ALS and speech Changes in speech and how

ALS and speech Changes in speech and how your SLP can help By Tiziana di Rocco, MSc(A), S-LP with guest Mme Johanne Landry

ALS and speech A little info about me… • speech pathologist at the Montreal Neurological Hospital (MNH) • part of the interdisciplinary team of the ALS Clinic of the MNH

ALS and speech A little info about me…in the ALS Clinic of the MNH • help persons with ALS retain access to communication • explain what is happening to their speech

ALS and speech What we will learn today… • how ALS affects speech • how the SLP can help • what the person with ALS can do to help retain use of natural speech • ways to supplement natural speech

ALS and speech How ALS affects speech • among presentations of ALS, the most common are spinal and bulbar • degeneration of the neurons in the brainstem and cerebellum (bulbar area) results in symptoms of bulbar ALS

ALS and speech How ALS affects speech Bulbar area

ALS and speech How ALS affects speech • symptoms of bulbar ALS are weakness (flaccidity) and, tightness and stiffness (spasticity) of the muscles involved in the production of speech and in the ability to chew and swallow

ALS and speech How ALS affects speech • bulbar neurons are the nerve cells responsible for bringing messages from the bulbar region of the brain to the muscles that move the lips, tongue, soft palate, jaw, and vocal cords • lung muscles are also weakened and their weakness affects speech as well: shorter sentences and low voice volume

ALS and speech How ALS affects speech • weak and stiff muscles are harder to use and require that healthy muscles work harder to compensate for them • unaffected muscles will therefore fatigue faster and will need frequent and extended rest • rest can often help improve speech for short periods

ALS and speech How ALS affects speech • exercises for strengthening the muscles have not been shown to improve speech for people with ALS • stretch and massage may be recommended to reduce tightness or maintain range of movement

ALS and speech How ALS affects speech Bulbar onset ALS will typically present with a mix of both: • • swallowing difficulty (dysphagia) = coughing and choking on food speech difficulty (dysarthria) = slurred, nasal speech with difficulty pronouncing consonants, slow rate, low pitch, reduced stress, and strained-strangled/harsh voice quality, audible inspiration and nasal emission

ALS and speech How ALS affects speech • with disease progression and increased muscle wasting and atrophy, muscle weakness will have the greatest impact on speech quality

ALS and speech The role of the SLP • speech-language pathologists can assist individuals with ALS to maintain their ability to communicate using compensatory strategies and AAC (augmentative alternative communication) aids and techniques.

ALS and speech The role of the SLP • as the quality of speech declines, the SLP will focuses on maintaining functional communication instead of trying to improve speech quality

ALS and speech The role of the SLP • intervention will involve: o provide strategies to improve speech intelligibility by using the abilities retained o suggestions to prevent fatigue during communication o introduction, assessment, and training in the use of the most appropriate augmentative and alternative communication (AAC) device

ALS and speech The role of the SLP • speech decline in ALS occurs in stages • for each stage, interventions are provided to deal with immediate needs, and suggestions for planning for future communication needs

ALS and speech The role of the SLP Stage 1 – normal speech • intervention: assessment of speech and provide information

ALS and speech The role of the SLP Stage 2 –changes in the quality of speech are present • Intervention: o make changes in the environment to make communication easy and effortless so as not to tire the speech muscles Ø reduce competitive noise in order to eliminate the need to increase volume Ø speak in well lit areas Ø maximize the hearing of communication partners Ø position yourself so that all involved in the conversation can see you o communication partners should allow for more initiation and response time

ALS and speech The role of the SLP Stage 2 –changes in the quality of speech are present • Intervention: o make behavioural changes Ø communicating in small groups Ø be aware of fatigue Ø plan conversations for high energy times and allow for breaks Ø slow down speech and exaggerate the sounds especially at the ends of words Ø alert conversation partners if you are shifting topics and name the new topic Ø establish a non-verbal signal to communicate that you wish to speak Ø set rules for conversation, i. e. , let people know to let you finish speaking, that you want to know when they have not understood you.

