speech therapy exercises for ms patients

Multiple Sclerosis and Speech Therapy

Multiple sclerosis affects many aspects of an individual's life. One of these aspects that are usually affected is a person's ability to communicate. As a way to combat this, an individual with multiple sclerosis might be referred for speech therapy. This article will discuss some of the areas of speech that are directly affected by multiple sclerosis as well as how a speech-language pathologist can be of help in treating these affected areas.

In this article, we will discuss:

What is Multiple Sclerosis (MS)?

Multiple sclerosis symptoms, multiple sclerosis speech symptoms, communication disorders and multiple sclerosis, how speech therapy can help individuals with multiple sclerosis, goals of speech therapy treatment for multiple sclerosis, preventing communication isolation in individuals with multiple sclerosis.

Multiple sclerosis is an autoimmune disorder in which the immune system attacks what is known as the myelin sheath. This myelin sheath is meant to carry signals between neurons and when it is destroyed, the transfer of these signals is inhibited. This results in what we know as multiple sclerosis. MS is often broken down into a few categories depending on certain criteria:

Relapsing Remitting Multiple Sclerosis (RRMS): Characterized by autoimmune attacks happening months or even years apart. An individual with RRMS might experience deficits when the attacks occur, but then improvements between attacks. Typically though, these attacks will leave lasting effects.

Secondary Progressive Multiple Sclerosis (SPMS): SPMS is similar to RRMS, however overtime the time frame between attacks lessens and eventually the attacks will often become constant, resulting in the steady progression of deficits.

Primary Progressive Multiple Sclerosis (PPMS): PPMS is different from RRMS and SPMS because PPMS is a constant attack on the myelin sheath, resulting in constant disability progression.

Progressive-Relapsing Multiple Sclerosis (PRMS): Similar to PPMS, this is one constant attack. However, the disability will often progress even faster than with PPMS.

Other types of multiple sclerosis exist, however they are less common. But as MS studies continue to change, so do the classifications.

Reduce the impact of MS on your speech skills

Depending on the type and the extent of the progression, MS can look different for many people. However, some common symptoms include:

Tingling sensations

Numbness/weakness in the limbs

Double vision

Incoordination

Difficulty walking/unsteadiness

Cognitive deficits

Fatigue/Tiredness

Slurred speech

As mentioned above, MS can cause slurred speech. But 'slurred speech' does not encompass the entire picture of how MS can affect a person's ability to communicate and overall thrive.

An individual with MS may struggle to coordinate the movements needed to articulate speech in a manner that is comprehendible to a listener or communication partner. This is where the slurred speech comes from. But the speech is not always slurred. Sometimes an individual may sound strained, hoarse, or raspy. This is dependent on how the MS is affecting the motor speech functions of the body/brain.

Multiple sclerosis can cause what is known as dysarthria, dysphonia, and dysphagia in affected individuals. However, these three areas are not necessarily the limit to what speech areas can be affected by multiple sclerosis and the symptoms do not always present themselves the same way in all individuals.

Spastic-Ataxic (Mixed) Dysarthria

There are several types of dysarthria , which is a motor speech disorder. However, spastic-ataxic dysarthria is most commonly associated with multiple sclerosis. A mixed dysarthria occurs when symptoms from two or more dysarthria types are present. Ataxic dysarthria is most commonly associated with uncoordinated/slurred speech. Spastic dysarthria is usually characterized by a strained voice, monotonous speech, and a slow rate of speech. Spastic-ataxic dysarthria is characterized by the presence of both of these dysarthria types in a singular individual.

Dysphagia is characterized by problems with swallowing . This can present itself in obvious symptoms, such as choking on saliva, liquids, or foods. It may be less obvious, and an individual may only choke on certain consistencies (i.e., thin liquids, solid foods, etc.) Or there may be no outward signs of choking at all, which is known as silent aspiration. A person with MS can experience all of these symptoms, making it difficult for them to acquire the nutrition they need on a day to day basis.

Dysphonia is characterized as a voice disorder. It can present itself as breaks between words or sentences in which the voice seems to disappear and return. It may also sound like a hoarse or grating voice that seemingly appears without cause (i.e., illness). It can also sound like breathy or nasally speech.

Adult speech therapy can assist in the lessening of MS symptoms on speech as well as assist in coping with what affects may be permanent. Speech therapy includes methods to treat the communication deficits discussed above: dysarthria, dysphagia, and dysphonia. A speech therapist is also equipped to educate patients about said communication deficits, in order to help the patient feel more prepared and knowledgeable about what is happening to their speech and swallowing. This can also, ideally, assist the patient in educating others about their condition should the situation arise in which they feel the need to do so.

A speech therapist will often times begin with an assessment, in most cases to specifically assess the dysarthria, dysphagia, or the dysphonia. These assessments are tailored specifically to the affected area and can give the speech therapist an idea of where to begin in treatment and what areas the individual is in need of assistance in.

A speech therapist's goals vary depending on the individual's affected areas. The ultimate goal of the speech therapist is to improve the patient's quality of life and to take into account the patient's desires for their treatment and what they would like to focus on in therapy, while also making it realistically achievable in home life .

Dysarthria Goals

Treatment and goals for dysarthria tends to depend on the type of dysarthria that is present. However, an overarching goal for dysarthria treatment, especially when it comes to people with MS, is to retrain and strengthen the muscles that are affected. These muscles are uncoordinated and weak, and the speech-language pathologist will in many cases, give oral motor exercises. Just like going to the gym to exercise the body, the individual will exercise the muscles utilized for speech to rebuild the muscle's abilities as well as retain what remains.

Dysphagia Goals

For many speech therapists, the ultimate goal of dysphagia treatment is to give the individual access to an adequate and safe diet. Dysphagia treatment can look different in a variety of ways, depending on the patient's wants a needs. The goals might be centered around exercises to strengthen the swallowing mechanisms. Goals might focus on making eating and drinking safer. Or the goals might even focus on simply modifying the patient's diet to maintain nutrition. Depending on the severity of the dysphagia, a patient might not be able to maintain an oral diet at all and might be in need of an alternative form of nutrition intake. A combination of all of these treatment plans may also be required for an individual, as they might only need diet modifications temporarily while also performing exercises to strengthen their swallowing mechanisms.

Dysphonia Goals

The goal of dysphonia treatment might involve implementing vocal exercises into the patient's treatment plan. The goal of these exercises could be to improve the individual's prosody (as mentioned above, patients with MS can sometimes have monotonous speech). Also, the goals might center around improving the patient's volume and rate of speech. Many times, with MS a patient might speak at an inappropriate volume, whether it be what is considered too loud or too quiet for a social situation. Or they may speak at a rate of speech that is difficult to comprehend, whether that be a rate of speech that is considered too fast or a rate of speech that is considered too slow.

