Hard to swallow
Swallowing problems can occur as part of MS, but a range of treatments can restore dignity and pleasure to mealtime.
by Cynthia L. Kryder
Imagine taking a bite of your favorite meal—and being unable to swallow. It happened to Ruth Bollo—and not just once. “I developed painful esophageal spasms and felt like I was going to choke whenever I tried to eat or drink,” says Bollo, who has lived with multiple sclerosis since 2003.
About 40 percent of people with MS have trouble swallowing at some point in the course of the disease. Although swallowing problems are often mild and transient, when chronic they can lead to dehydration, poor nutrition and weight loss. For some people, problems with eating and swallowing may also be associated with respiratory infection if food particles or liquids accidentally get into the lungs.
Impaired swallowing, known medically as dysphagia, can often negatively affect the pleasure of sharing meals with friends and family. “I didn’t want to eat in public because I was afraid and embarrassed,” Bollo explains. “As my weight dropped, my friends began commenting about my weight loss and I started feeling bad about myself.”
Biting into it
Until a problem develops, swallowing seems easy to most people, but it’s actually a complex process. The lips, jaw and tongue must work in a coordinated fashion to move substances into the mouth to be chewed, which then must be formed into a cohesive ball (called a bolus) and propelled to the back of the mouth and into the throat. From there, swallowing becomes somewhat automatic; in a rapid sequence of overlapping events, the bolus travels down the throat into the esophagus and eventually the stomach—if everything works properly.
Things can go wrong, however, at any stage. In MS, muscle spasms, weakness, decreased sensation and decreased coordination of the tongue and other muscles in the mouth can contribute to dysphagia in the oral stage of swallowing. Problems can occur in the later stages, too, partly because the windpipe (also known as the trachea) and the food pipe (the esophagus) are situated one behind the other in the throat (pharynx). During a healthy swallow, a structure known as the epiglottis closes off the trachea, preventing food and liquid from entering the lungs. If the trachea isn’t completely protected—due to uncoordinated breathing or weak or spastic muscles—coughing and choking can occur. Worse, if people have reduced sensation, food or liquid may enter the airway and not trigger a coughing reflex to clear it.
MS-related fatigue can also affect either the oral or pharyngeal stage of swallowing.
Some therapies, such as steroids used to treat MS relapses, or medications used to treat spasticity, can also lead to impaired swallowing or cause dry mouth. “I’ve worked with individuals who stopped taking prescription medications because the dry mouth was so bad, and their swallowing changed too much while on the medication,” says Lori Kostich, a speech-language pathologist (SLP) and MS-certified specialist at Mt. Sinai Rehabilitation Hospital/Mandell Center for MS Treatment and Research in Hartford, Connecticut. “Of course, if the side effect interferes with swallowing or any other function, people should first talk with their physicians about changing the dose or prescribing a different agent before discontinuing a medication.”
Dysphagia seem to occur with equal frequency in progressive and relapsing forms of MS, says Kris Tjaden, PhD, an SLP and professor at the State University of New York at Buffalo. However, some evidence suggests that dysphagia is more strongly correlated with higher levels of disability.
As with most symptoms of MS, the presence, nature and severity of dysphagia is highly variable, according to Dr. Tjaden. “Some people have problems chewing; others can’t trigger a swallow reflex,” she notes. And some people may have difficulty swallowing only certain textures of food or liquid.
Food for thought
When swallowing goes awry, people should speak with their doctors, who may refer them to an SLP who is trained to evaluate and manage dysphagia. Getting to the bottom of dysphagia begins with a detailed medical history and physical examination. The SLP will ask about the conditions when swallowing problems arise, and will test the strength and coordination of the oral muscles. He or she may offer bites of food and liquid, and carefully observe the individual’s swallowing process. Sometimes, a laboratory study known as videofluoroscopy, or modified barium swallow, is performed.
As an individual consumes various foods and liquids—mixed with barium so they show up on video X-ray—clinicians watch the movement of each bolus and of the structures in the mouth and throat. This enables them to detect where—and why—problems are occurring.
But, as Kostich explains, dysphagia symptoms aren’t always present on the day of the exam. “With a disease process [like MS], known for symptoms that wax and wane over time—or even over the course of one day—catching the swallowing problem at the time may not be possible,” she says. In such scenarios, Kostich provides treatment based on the symptoms the individual describes, rather than waiting for the problem to get worse.
Licking the problem
There is no one-size-fits-all treatment for dysphagia; it depends on the person’s specific problems. An SLP can teach compensatory strategies, such as tucking the chin toward the chest with every swallow to protect the airway, or how to modify the consistency of foods. Something as simple as changing posture might alter the dimensions of the throat and improve the flow of food and liquid. Therapy might also include exercises to improve muscle strength, movement and coordination for more long-term issues.
Bollo learned techniques to control the muscle spasms that affected her swallowing, and she still uses them today. “Once I knew how to manage the spasms, I felt as though I had my life back,” she says.
For the majority of people with MS, dysphagia is not an expected complication. For those who do have trouble swallowing, education and individualized therapy can be the keys to making eating and drinking pleasurable again.