Lori Kostich, CCC-SLP, on Managing Dysphagia in Multiple Sclerosis

In this podcast, Lori Kostich, CCC-SLP, from the Mandell Center for Multiple Sclerosis Treatment and Research, discusses how she identifies and manages dysphagia among her patients with multiple sclerosis, and when neurologists should refer patients to a speech-language pathologist for dysphagia-related concerns (transcript below).

Discover more insights from your peers in our Multiple Sclerosis Excellence Forum.

Lori Kostich, CCC-SLP, is a speech language pathologist and multiple sclerosis certified specialist at the Mandell Center for Multiple Sclerosis Treatment and Research in Hartford, Connecticut.


Christina Vogt: Hello, everyone, and welcome back to another podcast. I'm Christina Vogt, associate editor of Neurology Consultant. I'm joined by Lori Kostich, who is a speech-language pathologist and multiple sclerosis‑certified specialist at Mandell Center for Multiple Sclerosis Treatment and Research in Hartford, Connecticut.

Today, we'll be discussing dysphagia in multiple sclerosis and when neurologists should refer patients to a speech language pathologist. Thank you so much for joining me today, Lori. First, could you discuss some important aspects of identifying and managing dysphagia among patients with MS?

Lori Kostich: I'm an outpatient therapist, and we're an adult clinic. I see patients from 18 years old all the way into their 90s. We have the full age range, and swallowing concerns can happen at any age and at any point in time in the disease process.

People think that MS is a continuous decline, but from my perspective, I prefer the word "change." People who are living with and managing MS change. Their symptom presentation changes over time.

From the swallowing perspective, I've had 18‑year‑old patients kind of sit down in my chair and say, "Lori, I'm embarrassed to say this, but when I drink, I cough. And it's scary." Of course, the young people get online, and they Google everything first. Then, they see all the possible ramifications of not being able to swallow, and it scares them.

Part of my job is to touch base with those people who are having milder symptoms early in the disease process. We don't want to wait for a catastrophe. We want to get in there, provide some education about how you swallow, the mechanism of swallowing, and how to keep it smooth, but to get in there early, to provide education early.

Because it's swallowing, you can't see it. You don't ever really think about it until it doesn't work. Some of the things I hear are that they start coughing when they drink. Food goes down the wrong pipe. Food grinds its way down.

One of the first things I ask about is whether or not they have dry mouth because if you think about the process of swallowing, the first thing you do is put the food in your mouth and mash it up. If you don't have any spit, it's really hard to mash that food up.

A lot of the medications that are very successfully prescribed to manage other symptoms in MS, such as urinary dysfunction and others, have a very high prevalence of dry mouth as a side effect.

I feel that a number of my patients who come to me for swallowing are inadvertently medicated into some swallowing problems. No, that doesn't mean they're not supposed to take the medication. They do not stop the medication, but we do work on adapting how they approach food and how they chew and swallow.

I encourage people to watch out for foods that are like sponges, so absorbent foods. These are things like pasta, rice, rice cakes, cookies, cake, donuts. Because these foods, when you put them in your mouth, the first bite will use up all the saliva, and the first swallow go down fine.

Then all the saliva in your mouth is gone, so every bite of food that's chewed after that really can often only get mashed to the consistency of paste. You're essentially trying to swallow paste, and it doesn't go down well.

What I recommend is that when people are looking at their plate of food, to sort of analyze. Is this something that will absorb fluids, absorb saliva? If so, let's put some sauce on it. Let's put some ketchup on it. Let's put some jelly on it, as their diet allows.

That's where I always start. The first thing is making the food moister outside of their mouth, adding something to just be substitute saliva. Then the next part is if it's in their mouth and they realize it's not mashing up, just to take a little sip of whatever it is they're drinking with that meal, mash it all together, and then swallow it.

What I tell my patients is you want food to be the consistency of applesauce before it leaves your mouth, not Play‑Doh. It's got to be nice and mushy before it leaves your mouth.

We can also do a food journal. I look for 4 things in a food journal. For 1 week, and it's just for 1 week, what are you eating? What time are you eating? What was the result? Did you cough, or did everything go down fine, and what was the setting?

You can tease out really subtle things. Again, it's very concrete. Patients can say, "See, whenever I eat blueberry muffins, I cough. Whenever I have my morning toast, I cough."

Then we know that we're not necessarily cutting out toasted muffins, but those are foods that are absorbent. We're putting butter on them. We're putting jelly on them. We're doing something with those foods so they go down.

Another one that I find that is very interesting is some of my patients only cough when they're eating with other people, which tells me they're probably talking with food in their mouth, and when they inhale to say something, food is potentially going down the wrong pipe. That's another thing I do, food journals.

The next thing I look at is motor function or oral motor function, so how well the structures in their mouths are working, so tongue function. I use something called the diadochokinetic rate. What that is is just repetitive sounds.

How fast can your lips move? Puh, puh, puh, puh, puh, puh, puh, puh. How fast can the tip of your tongue move? Tuh, tuh, tuh, tuh, tuh, tuh, tuh, tuh, tuh. How fast can the base of your tongue move? Kuh, kuh, kuh, kuh, kuh, kuh, kuh, kuh, kuh, kuh.