Goals for Alternative Forms of Communication

In some cases, restoring speech to its former functions may not be possible in the case of MS. However, a speech-language pathologist can assist patients in coming up with an alternative form of communication. This might involve acquiring an AAC device (Augmentative and Alternative Communication). This could be in the form of a device that has been programmed with options for communication in which the device may 'speak for' the patient. Or this can be without the assistance of technology through writing or picture boards with common phrases accessible and individualized to the patient.

Speech-language pathologists might make learning to utilize these forms of communication a goal for their patient.

An unfortunate side effect of dysarthria, dysphagia, and dysphonia can sometimes be communication isolation. Individuals with dysarthria and dysphonia struggle to communicate with their communication partner and may have difficulty getting their wants and needs across verbally. Socially, they may struggle to participate in conversation with groups. An individual with dysphagia may feel isolation during social eating settings. They may be unable to eat the same food that is being serviced to their peers. These are all things to be considered if you or a loved one is struggling with MS. Group speech therapy exists to connect people experiencing similar situations, and can be very beneficial to one's emotional state.

It is sometimes helpful to prepare for social situations by prepping social partners beforehand. Many times, this isolation is not intentional on the part of the social partners and a simple briefing beforehand or sharing how one feels emotionally with the assistance of an AAC device can make the experience much more enjoyable.

In many cases, a speech therapist can act as a mediator with the family to assist the patient in expressing their desires for their communication and their personal goals for social situations.

At Better Speech we know you deserve speech therapy that works. We have experts in your needs and assign the right therapist, not just the therapist that happens to be in your area. Having multiple sclerosis can be difficult, but with the right support, you or your loved one can learn to lead a happy and successful life.

At Better Speech, we offer online speech therapy services convenient for you and tailored to your child's individual needs. Our services are affordable and effective - get Better Speech now.

Frequently Asked Questions

How does multiple sclerosis affect speech?

Multiple sclerosis can affect speech in different ways, depending on the location and severity of the damage to the central nervous system. It can cause slurred or slow speech, difficulty with pronunciation or articulation, voice tremors, and changes in pitch or volume.

Can speech therapy help with multiple sclerosis-related speech problems?

What other communication problems can multiple sclerosis cause?

How long does speech therapy for MS-related speech problems typically last?

About the Author

Denni Hickman

I am a speech-language pathologist with six years of academic experience and two years of workforce experience. I have completed a Bachelor of Science in Speech-Language Pathology and a Master of Science in Speech-Language Pathology, as well as a minor in English. I have worked with both children and adults in the school setting, private practice setting, as well as medical setting (hospital inpatient and outpatient).

I love speech-language pathology because it offers such a wide variety of experiences with so many different groups of people, with different backgrounds and ages. For fun I enjoy reading, writing, and spending time with my loved ones.

• Articulation Speech Therapy
• Apraxia Speech Therapy

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by Patricia D. Myers

I'm not an English native speaker and I wanted to improve my speech. Better Speech onboarding process is AWESOME, I met with different people before being matched with an AMAZING Therapist, Christina. My assigned therapist created a safe place for me to be vulnerable and made all the sessions fun and helpful. Thanks to her, I received great feedback from my clients.

by John L. Wilson

​ Better Speech is a great program that is easy to use from home and anywhere online. Shannon was amazing at engaging our shy son - and building on their relationship each session! Her commitment to knowing him improved his confidence to speak and practice more. Truly appreciate her dedication. She cares for her clients.

by Christy O. King

​ Better Speech is an excellent opportunity to improve your speech in the convenience of your home with flexible scheduling options. Our therapist Miss Lynda was nothing short of amazing! We have greatly appreciated and enjoyed the time spent together in speech therapy. Her kind, engaging and entertaining spirit has been well received. She will surely be missed.

by Patricia W. Lopez

This service is so easy, i signed up, got a therapist and got to set up an appointment right away that worked with my schedule. so glad to see that services like speech therapy are finally catching up to the rest of the convenience age! therapy is great, i can't believe how many good tips, exercises and methods in just the first session. really recommend it!

Speech Therapy

Multiple sclerosis (MS) is a neurodegenerative disorder characterized by lesions in the brain and the spinal cord, which disrupt the communication between different parts of the brain, and between the brain and the rest of the body.

Nearly 40–50 percent of MS patients experience  speech difficulties , which are caused predominantly by damage to the parts of the brain that control the muscles of the tongue, lips, soft palate, cheeks, or diaphragm.

Types of speech difficulties in MS patients

MS patients may experience different types of speech difficulties. These are summarized below.

• Dysarthria  is a speech problem that occurs when the motor muscle components of speech are affected. The condition causes slurred, imprecise or slower speech, difficulty with resonance and pitch control, long pauses between words or syllables, and altered pronunciation.
• Dysphonia involves changes in voice quality such as harshness of voice, impaired pitch control, hypernasality, irregular pitch levels, breathiness, and hoarseness.
• Dysphasia is a language disorder where patients have difficulty understanding what’s being said (receptive dysphasia), recalling vocabulary, or finding the right way to say something (expressive dysphasia). It can occur due to cognitive issues that cause changes in memory and thinking.

Fatigue , tremors , and spasticity  can also affect speech, as can some treatments because they cause a dry mouth.

Speech therapy for MS patients

There are many ways in which speech therapy  can help people with MS. These include:

• exercises to help improve the strength and coordination of the muscles in the throat, tongue, cheeks, mouth, diaphragm, soft palate, and lips
• voice training including teaching patients how to slow down, articulate more carefully when speaking, sometimes by exaggerating articulation, and controlled and modified breathing
• exercises that strengthen or relax the muscles controlling the vocal cords for speech difficulties affecting volume and pitch, or making speech breathy and hoarse
• exercises that help improve breathing, emphasizing certain words in a sentence, and catching quick breaths between thoughts
•  exercises that help with the movement of the jaw, tongue, and lips to assist with clear articulation and pronunciation

There is also a range of special high-tech communication devices that can help people with MS who have speech difficulties better communicate. These include alphabet cards, machines that offer speech output either by typing the message or accessing visual symbols on a screen via touch or scanning, voice amplifiers, and computers that respond to eye blinks.

Low-tech options such as an E-tram frame and partner-assisted scanning  are also available.

Medical treatment of speech difficulties

While there are no medications available to specifically treat speech problems in MS patients, treatments that are used to control other symptoms of the disease can also be beneficial in improving speech.

• Medications used to treat spasticity such as Lioresal (baclofen) and Zanaflex (tizanidine) may be useful in cases where spasticity affects muscle tone in the vocal cords, tongue, lips, and soft palate or diaphragm.
• Medications used to decrease tremors such as Klonopin (clonazepam), Inderal (propranolol), Mysoline (primidone), and Doriden (glutethimide) can improve voice quality.
• Medications for managing fatigue such as amantadine , Provigil (modafinil), and Nuvigil (armodafinil) can improve muscular coordination and strength necessary for sound production.

Multiple Sclerosis News Today  is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

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Speech Therapy Can Help Patients with MS

• MARCH 21, 2019

Speech and swallowing problems are among the most frustrating of MS symptoms, but speech therapy can help patients speak and swallow better. For the millions of people throughout the world with multiple sclerosis, symptoms can be debilitating, especially when it comes to speech difficulties and swallowing problems.

