Speech Solutions

Speech and Voice Problems Associated with MS
In the spring 2003 issue of The Motivator, the column entitled, “Symptom Awareness” highlighted speech and voice problems. This provided information on the different types of speech and voice disorders, and how MS damage to the myelin and axons can affect the controlled movements of the mouth (including lips, tongue, jaw, and soft palate) needed to form words. MS can also result in spasticity, tremor, weakness, and slowness in the muscles that control speech, and fatigue may affect one’s ability to push enough air through the vocal cords to produce sound.

Anyone experiencing speech or voice problems needs to see his or her doctor who can provide a prescription to see a speech-language pathologist. This specialist can formally evaluate symptoms and recommend a treatment program, which can include several medical professionals and a number of treatments – from medications to treat underlying symptoms (such as spasticity, tremor, and fatigue) to exercises and relaxation techniques, to assistive devices.

Studies indicate that 41 to 44 percent of the MS population experiences some type of speech or voice dysfunction. A portion of this group may benefit from Augmentative and Alternative Communications (AAC), a term that refers to any method, strategy, or device used to help someone with a communication impairment to communicate more effectively with others.
Augmentative and Alternative Communications

Carrie Bruce, MA, CCC-SLP, ATP, is a project coordinator with the Center for Assistive Technology and Environmental Access (CATEA) at the Georgia Institute of Technology in Atlanta, Georgia. She is also a part-time speech therapist with the Sheppard Center in Atlanta. Ms. Bruce sees people with many different types of speech difficulties resulting from various injuries and disorders, including brain injury, spinal cord injury, MS, and ALS. She specializes in communication devices for individuals with speech impairment, which are referred to as “speech generating devices” in the industry. According to Ms. Bruce, these strategies and devices may be grouped into three categories: no-tech, low-tech, and high-tech.

“No-tech” speech generation usually involves a quick and easy strategy, and is useful for individuals unable to speak (less common for individuals with MS). Examples of no-tech speech generation include an eye blink to signal a selection or answer; gazing at things wanted; putting thumb up or down; nodding or shaking one’s head; or using sign language.

“Low-tech” speech generation involves the ability to recognize and understand symbols, and as with the no-tech strategies, is most often used for individuals unable to speak. Communication boards allow an individual to gaze at a letter or symbol for selection, or to use a pointer. Sometimes an assistant may help with scanning or will write options on paper for an individual to select and indicate what they want to say. Several keyboarding devices are also available that have a basic text display.

Recorded and Computer-Generated Speech
“High-tech” speech generation devices are far more complex and may involve equipment with a memory component (the ability to record or store speech). Some devices have “digitized” speech, which play back recorded speech, while others have “synthesized” speech that is computer generated by typing in or otherwise selecting letters, words, or symbols.

Those with digitized speech can include a single-message device that might ask someone to come over or ask for help when a button (or other switch of some type) is activated. Other devices may have multiple common messages, and the user may have an entire menu of buttons to press. These messages may tell a person’s name and address, how one prefers his or her coffee, or ask for the time.

“Multi-level” devices will have different groups of menus to choose from, and menus may be changed with sheets that slide under the buttons to change the selections. “Dynamic display” devices have a touch screen with a computer that changes the pictures for each button, without having to slide a sheet into the device. Sometimes these are “activity specific,” such as when someone is playing bingo – all of the typical phrases one would use while playing bingo would be pre-recorded and ready to select from a menu. The synthesized speech devices with dynamic displays vary in size and skill level. Some are large (approx. 13 inch) to accommodate decreased fine motor skills, while others may come in a palm size with a touch screen and stylus.

Voice Amplifiers
Voice amplifiers (also part of the “high-tech” category) are useful when an individual speaks too quietly. Breath-support issues are the most common cause of a quiet voice for someone with MS. This is when someone does not have the strength to push adequate air through the vocal cords to produce loud sound. Provided that the person is able to form words clearly with his or her mouth, the voice amplifiers may be of help to an individual with MS who speaks quietly.