I'm looking sort of for lingual coordination. I ask patients to put it all together. Pah‑ti‑kuh, pah‑ti‑kuh, pah‑ti‑kuh, pah‑ti‑kuh, pah‑ti‑kuh, pah‑ti‑kuh.

My patients who have some swallowing issues will often, not always but often, that tongue bass sound, that ka, ka, ka, ka, ka, ka, ka, ka, it'll be really mushy, ku, ku, ku, ku, ku, ku or noticeably slower than the other sounds.

That's feedback we can give the patient right away. I'm always very careful. You can't present it like you're having problems because you can't move your tongue. I present it as, "Okay look, you can see and observe now. You hear that your tongue is not moving as efficiently or smoothly as the rest of your tongue, and the base of your tongue is really important when you swallow, because the base of your tongue actually gives the food the first push down." People will understand that.

It gives the patient something also. Because so many of the symptoms of MS you can't see, well, this is something you can see and measure that can be correlated with swallow function.

Swallowing is a muscle‑based task, and we know that people who are living with MS, their muscles do respond to strengthening exercises and rehabilitation exercises. You can exercise your tongue. There's a couple of wonky exercises.

The first one is you take your tongue and push it against the roof of your mouth as hard as you can, like you're trying to push through to your nose. Count to 5. Five seconds. One, 2, 3, 4, 5, and then swallow. Relax your tongue and swallow and then swallow again. Do it again. Push your tongue up. Two, 3, 4, 5. Swallow and swallow again.

What you're doing by doing that, you're engaging your tongue as a muscle. Your tongue is a really big muscle. I've found that this exercise is very helpful in smoothing out swallowing issues.

The other exercise is more of a range of motion exercise for your tongue. You hold the tip of your tongue between your teeth. You're pulling your tongue forward and then when your tongue is there, you swallow.

What that does, when you swallow, if you swallow right now, you'll feel that the base of your tongue pulls back. By holding the tip of your tongue forward, the base of your tongue has to pull farther back, and the walls of your throat have to close in closer so that it actually makes all the musculature in there stretch in a different direction.

Those are the 2 exercises I always start with. There are others. We want to make sure everybody's cough is strong, so I do ask my patients to cough for me. If I feel their cough is weak, we may do some breathing exercises to shore up the cough because we need that cough to be strong. Always we need the cough to be strong.

Patients who become more physically impaired, they move around less. They may become deconditioned. A lot of people associate pulmonary fitness with exercise, like the Pilates and the jogging and the running, but for me, pulmonary fitness is the foundation, first of all, of speech. In order to speak well, you have to take a good breath, but also to cough.

In order to cough strong, you need to take a really nice inhale first so you can cough. Our patients who become less mobile and our patients who have progressed to the point where they're seated all the time, they become deconditioned. From a swallowing perspective, what happens is their cough can get weaker and weaker.

A place for speech therapy to step in is to work on breathing exercises to strengthen that cough to keep everything clearing.

Most of my patients who are ambulatory, who come to see me, who I catch early, have not had or encountered aspiration pneumonia. They haven't contracted pneumonia because something went into their lungs and it's become an infection. However, the more seated and the weaker and more physically impaired these patients become, the risk of aspiration pneumonia goes up.

If a patient complains of swallowing impairments ‑‑ They're coughing. Things are going down the wrong pipe ‑‑ and they're more physically impaired, it is very appropriate to refer for an objective swallow evaluation, which is not the same as an outpatient evaluation.

You would want to refer them for a modified barium swallow study so they can actually take a look at what's going on in there. Our patients are appropriate for fiber optic endoscopy, so FEES studies, provided there's no tremor or other contraindication, to give the treating outpatient speech therapist an idea of what's going on.

Christina Vogt:  Could you talk a bit more about when neurologists should refer patients to a speech language pathologist for dysphagia‑related concerns?

Lori Kostich:  If a patient mentions a swallowing challenge, change, problem to a neurologist or a primary care doctor, refer to the speech therapist, and then the speech therapist can start ticking off. Is it dry mouth? Is it where you're eating? Is it who you're eating with? Is it what you're eating?

If a person living with MS is less mobile, so maybe EDSS 5, 6, in that range and higher, it's probably worthwhile sending for an objective study, so a modified barium swallow study, first and then referring to outpatient therapy.

If there's a clinical pneumonia of any kind, I would refer for a modified barium swallow study first and then to outpatient speech therapy. Multiple sclerosis is not going away, you know. They're going to be living with and managing this disease process for the rest of their lives.

The model of care is a little different than, say, someone who's had an acute event, like a stroke. With MS, we want to try to get ahead of issues before they become big issues because it will be harder to come back.

Just to use swallowing as an example, if we get in early, provide the education, provide some strengthening exercises, we can potentially put off or eliminate the risk for pneumonia and those expensive bills. You want to get in early and teach people about themselves and how to take care of themselves.

Christina Vogt: Thanks again for joining me today, Lori. Stay tuned for more podcasts like this.