Speech and voice disorders affect 25 percent to 40 percent of people with multiple sclerosis, and are often accompanied by difficulty swallowing, according to the National Multiple Sclerosis Society. Complications include slurred speech, unclear articulation of words, difficulty controlling loudness, and changes in vocal quality such as hoarseness, breathiness, and nasality. These disorders are caused by damaged nerves in areas that control these functions. Speech and voice problems are most likely to occur during MS relapses or periods of extreme fatigue. Speech therapy may be part of a multiple sclerosis treatment plan if weak facial muscles or lesions (damaged areas in the brain) have affected your ability to talk or swallow. Multiple sclerosis treatment involving speech therapy is tailored to the specific MS symptoms of each patient.

Speech therapy for people with MS may involve exercises to help strengthen the muscles in the tongue, cheeks, mouth, and lips. Other speech therapy techniques can teach patients how to slow down and articulate more carefully when speaking, sometimes by exaggerating articulation. Breathing control is an important part of speech therapy for multiple sclerosis treatment. Given that many of the muscles used in speech are also used in swallowing, it’s not surprising that MS patients with speech impediments may also have difficulties in that area. Swallowing problems, referred to as dysphagia, result from damage to the nerves that control the muscles in the mouth and throat. Symptoms of dysphagia include coughing or choking when eating and feeling like food is stuck in the throat.

If problems with swallowing aren’t corrected, malnutrition or dehydration can result. Lung infections are another possible consequence because food and liquids may be inhaled into the windpipe instead of passing through the esophagus and into the stomach. Once in the lungs, the food can lead to aspiration pneumonia.

Speech-language pathologists use various techniques to help MS patients, including:

• Oral motor exercises
• Voice training
• Special communication devices
• Dietary modifications
• Altered positions while eating
• Atlantic ENT

It makes a lot of sense that you would want to look into the various ways in which speech disorders affect work. This is a big reason to want to try and improve this aspect. My sister might like knowing this as she looks into getting speech pathology help.

• Camille Devaux
• MAY 15, 2019 12:12 am

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The Voice Foundation

Advancing understanding of the voice through interdisciplinary research & education , philadelphia, new york, los angeles, cleveland, boston, paris, lebanon, brazil, china, japan, india , mexico.

Overview  |  Stroke  |  Parkinson’s Disease  |  Benign Essential Tremor (BET)  |  Amyotrophic Lateral Sclerosis  |  Myasthenia Gravis (MG)  | Multiple Scleroris (MS) |  Spasmodic Dysphonia

Neurological Voice Disorders: Voice problems caused by abnormal control, coordination, or strength of voice box muscles due to an underlying neurological disease such as: stroke, Parkinson’s disease, multiple sclerosis, myasthenia gravis, or ALS

Dysarthria: Difficulty forming words – presenting with imprecise consonants and hard-to-understand speech as seen with stroke patients

Speech Disorder: Malfunction of the tongue and/or lip muscles resulting in garbled words or parts or words.

What are the typical symptoms of voice dysfunction in patients with multiple sclerosis (MS)?

• MS is a chronic neurological disease characterized by episodes of dysfunction of the nervous system that increase and decrease (remit and recur) over several decades. Commonly, long periods of normal function occur in between these episodes.
• Voice symptoms may include hoarseness and poor control of volume and pitch.
• Speech problems are more common and have been characterized as “scanning speech,” in which each syllable is produced slowly and hesitantly with a pause after every syllable.
• Other important symptoms of MS include dizziness (vertigo) and altered vision.

What is the cause of MS? Who is at risk? The cause of MS is unknown, but it is thought to be viral in origin. The process involves loss of the protective sheath around nerves in the brain/brainstem. The disease is more common in females, higher socioeconomic groups, and at northern and southern latitudes (more rare at the equator). Onset of disease most frequently occurs in young adulthood.

How is MS diagnosed? Diagnosis of MS may take years. MS is characterized by multiple signs and symptoms, with remissions and exacerbations of the disease. CT or MRI scans may show the characteristic scar changes in the brain, and fluid from spinal tap may also help in the diagnosis.

Difficulties in Diagnosis Because of the long latent periods (periods where disease is not present) and the waxing and waning of symptoms, MS is easily missed. Repeated examinations and clinical suspicion by a neurologist will help make the diagnosis.

How is MS treated and what is the prognosis?

• There is no cure for MS at this time. Care is directed towards controlling symptoms.
• Speech therapy plays an important role in improving quality of life in patients.
• Medical therapy includes corticosteroids for acute exacerbations of MS symptoms.
• For chronic treatment of MS, interferon and chemotherapeutics such as Novantrone have been used to slow the progression of the disease.

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Rehabilitation Therapies in Multiple Sclerosis

Therapy is a critical element of your MS care plan

Physical Therapy

Occupational therapy, speech-language therapy, cognitive rehabilitation, vocational rehabilitation, multidisciplinary programs.

Along with the medications that treat multiple sclerosis (MS), rehabilitation is a key part of managing your condition effectively, particularly after a relapse. Depending on your symptoms, you may only occasionally need rehabilitation or you may require these therapies regularly to help you stay as healthy as possible.

From physical therapy to speech-language therapy to cognitive therapy (and more), there are a number of effective, engaging rehabilitation options that can minimize the impact of MS-related disabilities and help you function at your best in every aspect of your life.

Physical therapy can help treat a number of MS-related symptoms and needs.

Mobility and Muscle Problems

Walking problems are extremely common in MS and may be one of the first symptoms you experience. Physical therapy can help you improve your mobility and independence.

A physical therapist can teach you exercises to reduce muscle pain, spasticity , and weakness, as well as help you improve your balance, coordination, strength, and flexibility. This may delay your need for a mobility device and help prevent falls, something that can put you five steps back in your MS care.

3 MS Patients Share Their Experiences Facing Mobility Challenges

If you do need a mobility device (or you're not sure if you're using the right one), a physical therapist can help you find what's best for you. Examples of mobility devices include single-point or quad canes, motorized scooters, rolling walkers, and manual or power wheelchairs.

You may also be surprised to learn that, in addition to muscle and mobility problems, physical therapy exercises can improve MS-related fatigue. Treating fatigue is pretty crucial since it affects between 75 percent and 95 percent of patients, and 50 percent to 60 percent report that it's one of the most difficult MS symptoms to deal with.

One of the reasons that exercise helps is that being inactive actually contributes to fatigue by causing your body to work harder to do everything because it's out of shape. Exercise can also combat stress, help you sleep better, and improve your mood—all factors that can affect your fatigue level.

A 2019 Cochrane overview of Cochrane reviews on rehabilitation therapies for people with MS determined that physical therapies such as exercise and physical activity may not only improve functions such as strength, mobility, and lung capacity, they can also reduce fatigue and improve your overall quality of life.