Pamela Miller Sorensen, MA, CCC-SLP, is a speech-language pathologist in Denver, Colorado, and specializes in treating individuals with MS. When asked about the effectiveness of voice amplifiers, she explains, “There are many variables to consider, so this question is best answered by a speech/language pathologist during an individual evaluation.

“There are a variety of portable, battery-operated voice amplifiers available. They are worn using a headset with attached microphone to speak into, and a small receiver with amplifier clipped onto the body, where loudness level may be adjusted. For some it can open their world and make one-to-one communication possible (even if inconsistently so), where speech is otherwise too soft to hear. For others, it can be less effective because of physical and cognitive challenges.

“Several questions should be considered before a professional can determine if someone is a good candidate for a voice amplifier. Among others, these include asking if the person can produce voice, or is it just a whisper; is breath support/control adequate to drive the microphone; how is sitting posture and head control; and how well can the person control the lips and tongue, to shape the speech sounds which are articulated and later amplified? Increased loudness, as made possible by a voice amplifier, may be very effective for some people. For others, the answer may not be so simple.”

Ms. Bruce of CATEA explained that with the many types of voice amplifiers, a speaker may be setup in a fanny pack, small bag, or mounted on a wheelchair or scooter. A high-end system will specifically amplify voice sounds versus other sounds in the environment, so with less outside noise, the sound will be crisper.

Phone Call Assistance
If using a voice amplifier while on the phone, bringing the microphone too close can cause “feedback.” Phones are available with built-in amplifiers – both for hearing and for speaking – but these are made for the general population and their amplification may not be adequate.

For assistance making phone calls, Ms. Bruce recommends taking advantage of a speech relay system that is a free service from the Federal Communications Commission. This is a system setup for individuals with speech disabilities who have difficulty being understood on the phone.

The “Speech-To-Speech” (STS) service has communications assistants (CA) who are trained to understand many different types of speech patterns. Individuals with speech problems may call the toll-free number for their state and then ask the CA to dial the number of the person they wish to call. The CA then repeats the words exactly as the caller gives them. To get the toll-free number for the STS in a specific state, individuals may go to http://ftp.fcc.gov/cgb/dro/sts.html. Those without access to the internet may call MSAA’s Helpline consultants for the STS phone number in their state.

Other Helpful Devices
For those who have trouble getting their vocal cords to move, often from nerve damage caused by trauma to the vocal cords or from cancer, an “electro larynx” is available. This sends out a vibration to move the vocal cord folds, allowing for sound to be produced. Many types and models are available. One type is held against the neck, another is “intra oral,” held in the mouth like a straw, while others may be implanted in a retainer or even in a person’s dentures.

Speech-language pathologists also specialize in swallowing disorders, another potential symptom of MS. While such problems would need to be thoroughly evaluated and medications or strategies may be prescribed, an electric stimulator, or “E-stim” may be used. This uses nodes worn along the neck to stimulate different muscles and actions that improve the ability to swallow. Some are switched on or timed, while others are “intuitive” and can recognize when to activate.

For More Information
The different types of strategies and devices listed in this article are just a sampling of the wonderful technology available for individuals with disabilities. For additional information on assistive technology of any type, accessibility information and resources, catalog and product listings, etc., individuals may go to www.techconnections.org for more information. This website was created by the Georgia Tech Center for Assistive Technology and Environmental Access (CATEA) located in Atlanta, Georgia, and is funded by the National Institute on Disability and Rehabilitation Research (NIDRR).

Once on the home page, clicking on “resources” will bring up many valuable on-line publications, guides, and listings, including a new reference on making the home more accessible. Clicking on “Find AT Products” will bring up another site created by CATEA that lists more than 15,000 assistive technology products. For those without access to the internet, or for additional information on anything related to accessibility (including services available, product information, vendors, local resources, and how things may be funded) Carrie Bruce may be contacted at (800) 726-9119.

Many thanks to Carrie Bruce for her extensive information on the assistive technology mentioned in this article. Special thanks also go to Pamela Miller Sorensen for her valuable contributions.