ALS and speech The role of the SLP Stage 2 –changes in the quality of speech are present • Intervention: o make behavioural changes Ø teach communication partners to repeat any part of a sentence that they DID understand, insert the word “blank” for the word they missed so that person with ALS needs only to repeat back the word or words in question rather than saying the whole sentence Ø consider spelling misunderstood words aloud or using a finger to spell on the palm or on the table Ø consider eating and drinking prior to social gatherings

ALS and speech The role of the SLP Stage 3 - speech intelligibility might be reduced and repetitions may be needed • Intervention: o make behavioural changes: Ø Ø Ø do not try to increase rate of speech increase precision of speech sounds: slow rate, exaggerate pronunciation pay special attention to include final consonants. conserve energy – no exercises to strengthen muscles, avoid trying to increase voice volume, reduce length of breath groups so not to ‘squeeze out’ the last few words

ALS and speech The role of the SLP • voice banking (more energy required) - voice is imported into a speech generating device will speak any message you enter using a voice that resembles the speaker’s • message banking (less energy and speech precision required) involves recording speaker’s common expressions • amyandpals. com/message-voice-banking/

ALS and speech The role of the SLP Augmentative & Alternative Communication (AAC) • AAC aids range from low-tech alphabet boards to high-tech computer-based systems • provide speech and writing augmentation to maintain access to communication

ALS and speech The role of the SLP Augmentative & Alternative Communication (AAC) • recommended when quality of speech is impaired enough to require frequent repetitions or when speech rate is very slow • hi-tech devices are best obtained and customized before speaker may need to rely on them for communication

ALS and speech • AAC of low technology type: alphabet/word/sentence board(s) • essential backup to high-tech speech generating device • sometimes a low-tech AAC system is preferable in some settings and situations • the primary difference between high-tech and low-tech AAC systems is there is no voice produced by low-tech AAC.

ALS and speech • Voice volume amplifier

ALS and speech The role of the SLP • portable writing systems o paper and pencil o boogie boards

ALS and speech When reading and writing abilities are intact AAC aids that allow the generation of messages through spelling are an option Communication board

ALS and speech • with hand or limb movement is limited, alternative access to communication is needed • assistive technology modifications include: o using a thick barreled pen if grip is reduced o increasing the cursor speed of a mouse so less movement is required o eliminating the need to double click on items to select them o a mouse with an onscreen keyboard rather than touch typing o head, foot or eye movement access

ALS and speech • Tobii with infra red eye control

ALS and speech Text to speech apps for tablets and smart phones: Speak. It, Abilipad, etc. • • • provide a means to produce voiced speech SLP will make sure you have the needed accessories (e. g. mounting and alternative access equipment) to make the system work optimally for you SLP can also assist you in installing banked message or personal, synthesized voice created into the SGD or TTS app.

ALS and speech • alerting systems/calling attention: • buzzers, baby monitors that transmit signals to different areas of the house Baby monitors

ALS and speech The role of the SLP Cognitive changes • up to one-third of individuals with ALS may develop cognitive impairments or a form of dementia • dementia-type is usually consistent with frontal lobe involvement • symptoms may involve difficulty performing in tasks demanding sustained attention, ability to shift quickly from topic to topic, word-finding, judgment, and insight • complex AAC devices that require extensive new learning may not be ideal

ALS and speech Johanne and her communication device, the Ipad

References • American Speech and Hearing Association (ASHA) • Pamela Mathy (ASHA) • Suggestions and Information about Speech Changes & Augmentative Alternative Communication (AAC), by Amy Roman, MS, CCC-SLP, Speech-Language Pathologist, Forbes Norris ALS Research & Treatment Center • The ALS Association - 1275 K Street NW - Suite 250 - Washington, DC 20005 • http: //sla-quebec. ca/images/finder/files/als_overview_en. pdf • Yorkston, Miller, & Strand, 1995 • Duffy, 1995 • Yorkston, Strand, Miller, Hillel, and Smith (1993) *

References • Duffy, J. R. (1995). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis: Mosby. • Jackson, C. E. , & Bryan, W. W. (1998). Amyotrophic lateral sclerosis. Seminars in Neurology, 18 (1), 27 -39. • Louvel, E. , Hugon, J. , & Doble, A. (1997). Therapeutic advances in amyotrophic lateral sclerosis. Trends in Pharmacological Sciences, 18 (6), 196 -203. • Mathy, P. , Yorkston, K. M. , & Gutmann, M. (in press). Augmentative communication for individuals with amyotrophic lateral sclerosis. In D. R. Beukelman, K. M. Yorkston, & J. Reichle (Eds. ). Augmentative communication for adults with neurogenic and neuromotor disabilities (Vol. 2). Baltimore: Paul H. Brookes.