Exercising with MS requires a delicate balance. You don't want to overexert or overheat yourself, so designing an exercise regimen with a physical therapist who works with people who have MS is your best bet.

Posture and Positioning

A physical therapist can teach you how to maintain good posture and body positioning, which may alleviate some of your MS-related pain. If you're in a wheelchair or you have limited mobility, proper positioning can also prevent pressure sores .

Occupational therapy helps you maximize your daily functioning at home and/or in the workplace.

Energy Management

An occupational therapist can work with you on ways to conserve your energy. For example, if your fatigue limits your ability to go grocery shopping, your occupational therapist may suggest using a scooter when running errands.

Skills and Devices for Daily Activities

Occupational therapists may recommend changes in your home to prevent falls and ease your comfort in performing activities of daily living, such as:

• Getting rid of loose rugs to prevent falls
• Installing handrails in the bathroom to maximize safety and accessibility
• Adjusting lighting to address vision problems
• Teaching you and/or loved ones how to evaluate and maintain the safety of mobility devices
• Providing tips on hiring and working with a caregiver
• Instructing you on how to dress, bathe, and prepare meals based on MS-related disabilities
• Giving you exercises that strengthen your hands and arms and improve your coordination
• Determining what adaptations you may need to keep driving
• Assessing what sort of devices or adaptations you need to use a computer and other electronic equipment

Some occupational therapists also focus on cognitive rehabilitation and vocational rehabilitation (see below).

As MS progresses, you're at an increased risk for developing problems with swallowing, speaking, and taking deep breaths. Often, these problems coincide because similar muscles are used to control all of these functions.

A speech-language pathologist can help you tackle these difficulties with specific strategies.

Improve Breathing

To improve breathing capabilities, speech-language pathologists may work with pulmonologists (lung specialists). Strategies a speech-language pathologist may use include:

• Techniques to clear mucus from your throat
• Exercises to help you breathe more easily
• Medical therapies like nebulizers or oxygen

Minimize Aspiration

When a person with MS develops difficulty swallowing foods and liquids, this causes major concerns, including dehydration, poor nutrition, choking, and aspiration (when you breathe food or drink into your lungs).

A speech-language pathologist may recommend eating techniques that will maximize your nutritional intake while minimizing your risk of aspiration. These approaches often include:

• Resting before eating
• Sitting in an upright position
• Keeping your chin parallel to the table
• Performing double swallows

Reduce Speech Difficulties

Speech problems are common in MS, affecting up to 40 percent of patients at some point. These problems may include difficulties with articulation (slurred speech), slowed speech, soft speech, or impaired voice quality like hoarseness, breathiness, or a nasally speaking voice.

A speech-language pathologist can help reduce these speech difficulties by teaching you mouth-strengthening exercises. He or she may also recommend communication devices like voice amplifiers so you can be heard better.

Some speech-language pathologists also do cognitive evaluations and cognitive rehabilitation (see below).

Cognitive problems affect an estimated 34 percent to 65 percent of MS patients. They usually come on gradually and can occur at any time during the disease course. For some people, they're even the first symptom of MS.

Possibilities include issues with:

• Speed of information processing
• Reasoning and problem solving
• Visual-spatial abilities
• Verbal fluency

While there's no medication for such problems in MS, cognitive rehabilitation may help. It's performed by a qualified neuropsychologist, occupational therapist, or speech-language pathologist and helps you learn to compensate for your cognitive concerns and improve your overall function.

The good news about cognitive function in MS is that it's rarely ever severely impaired. Regardless, even with mild cognitive deficits, you may feel isolated or anxious about engaging with others at home or at work.

Cognitive Evaluation

The cognitive therapies you need hinge on your cognitive evaluation. Some people with MS who have cognitive dysfunction choose to be evaluated if their cognitive issues are affecting how they function in their daily lives.

Although cognitive testing can be time-consuming (it requires a number of standardized tests), it can help you develop a clear picture of how MS has affected your cognition or if there's another health concern going on, like depression or MS-related pain, which can worsen cognition.

Seeking cognitive evaluations early in your disease and having follow-ups allows your provider to compare recent results to those of prior years, helping establish whether your cognition has worsened, stayed the same, or even improved.

Cognitive testing can be expensive. Some insurance plans will cover it, though, so it's best to contact your carrier for more information.

Based on your evaluation, your cognitive therapist may recommend one or more of the following, among other possibilities. The strategies you may use over time may also be changed.

• Planning your most brain-intense activities for the part of the day when you're most alert
• Using electronic devices or simply a pen and paper to remember things
• Focusing on a single task at a time and learning how to block out potential distractions
• Engaging in brain-stimulating activities like reading or card games
• Engaging in pleasurable activities, which can improve your brain's resiliency to MS-related damage
• Engaging in physical exercise, which has been shown in studies to help improve cognitive function

Stress management and psychotherapy may also be a part of cognitive rehabilitation, especially considering the fact that depression is so common in MS.

A 2017 review of studies on rehabilitation therapies in MS found moderate-quality evidence that cognitive-behavioral therapy (CBT), a type of psychotherapy, is beneficial for treating depression and helping patients accept and cope with MS. If you have symptoms of depression, be sure to talk to your healthcare provider about getting treatment.

Vocational rehabilitation specialists can train you to use assistive devices or make accommodations that adapt your current workplace to meet your needs, or help you find a new job that does. They also assess job readiness and perform job coaching and mobility training.

Some occupational therapists also do vocational rehabilitation since there's quite a bit of overlap between the two disciplines.

Vocational rehabilitation programs may be available through your county or state. Contact either of these for more information.

Multidisciplinary rehabilitation programs involve a team of healthcare professionals from two or more specialties, such as medical, physical therapy, occupational therapy, speech-language therapy, cognitive rehabilitation, neurology, nursing, etc. These programs can be in-patient or out-patient.

The aforementioned 2019 Cochrane review found that a comprehensive multidisciplinary rehabilitation program improves function and disability and leads to longer-term improvement in the quality of life and activity. These findings suggest that utilizing all the rehabilitation therapies you need is a good way to maximize the potential benefits.

A Word From Verywell

Rehabilitation therapies play a paramount role in your MS health, but they aren't a quick fix—it takes time and patience to see results. You may experience obstacles and some frustrations along the way, but the overall benefits to your long-term health are worth it. Talk to your healthcare provider about which rehabilitation therapies are appropriate for your individual needs and when you might need them.

Keep in mind, too, that it's OK to switch therapists or therapy sites if you're not content with your current one. Getting a second opinion is never a bad idea, and sometimes it takes time to find the right healing, trusting relationship. Our Doctor Discussion Guide below can help you start that conversation.

Multiple Sclerosis Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

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Amatya B, Khan F, Galea M. Rehabilitation for People With Multiple Sclerosis: An Overview of Cochrane Reviews . Cochrane Database of Systematic Reviews . 2019;1:CD012732. doi:10.1002/14651858.CD012732.pub2.

