suggest that over 80% of patients with MS have dysphagia. But studies also show that dysphagia is greatly underreported by these patients (The France Foundation, 2015).

This means that even if your patient with MS isn’t reporting dysphagia symptoms, it’s important to be on top of oral care, xerostomia, swallowing screens, and periodic instrumental and bedside swallowing assessments.

Symptoms of Dysphagia in MS

Symptoms of dysphagia in multiple sclerosis include:

• Muscle weakness and discoordination
• Slowed or delayed swallow
• Coughing or choking
• Oral and pharyngeal residue
• Impaired airway protection
• Xerostomia
• Difficulty chewing
• Difficulty with oral containment and transit
• Reduced hyolaryngeal excursion
• Impaired sensation
• Signs of aspiration (wet-sounding voice, pneumonia, weight loss, etc.)

(Mansolillo, n.d., The France Foundation, 2015)

Multiple Sclerosis Dysphagia Treatment

There’s a lot of evidence that dysphagia therapy improves swallowing symptoms and quality of life in patients with multiple sclerosis!

For instance, a recent systematic review found that traditional dysphagia therapy (oral motor exercises, swallowing maneuvers, electrical stimulation, and respiratory muscle exercises) significantly improved dysphagia in people with MS (Kesik, 2021).

Dysarthria treatments for MS:

1. Respiratory training
2. Oral hygiene
3. Compensatory strategies
4. Electrical stimulation

1. Swallowing Exercises for Multiple Sclerosis

Respiratory training, including inspiratory muscle strength training and expiratory muscle strength training, are evidence-based swallowing exercises for multiple sclerosis (Martin-Sanchez, 2020).

EMST has been shown to improve airway protection, cough, and saliva management (Silver, 2017; Gosselink, 2000).

Again, never push patients with MS to the point of fatigue (Mansolillo, n.d).

2. Oral Hygiene for MS

Encourage good oral hygiene to decrease the risk of aspiration pneumonia.

Oral hygiene tips for MS:

• Use a clean toothbrush with soft bristles and toothpaste
• Brush your teeth and tongue once in the morning and once in the evening (some may need to brush more often)
  • If NPO, lean forward over the sink/basin to catch oral secretions
• Do oral care before eating or drinking to avoid bacteria entering the airway
• Floss before bed
• Treat xerostomia:
  • Stay hydrated
  • Sip water during meals
  • Use products with xylitol to increase saliva
  • Rinse your mouth every 2 hours
• Have a dental cleaning & check-up every 6 months
• If using mouthwash, choose one that’s alcohol-free and sugar-free
• Avoid caffeine, alcohol, and sugary drinks

3. Compensatory Strategies

Teach your patients compensatory strategies to improve their safety, quality of life, and energy conservation. What strategies you choose will depend on each patient’s unique dysphagia symptoms, wants, and needs.

• Slow the rate of eating
• Smaller bites/sips
• Stop eating/drinking when too fatigued
• Take breaks
• Sit upright with any PO intake
• Have smaller, calorie-dense meals more often
• Choose softer foods to conserve energy (less chewing)
• Choose finger foods or use adaptive equipment
• Chin down posture, head turn or tilt¹
• Diet modifications²
• Alternate solids and liquids³
• Specialized positioning³
• Improve sensory awareness by adding intense flavors, cold food or drink, or carbonation

(1. Mansolillo, n.d; 2. Newsome, 2017; 3. The France Foundation, 4. 2015; Brewer, 2021)

4. Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation designed for dysphagia may improve pharyngeal swallow function in multiple sclerosis (Restivo, 2013; Bogaardt, 2009; Alali, 2016).

Cognitive Treatment for MS

Cognitive Symptoms of Multiple Sclerosis

Cognitive impairments in multiple sclerosis usually progress slowly and are mild to moderate in severity.

If you notice cognitive symptoms, first rule out depression and sleep disorders. Both are common in MS. Refer to a mental health provider or primary care doctor for help.

