Speech and swallowing problems

Due to demyelination of the cranial nerves, patients with MS can experience significant problems with speaking and the ability to swallow normally. The term dysarthria refers to problems with articulating words and slurred speech that may be difficult to understand. Persons with MS who slur their speech may be viewed as being under the influence of drugs or alcohol, or being of less than normal intelligence. Speaking difficulties can also significantly interfere with the ability to communicate with others.

Swallowing problems can cause fear of choking and aspiration, exhaustion due to the time needed to consume a meal, a decrease in food intake, and loss of pleasure usually associated with meals. Dysarthria can be modified through speech therapy, and some patients can use alternative communication devices if needed to improve speech clarity. Interventions for dysphagia include eating a modified diet, using thickened liquids rather than thin liquids, blenderizing food if necessary or using non-oral feeding techniques such as enteral feedings.

Motor dysfunction

Motor problems experienced by people with MS include spasticity, muscle weakness, impaired balance, and tremor. Lesions affecting the cerebellum can also produce uncoordinated movements and an abnormal gait referred to as ataxia.

Increased muscle tone and resistance to movement produce spasticity in MS. As a result of MS plaques in the brain, messages descending from the brain to suppress overactive muscle tone are altered. Spasticity most often affects the antigravity muscles that are used to maintain posture, such as the muscles of the legs, and the upper extremities. Spasticity can range from mild symptoms to severe muscle spasms that greatly interfere with functional activities. Spasticity can pull limbs into abnormal positions that interfere with walking, sitting, and the ability to perform daily self-care tasks. Triggering factors such as improper positioning, pressure sores, or a full bowel or bladder increases spasticity.

The first approach in managing spasticity is to reduce triggers that cause spasticity. The second approach, and often most effective way to reduce spasicity, is passive stretching, in which each affected joint is moved slowly into a position that stretches the spastic muscles. Once the muscles reach their stretched position, they are held for about a minute to allow slow relaxation and release muscle tension. Range of motion exercises differ from stretching exercises in that with joint range of motion, the movement around the joint is not held for a specific length of time. Although maintaining range of motion is extremely important, holding muscles in a stretched position is important to reduce spasticity.

The third management strategy is the use of medications. Antispasmodic medications include baclofen (Lioresal ®), tizanidine (Zanaflex ®), and diazepam (Valium ®). Baclofen is the drug used most commonly to control spastictiy. The dose for each patient must be carefully titrated. Too little medication is ineffective in relieving spasticity; however, too high a dose produces fatigue and undesirable sedation. A baclofen pump, implanted surgically in the abdomen, with an extension that delivers very small doses of baclofen into the spinal canal to circumvent the blood-brain barrier, can control spasticity effectively for persons whose spasticity is severe and unrelieved by other measures.

Tremor refers to involuntary muscle movements. MS related tremor is often the least treatable and most debilitating symptom of MS. The most common type of MS associated tremor occurs as a result of demyelination in the cerebellum, an area of the brain involved in coordinating movement. This type of tremor is often a gross tremor that occurs with purposeful movements of the arms or legs. Tremor is also often increased during period of stress. Physical rehabilitation techniques that can help patients manage tremor include muscle patterning, immobilizing a joint to reduce random movement, and adding weight to a part of the body to provide increased muscular control. Medications that are used to reduce tremor include propanalol (Inderal ®), clonazepam (Klonopin ®), primidone (Mysoline ®), isoniazid (Laniazid ®), buspirone (Bu-Spar ®); and ondansetron (Zofran ®).

Visual disturbances and vertigo

Two major components of effective vision are the ability to correctly image what one sees and proper coordination and strength of the muscles that surround the eye and control its movements. Demyelination affecting the optic nerve produces a condition known as optic neuritis that impairs both of these eye functions. Optic neuritis is often one of the first symptoms that people developing MS experience.

Other eye symptoms include sensations of blurred central vision, and double vision. Visual disturbances can interfere with independent functioning, such as driving, and interfere with activities at work and home. If eye symptoms are severe, they are treated with corticosteroid drugs.
Vertigo in MS often results from a irritation of areas of the brain stem that are involved in maintaining balance and disturbance in the conduction of messages from the brain to the inner ear. Antihistamine type drugs may be given to help mange vertigo or sensations of dizziness. A physical therapist can help the patient with dizziness learn how to avoid body position changes that increase symptoms.

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