Khan F, Amatya B. Rehabilitation in Multiple Sclerosis: A Systematic Review of Systematic Reviews . Archives of Physical Medicine and Rehabilitation . 2017;98(2):353–367. doi:10.1016/j.apmr.2016.04.016.

National Multiple Sclerosis Society. Fatigue: What You Should Know . Updated 2019. https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Brochure-Fatigue-What-You-Should-Know.pdf.

National Multiple Sclerosis Society. Managing Cognitive Problems in MS . Published 2019. https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Brochure-Managing-Cognitive-Problems.pdf.

National Multiple Sclerosis Society. Speech & Swallowing: The Basic Facts . Published 2014. https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Brochure-Speech-Swallowing-BasicFacts-FINAl.pdf.

By Colleen Doherty, MD Dr. Doherty is a board-certified internist and writer living with multiple sclerosis. She is based in Chicago.

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Speech Therapy

Speech therapy.

Speech therapy can help those with MS who are having difficulty speaking, to communicate better and to break down the barriers that result from communication impairments.  Speech therapy can also help if you are having trouble forming sentences or are having difficulty understanding what someone is saying to you.  This type of disorder can be a result of your MS and is called expressive and receptive aphasia. The goals of speech therapy include improving pronunciation and strengthening the oral muscles.  Our speech therapists are MS certified specialists and will help you develop strategies to improve your ability to communicate with others as well as understand what they are saying to you.

Speech therapy can be used for a lot of different impairments and disorders. Communication disorders resulting from your MS, can affect your ability to speak, to name objects and build complete sentences. This can have a profound effect on your quality of life and overall independence.

Oral Dysphagia is when a person has difficulty preparing and manipulating food/liquids in preparation for swallowing due to reduced tongue, lip or palate ROM and weakness.  Pharyngeal Dysphagia is when a person has difficulty swallowing food or liquid through the pharynx leading to residual food and /or aspiration of the food/liquid.  Aspiration is when food/liquid has entered the airway (trachea) and continues on to enter the lungs either before, during or after the initiation of a swallow. This can lead to aspiration pneumonia. Our Speech Language Pathologists  conduct an in depth swallow evaluation and determine the least restrictive diet. They will also determine if therapy and additional testing is indicated.  Following an evaluation by the SLP, a treatment plan will be developed. This plan may include diet modifications for solids, thickening liquids, oral, laryngeal, and pharyngeal exercises, and various swallow strategies.

Our speech therapists who are MS certified specialists will provide you with:

• Immediate feedback and education on where your speech or aphasic deficits are and the best course of initial treatment.
• Educate on the most effective way to improve your overall communication.
• A plan of care that identifies the specific deficits which can lead to larger impairments.
• Constant visual assessment and subjective feedback to determine the effectiveness of your plan of care as is relates to your communication.
• Exercises that you will perform with our specialists.
• Perception exercises to differentiate between individual sounds and syllables.
• Exercises to produce certain sounds and improve the fluency of your speech.
• Exercises to improve breathing, swallowing and your voice.
• Help with communication and if necessary, use of communication boards and computer-assisted speech.
• Education for people who need speech therapy, their family and other loved ones.
• Support in implementing these measures in everyday life.

For more information on our speech services please contact us at [email protected] or

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Therapies to Treat MS

Medicine plays a key role in treating your multiple sclerosis (MS), but it takes more than pills to manage the effects of the disease on your daily life. If you want to help your mind and body work better, whether it's for work or play, rehab therapy may be the answer.

Different forms of rehab therapy, also called restorative rehabilitation, target the way MS changes your life. It helps you stay independent and handle many of the physical, mental, and emotional challenges you face.

Physical Therapy (PT)

MS affects everyone differently, but you'll probably find that it limits movement in at least one part of your body. You may find you have pain in a certain area, balance problems, trouble walking, dizziness, fatigue , or bladder issues. For all these problems, physical therapy can help by building up your strength.

Ask your doctor for a referral, and check with other people who have MS for suggestions on where to go in your area. You may have one to three sessions to learn exercises to do at home, and then follow-ups as needed. Some therapists may be able to come to your home to work with you.

Your physical therapist will help you set up a fitness program that's good for your strength and goals. Regular exercise helps with all types of MS , but it can be hard when you're tired or you overheat easily. You'll learn how to work around these issues to get the most from your workouts.

You may also learn:

• Stretches to prevent or ease muscle spasms
• Exercises to keep muscles strong and improve coordination and balance
• Range-of-motion exercises, like straightening and bending your arms and legs
• Tips to prevent falls
• How to use canes, crutches, scooters, wheelchairs, or other aids, if necessary

If your MS symptoms make it hard to do your job, your therapist can take you through some tests and document the kind of trouble you're having. This is called a functional capacity evaluation. It measures whether you can work an 8-hour day and may help if you need to apply for Social Security disability benefits.

Occupational Therapy (OT)

Occupational therapy tries to change and simplify the way you do everyday tasks at home. The goal is to let you work safely without having to rely on help from other folks, and make your daily life easier and more enjoyable.

In general, an occupational therapist can help you find easier ways to:

• Cook and do chores
• Have fun and enjoy your hobbies
• Bathe and use the toilet
• Get dressed and groom yourself

An occupational therapist also can give you information on how to adjust your surroundings to suit your needs. They might suggest ways to alter your home, your car, or your computer to make them easier to use. They can also look at your workplace and suggest changes to help you do your job safely and comfortably.

Cognitive Rehabilitation

MS may alter the way you think, concentrate, or remember. If those are problems for you, cognitive rehab fights back by helping you work that big muscle called your brain.

Cognitive rehabilitation can make a big difference in your life. A neuropsychologist, someone who specializes in brain changes caused by disease or trauma, can show you activities to sharpen your skills.

They'll also give you strategies for organization and time management. You'll learn little tricks like leaving yourself reminder notes, making checklists, or using word association to trigger a memory.

MS can sometimes affect your mood in unpredictable ways. You may get worried about your future or feel isolated from your family and friends.

Just as other forms of rehab therapy focus on ways to help you handle your everyday tasks, your feelings may benefit from some training as well. Let a counselor or psychologist support you through the emotional issues that can come along with MS.

This might include something called “resilience training,” which focuses on how to respond in a healthy way to hard times. MS can cause plenty of stress , but resilience training offers strategies to help get back on your feet. These include:

• Stay social: Keep up with family and old friends or make new ones if necessary.
• Stay flexible: This can mean changing the way you think of normal. A good sense of humor and a positive outlook can help a lot when you’re dealing with some of the serious issues that MS can throw your way.
• Plan ahead: There are serious practical challenges that can arise with MS. You can help lessen the challenges and the anxiety that goes along with them if you plan for them. For example, as you start to become less mobile, you can slowly work toward making your home easier to navigate by wheelchair.
• Take care of yourself: This could mean walking outside, or doing your PT exercises, or resting. It could simply be meditation . It depends in large part on your MS symptoms and how far along you are in your MS journey.
• Seek meaning: This can mean involvement in your community through outreach, hobbies, or religious organizations. Or, it may be time together with friends and family. Art, music , and literature can be great ways to connect with what is meaningful in your life.