Common areas of cognitive impairment in multiple sclerosis:

• Memory
• Attention
• Executive functioning
• Visual processing
• Word retrieval
• Speed of information processing

(The France Foundation, 2015)

Treatment For Cognitive Impairment In Multiple Sclerosis

Use your assessment results to decide what areas of cognition to treat.

Focus on functional and meaningful cognitive tasks (medication management, financial management, work), safety, and independence. Involve caregivers and family when possible, especially with more severe deficits.

And encourage cardiovascular exercise! It can improve cognition (Kalb, 2018).

Memory	Teach memory strategies (write it down, spaced retrieval), use calendars and alarms, do functional memory activities
Working Memory	Take notes, take mental pictures, have a routine, do functional working memory tasks
Attention	Teach compensatory strategies (timers, task analysis, planner), decrease distractions, do functional attention tasks
Executive Functioning	Teach strategies (task analysis, Game Plan Worksheet), make modifications, get organized, do functional executive functioning tasks
Information Processing	Ask others to slow down, rephrase what they say, use your phone to record important information (The France Foundation, 2015)
Visual Processing	Declutter, improve lighting, add visual contrast, larger print, text-to-speech app (Aravich, n.d.)

More Speech Therapy Resources

For speech therapy worksheets and handouts designed for adults with disabilities, including multiple sclerosis, check out The Adult Speech Therapy Starter Pack.