Speech and Swallow Therapy

If MS causes problems with your voice or the way you speak, speech therapy works on your communication skills. A speech-language pathologist (SLP) tests your mouth, voice, and breath and shows you exercises that can strengthen weak areas.

Speech therapy is also useful if you're having trouble swallowing, called dysphagia .

Your doctor might use a special imaging procedure called a modified barium swallow, where you ingest a small amount of radioactive substance that shows up clearly on an x-ray machine. This tells your doctor and SLP useful information about how you swallow.

Your SLP will also test everything from your lips and throat to the larynx -- an organ in your neck that holds your vocal cords. They'll point out ways to change your diet or hold your head while swallowing.

Sexual Dysfunction Therapy

To start with, it’s a good idea to talk to your medical team about sexual issues. They may be able to adjust or change your medications in ways that improve your sex life. But nonmedical therapies also play a part. For example, physical therapy exercises can help lessen muscle stiffness and spasm and allow both men and women to better adjust their bodies for satisfying sexual activity.

A sexual therapist or other members of your team might also be able to help with strategies like conserving energy for sex by taking it easy and planning out bathroom habits and liquid intake so as not to interfere with sex.

You may be able to counter the weaker genital sensation that sometimes accompany MS with slightly harder stimulation by hand or vibrators.

Finally, there may be difficult emotional issues that come along with changing sexual function that sometimes happens with MS. Couples therapy can help you and your partner get on the same page. Cognitive Behavior Therapy, or CBT, can help you overcome certain unhelpful thought patterns that might interfere with a healthy body image and satisfying sex life.

Vocational Rehabilitation

When you look at your job and workplace, you may see the challenges MS presents. But a therapist looks at it through different eyes and sees the changes you can make to keep working.

If you want to move into a new career or brush up on your interviewing skills, a vocational rehab therapist can give you advice.

A vocational rehab specialist can also talk to you about your legal rights on the job. They can explain how the Americans with Disabilities Act may allow you to make tweaks to your workplace that take into account your MS symptoms.

Recreational Therapy

This form of rehab is work disguised as fun. Taking part in activities that you enjoy has physical and social benefits.

A recreational therapist will help you make a plan to take advantage of your own interests. You'll find out how your MS symptoms don't have to stand in the way of doing things like yoga , swimming, golf, and horseback riding.

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How MS Causes Speech Problems and How To Manage Them

Many people with multiple sclerosis (MS) experience speech problems as part of their MS symptoms . Speech disorders in MS occur as the result of brain lesions — the areas of damaged nerves and tissue brought on by MS. Lesions that develop in different parts of the brain and brain stem can cause a variety of changes to a person’s usual speech patterns.

These speech difficulties may come and go throughout the day, sometimes lasting for just a few minutes. They may also worsen when a person’s MS symptoms are relapsing (flaring up). Most people with MS experience only mild changes in their speech, although severe problems are possible. These changes may cause temporary or long-lasting difficulties.

There are ways to manage speech difficulties with MS. If you’re having problems speaking, get in touch with your neurologist. They may refer you to a speech and language therapist who can help you keep speaking and maintain clear communication.

Symptoms of Speech Problems in Multiple Sclerosis

Speech changes due to MS may cause a variety of disruptions to a person’s normal speech pattern.

Like other MS symptoms, MS speech problems can occur temporarily during a flare-up, or they can last longer. Some people find that their speech difficulties come and go in various situations or at different times of the day: “I have problems with speech at night when I’m really tired,” shared one member. “In the morning, my speech is back to normal.”

Another member wrote that they find speech more challenging when under pressure: “I speak much better when not answering questions, having to think, or being on the phone.”

Note that many people with speech difficulties also experience dysphagia (difficulty swallowing) .

MS and Explosive Speech

Some people may struggle to control the loudness of their voice, experiencing sporadic episodes of loud, rapid speech referred to as explosive speech.

MS and Scanning Speech

Scanning speech is another speech pattern commonly associated with MS. Scanning speech occurs when the normal melody of a person’s speech pattern is disrupted, causing abnormally long pauses between syllables or words. This disruption in rhythm and intonation can result in speech that sounds robotic.

MS and Slurred Speech

Some people with MS may slur their words, while others may speak nasally, as if they have a cold or a stuffy nose. Many MyMSTeam members have reported experiencing speech changes with their MS that make communicating difficult. As one member wrote, during a morning meeting, they were “stuttering, not talking clearly, [and] difficult to understand.”

What Causes Speech Problems in Multiple Sclerosis?

There are several types of speech problems in MS, and dysarthria is the most common.

Dysarthria, the medical term for a motor speech disorder, affects about 40 percent of people with multiple sclerosis.

In people with MS, white blood cells — the body’s defenders — attack the central nervous system, which includes the brain and spinal cord. These attacks cause inflammation and strip the nerves of their myelin, which is the protective coating around nerves. This results in areas of nerve damage known as lesions or plaques. Dysarthria can occur when the damage affects parts of the brain and brain stem responsible for controlling speech.

Damage to different areas of the brain can result in different types of speech changes . Damage in one area may weaken the diaphragm (the muscle that plays a key role in breathing), reducing breath control and causing a person to speak more softly. Damage in other areas may affect the muscles in the lips and tongue, causing speech to become slurred, slower, or less precise.

Scanning speech and explosive speech are other forms of MS-related dysarthria. Both result from lesions in the cerebellum — the part of the brain responsible for motor skills, including muscle coordination. These two speech patterns feature a disruption in the coordination between the muscles responsible for articulation and exhalation, which are essential to volume control.

Although rare, dysphasia is another type of speech problem that can occur in people with MS. Unlike dysarthria, which occurs as the result of motor impairment, dysphasia is a language disorder. It results in a person having difficulty finding the right words to explain their thoughts (expressive dysphasia) or understanding what others are saying to them (receptive dysphasia).

One MyMSTeam member described their experience with dysphasia: “I stutter and can’t find my words a lot. I often find it hard to talk to people because I am afraid I’ll stutter or say something crazy.”

Cognitive Difficulties

Multiple sclerosis can cause cognitive difficulties (sometimes called brain fog ), which can affect the way a person speaks in some cases. Cognitive difficulties usually result in only mild speech problems related to memory and word-finding.

Some medications used to treat MS symptoms like bladder problems can lead to dry mouth as a side effect, which may make speech more difficult. Talk to your doctor if you experience this side effect. They may be able to change your medication or adjust your dosage.

Managing Speech Problems With Multiple Sclerosis

Communication plays a huge role in our day-to-day lives. Experiencing problems with the way you communicate can be upsetting. As one member wrote, “I get so sick of people saying they can’t hear me.” Another shared, “I will be talking and just searching for that word that I’m trying to say to explain what I’m trying to say — if that even makes sense … It stops me midsentence as I go searching, and everyone is looking at me, and I feel so foolish, which makes me not want to talk.”