References

• Alali, D., Ballard, K. & Bogaardt, H. Treatment Effects for Dysphagia in Adults with Multiple Sclerosis: A Systematic Review. Dysphagia 31, 610–618 (2016). https://doi.org/10.1007/s00455-016-9738-2
• American Speech-Language-Hearing Association. (n.d.). Dysarthria in adults [Practice portal]. Retrieved March, 2024 from https://www.asha.org/Practice-Portal/Clinical-Topics/Dysarthria-in-Adults/
• Antonsson, M., Johansson, K., Dalemo, A.B., Ivehorn Axelsson, C., Burge, Å., Lesueur, U., & Hartelius, L. (2023) Effect of expiratory muscle strength training on voice and speech: An exploratory study in persons with Parkinson’s disease or multiple sclerosis, International Journal of Speech-Language Pathology, DOI: 10.1080/17549507.2023.2243402
• Aravich, D., Troxell, L., Stants, H. (n.d.) Vision Deficits: Parkinson’s Disease, Dementia, and Multiple Sclerosis. Medbridge. Retrieved from https://www.medbridge.com/courses/details/vision-deficits-parkinsons-disease-dementia-and-multiple-sclerosis-dana-aravich-holly-stants-laura-troxell
• Bogaardt, H., van Dam, D., Wever, N. M., Bruggeman, C. E., Koops, J., & Fokkens, W. J. (2009). Use of neuromuscular electrostimulation in the treatment of dysphagia in patients with multiple sclerosis. The Annals of otology, rhinology, and laryngology, 118(4), 241–246. https://doi.org/10.1177/000348940911800401
• Brewer, C. (2021). The Adult Speech Therapy Workbook. Harmony Road Design
• Corfield, F., Langdon, D. A Systematic Review and Meta-Analysis of the Brief Cognitive Assessment for Multiple Sclerosis (BICAMS). Neurol Ther 7, 287–306 (2018). https://doi.org/10.1007/s40120-018-0102-3
• Crispiatico, V., Baldanzi, C., Napoletano, A., Tomasoni, L., Tedeschi, F., Groppo, E., Rovaris, M., Vitali, C., & Cattaneo, D. (2021). Effects of voice rehabilitation in people with MS: A double-blinded long-term randomized controlled trial. Multiple Sclerosis Journal. https://doi.org/10.1177/13524585211051059
• Dugdale, D. (2022). Communicating with someone with dysarthria. MedLine Plus. Retrieved March, 2024, from https://medlineplus.gov/ency/patientinstructions/000033.htm
• Gosselink, R., Kovacs, L., Ketelaer, P., Carton, H., & Decramer, M. (2000). Respiratory muscle weakness and respiratory muscle training in severely disabled multiple sclerosis patients. Archives of physical medicine and rehabilitation, 81(6), 747–751. https://doi.org/10.1016/s0003-9993(00)90105-9
• Halabchi, F., Alizadeh, Z., Sahraian, M. A., & Abolhasani, M. (2017). Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations. BMC Neurology, 17. https://doi.org/10.1186/s12883-017-0960-9
• Kalb, R., Beier, M., Benedict, R. H., Charvet, L., Costello, K., Feinstein, A., Gingold, J., Goverover, Y., Halper, J., Harris, C., Kostich, L., Krupp, L., Lathi, E., LaRocca, N., Thrower, B., & DeLuca, J. (2018). Recommendations for cognitive screening and management in multiple sclerosis care. Multiple Sclerosis Journal. https://doi.org/10.1177/1352458518803785
• Kesik, G., & Özdemir, L. (2021). Non-pharmacologic Approaches to Dysphagia in Patients with Multiple Sclerosis: A Systematic Review. Turkish Journal Of Neurology.
• Martin-Sanchez, C., Calvo-Arenillas, J. I., Barbero-Iglesias, F. J., Fonseca, E., Sanchez-Santos, J. M., & Martin-Nogueras, A. M. (2020). Effects of 12-week inspiratory muscle training with low resistance in patients with multiple sclerosis: A non-randomised, double-blind, controlled trial. Multiple Sclerosis and Related Disorders, 46, 102574. https://doi.org/10.1016/j.msard.2020.102574
• National Multiple Sclerosis Society (n.d.). 1. MS Signs & Symptoms. Nationalmssociety.org. Retrieved March, 2024, from https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms
• National Multiple Sclerosis Society (n.d.). 2. What Is MS? Nationalmssociety.org. Retrieved March, 2024, from https://www.nationalmssociety.org/What-is-MS
• Newsome, S.D., Aliotta, P.J., Bainbridge, J., Bennett, S.E., Cutter, G., Fenton, K., Lublion, F., Northrop, D., Rintell, D., Walker, B., Weigel, M., Zackowski, K., Jones, D.E. (2017). A Framework of Care in Multiple Sclerosis, Part 2: Symptomatic Care and Beyond. Int Journal of MS Care. 19 (1): 42–56.
• Restivo, D. A., Casabona, A., Centonze, D., Marchese-Ragona, R., Maimone, D., & Pavone, A. (2013). Pharyngeal electrical stimulation for dysphagia associated with multiple sclerosis: a pilot study. Brain stimulation, 6(3), 418–423. https://doi.org/10.1016/j.brs.2012.09.001
• Rosca, E.C., Simu, M. (2020). Montreal cognitive assessment for evaluating cognitive impairment in multiple sclerosis: a systematic review. Acta Neurol Belg 120, 1307–1321. https://doi.org/10.1007/s13760-020-01509-w
• Silverman, E. P., Miller, S., Zhang, Y., Hoffman-Ruddy, B., Yeager, J., & Daly, J. J. (2017). Effects of expiratory muscle strength training on maximal respiratory pressure and swallow-related quality of life in individuals with multiple sclerosis. Multiple Sclerosis Journal – Experimental, Translational and Clinical, 3(2). https://doi.org/10.1177/2055217317710829
• Taylor, L.A, Mhizha-Murira, J.R., Smith, L., Potter, K-J., Wong, D, Evangelou, N., Lincoln, N.B., das Nair, R. (2021) Memory rehabilitation for people with multiple sclerosis. Cochrane Database of Systematic Reviews. Issue 10. Art. No.: CD008754. DOI: 10.1002/14651858.CD008754.pub4.
• The France Foundation (2015, October 31). A Practical Guide to Rehabilitation in Multiple Sclerosis. CmeAIMS.org. Retrieved March 25, 2024, from https://www.cmeaims.org/resources/AIMS-rehab-primer.pdf