There are several ways that you and your health care team can work together to help improve and manage MS-related speech problems, generally through speech and language therapy.

Speech and Language Therapy

Many MyMSTeam members have shared that they have undergone speech therapy . A speech and language therapist can help improve or address many speech-related issues through the following techniques.

Breath Control Exercises

Breathing exercises often involve practicing breathing in and out in a controlled way, ultimately allowing you to form longer sentences with one breath. A speech therapist may also direct you through exercises to take pauses between phrases, emphasize certain words in a sentence, and monitor your breathing while speaking.

Voice Quality and Articulation Exercises

Some speech difficulties can affect voice volume and pitch or cause breathiness or hoarseness while speaking. A speech therapist can recommend exercises to relax or strengthen the muscles that control the vocal cords. Other exercises can help improve articulation and pronunciation by altering the movement of the jaw, tongue, and lips.

As one MyMSTeam member shared, “The things that I have to remember are to slow down my rate of speech, increase my pitch, and exaggerate my words.”

Communication Aids

Assistive devices known as communication aids can help people with significant speech problems communicate by translating written words into speech, for example. Other MS symptoms, such as tremors or vision problems, may make using certain aids unusable. A speech and language therapist can help recommend the appropriate device.

Physiotherapy

Posture may also affect your speech. A physiotherapist can help you improve your posture in a way that works with your physical abilities. Using a pillow or foam supports while seated or lying down may also help maintain good posture and promote clearer speech.

At-Home Tips for Managing MS Speech Problems

Making certain adjustments to your environment and way of communicating may help make spoken conversations easier. Be sure to have someone’s full attention before speaking to them, and don’t try to compete with other noise, such as a TV.

Communicating face to face also provides important nonverbal cues — like body language and facial expressions — that may make it easier to get your ideas across. If you have trouble with finding the right word or remembering what you are trying to communicate, it may be helpful to use notes or remind yourself to slow down while speaking.

Find Your Team

Speech problems are just one of the symptoms of MS that can be challenging in day-to-day life. It may help to know you’re not alone. MyMSTeam is the social network designed for people with multiple sclerosis and their loved ones. Here, more than 192,000 members who understand life with MS gather to ask questions, give advice, and share support.

Have you experienced speech problems with MS? If so, how have you managed them? Share your tips in the comments below or by posting on MyMSTeam .

• Speech Problems — Pittsburgh Institute for Multiple Sclerosis Care and Research
• Speech Difficulties — Multiple Sclerosis Society
• Speech Problems — Multiple Sclerosis Trust
• Speech Problems — National Multiple Sclerosis Society
• Speech Difficulties — Multiple Sclerosis Association of America
• Speech and Pause Characteristics in Multiple Sclerosis: A Preliminary Study of Speakers With High and Low Neuropsychological Test Performance — Clinical Linguistics & Phonetics
• Multiple Sclerosis (MS) — Cleveland Clinic
• Causes of Speech Problems — Multiple Sclerosis Society
• Managing Speech Problems — Multiple Sclerosis Society

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Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations

Farzin halabchi.

1 Sports and Exercise Medicine, Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

Zahra Alizadeh

Mohammad ali sahraian.

2 Neurology, MS fellowship, MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

Maryam Abolhasani

3 Sports and Exercise Medicine, MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

4 Sports and Exercise medicine, Sina MS Research Center, Department of Sports Medicine, Sina Hospital, Hassan Abad Square, Tehran, Iran

Associated Data

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Multiple sclerosis (MS) can result in significant mental and physical symptoms, specially muscle weakness, abnormal walking mechanics, balance problems, spasticity, fatigue, cognitive impairment and depression. Patients with MS frequently decrease physical activity due to the fear from worsening the symptoms and this can result in reconditioning.

Physicians now believe that regular exercise training is a potential solution for limiting the reconditioning process and achieving an optimal level of patient activities, functions and many physical and mental symptoms without any concern about triggering the onset or exacerbation of disease symptoms or relapse.

Appropriate exercise can cause noteworthy and important improvements in different areas of cardio respiratory fitness (Aerobic fitness), muscle strength, flexibility, balance, fatigue, cognition, quality of life and respiratory function in MS patients.

Aerobic exercise training with low to moderate intensity can result in the improvement of aerobic fitness and reduction of fatigue in MS patients affected by mild or moderate disability.

MS patients can positively adapt to resistance training which may result in improved fatigue and ambulation.

Flexibility exercises such as stretching the muscles may diminish spasticity and prevent future painful contractions. Balance exercises have beneficial effects on fall rates and better balance.

Some general guidelines exist for exercise recommendation in the MS population.

The individualized exercise program should be designed to address a patient’s chief complaint, improve strength, endurance, balance, coordination, fatigue and so on.

An exercise staircase model has been proposed for exercise prescription and progression for a broad spectrum of MS patients.

Exercise should be considered as a safe and effective means of rehabilitation in MS patients. Existing evidence shows that a supervised and individualized exercise program may improve fitness, functional capacity and quality of life as well as modifiable impairments in MS patients.

MS or demyelinating disease of central nervous system is characterized with neurodegeneration, inflammation, axonal demyelination and transaction [ 1 – 3 ].

This disease has a chronic nature and affects young people, especially women [ 3 ]. However, it can be identified in childhood or late adulthood, although this is rare [ 4 – 6 ].

The chronic course of multiple sclerosis can result in significant mental and physical symptoms and irreversible neurologic deficits, including muscle weakness, ataxia, tremor, spasticity, paralysis, balance disorder, cognitive impairment, loss of vision, double vision, vertigo, impaired swallowing and speech, sensory deficits, bladder and bowel dysfunction, pain, fatigue, and depression [ 3 – 5 , 7 ].

Motor dysfunctions in MS patients are frequently due to muscle weakness, abnormal walking mechanics, balance problems, spasticity and fatigue [ 6 , 8 , 9 ].

MS has an unpredictable progressive nature and defects and restrictions of activities may suddenly occur and proceed further than the expected time [ 10 ].

It is reported that nearly 50% of multiple sclerosis patients use a an accessory device for moving following 15 years from the beginning of disease [ 11 , 12 ]. Patients frequently reduce their activities due to their fear of symptoms exacerbation [ 13 ]. Limited activities increase disability,unfitness, mobility, quality of life (QOL),gait abnormalitiesand lack of stability and muscle strenght [ 14 , 15 ].

Impairments related to the disease process itself are irreversible by exercise, but impairments resulting from deconditioning are often reversible with exercise [ 16 ]. Furthermore, inactivity places MS patients in raised possibility of comorbid health dependent conditions.

Hypercholesterolemia, hypertension, obesity, type 2 diabetes, cancer, arthritis, osteoporosis, depression, fatigue and death from cardiovascular diseases are the most frequently reported comorbid health -related conditions [ 13 , 16 ].

These comorbidities in MS have further been connected with a raised possibility of inability development because of reduced aerobic capacity, decreased muscle strength, increased muscle atrophyas well as further neurologic risks (e.g., stroke, etc) [ 16 ].

For many years, physicians advised newly diagnosed persons with MS to avoid anyphysical activity and exercise. But now, we believe that regular exercise and training is a possible solution during disease period by limiting the deconditioning process and achieving an optimal level of patient activity, functions and many physical and mental health benefits without any concern about a triggering onset or exacerbation of disease symptoms or relapse [ 13 , 16 ].

We review in this paper, therapeutic function of physical training in multiple sclerosis. The aim of this narrative review is to emphasize the current documents in exercise recommendation including aerobic, resistance, balance or combined trainingin MS patients, and to provide instructions for the sensible use of the physical modalities. Another aim is to outline the impacts of exercise on MS patients by summarizing the physiologic and health view of multiple sclerosis disease.

Physiological profile of MS patients

MS patients, especially with more severe impairments, may exhibit some differences in their physiological characteristics in comparison tohealthy age-matched people in terms of cardiovascular and muscle physiology [ 16 ].

Decreased aerobic capacity and cardiorespiratory fitness, in expression of VO 2 maxor maximal oxygen consumption, among MS patients has been about 30% lower than the healthy controls. Respiratory dysfunction due to respiratory muscle weakness and external causes like muscle defect and tiredness are contributing factors in reducing aerobic fitness [ 14 , 16 – 18 ].

Another cardiac factors such as basic heart rate and minimum blood pressure are noted to be increased in multiplesclerosis because of impairments in the autonomic control of cardiovascular function that has been estimated about 7% to 60% among MS patients [ 13 , 19 ].

Also, decreased muscle force calculated by isokinetic and isometric muscle contractions and endurance,muscle mass in total body and increased muscle atrophy are seen in MS patients [ 13 , 16 , 20 , 21 ].

It must be shown that muscle strength defect appears particularly clear in the lower extrimities in comparison to the upper extrimities [ 8 , 13 ].

Flexibility is another physiological characteristic that has diminished in MS patients specially in those with spasticity [ 16 ].

About 80% of MS patients feel high temperature intolerance that may be correlated with temporary exacerbation of clinical manifestations of the MS [ 22 ]. This is an important concern about MS and exercise. Physical activity is beneficialand important for people with MS, but it should not causeoverheating symptoms [ 22 , 23 ].

Benefits of exercise for MS patients

Appropriate exercise can lead to significant and important improvements in different areas of cardiorespiratory fitness (Aerobic fitness), muscle strength, flexibility, stability, tiredness, cognition, quality of life and respiratory function. At this section, the details of benefits are described [ 3 ].

Cardiorespiratory fitness

Aerobic training in MS patients is more extensively studied than resistance training . During aerobic training, the patients use multiple muscle acts opposite a low burdon with aim of increasing cardiovascular fitness [ 16 ].

In summary, aerobic training of low to moderate intensity is effective on cardiovascular fitness, mood and QOL(quality of life) in multiple sclerosis patients with EDSS < 7. This type of exercise is safe and tolerable in many individuals with MS. multiple sclerosis patients are shown to make favorable gains in cardiorespiratory fitness within a short term of exercise (for example, 4 weeks) [ 18 , 24 ].

Cardiorespiratory exercise training in MS is associated with increased VO 2 Max or VO 2 peak and working capacity, respiratory function and reduction of fatigue [ 18 , 25 ].

A number of studies have made better in cardiorespiratory fitness and aerobic capacity in response to exercise interventions. For instance, Rampello et al. (2007) showed that cardiorespiratory training is better than neurorehabilitation in improvement of functional and moving capacity in multiple sclerosis patients with EDSS < 7 [ 26 ].

In another study, Swank et al. (2013) showed that structural cardiorespiratory training can cause improvement in quality of life and emotion of multiple sclerosis patients [ 2 ].

In addition cardiorespiratory training can can increase aerobic fitness and reduce tiredness in MS patients some degrees of disability [ 27 ]. However, it is not clear whether MS patients with sever impairements have similar adaptations to the cardiorespiratory training benefits or not [ 13 ].

Muscle strength and endurance

During strength training, the patients use muscle contractions against a load for increasing muscle strength. Some studies have demonstrated the benefits strenght exercises in MS patients [ 16 , 28 ].

Increased muscular strength and endurance have also been shown following other exercise interventions in multiple sclerosis patients [ 18 ]. Increased strength in lower limbs, could be an important benefit of strnght training in MS. Strength of the lower limb is affected by the disease often previously and to a more range than arms and hands [ 29 , 30 ].

White et al. (2004) revealed the effects of the strenght exercise on leg strength, moving ability and self-reported fatigue and disability and showed significant improvements in knee extensor and plantar flexor muscle forces and thenwalking performance [ 8 ].

MS patients can make good adjustments to strenght trainings in accompanying by improvement in moving capacity and tiredness [ 30 ]. Gutierrez.et al. (2005) revealed that strenght training is a good intervention to improve moving and functional capacity in MS patients having moderate disabilities [ 9 ]. Surakka et al. (2004) reported that cardiorespiratory and strength training improves tiredness in MS patients with some degree of disabilities and the training type was more achievable in women patients with less disability in comparison to men patients with more disabilities [ 27 ]. In general, resistance training with moderate intensity can induce improvements in muscle strength and function among moderately impaired persons with MS. Thistype of exercise is safe and well tolerated in multiple sclerosis [ 8 , 9 , 16 , 25 , 29 ].

Bone health

The use of therapeutic corticosteroids and inactivity may both lead to osteoporosis and pathologic fractures in MS patients. Furthermore, the chronic process of disease and inactivity in multiple sclerosis patients can cause loss of muscle and bone mass. Shabas et al. (2000) showed that among 220 women with MS, 82% had corticosteroid’s history of use and 53% had loss of mobility and bone mass [ 31 ].

Weight - bearing exercise can slow the loss of muscle and bone mass in MS. For this reason, the resistance training program is recommended for maintaining and developing the muscle and bone mass in the whole of body [ 18 ].

Flexibility

People with multiple sclerosis frequently have limitation in joint motion because of spasticity and prolonged inactivity. Goals of flexibility exercises are to lengthen the muscles, enhance joint range of motion, reduce spasticity, and maintain good posture and balance [ 16 , 18 ].

Avoidance of spasticity in early stages of disease is very noted. Lenghening the muscles can delay coming aching muscle contractions and spasms. Studies regarding the effects of flexibility exercise on MS are limited, but this type of exercise are recommended. These exercises must be performed by using proprioceptive facilitation techniques and stretching tight muscles in pelvis, chest, leg and hip flexores. For preventing spasticity aggravation, activities like for example indicating the toes during traing must be prevented [ 6 , 13 , 16 , 18 ].

Impairments of balance, such as difficulty in maintenance of upright posture, are common in MS patients. Swing during silent standing, moving slowly following postural disturnances and inability to maintain the balance are common in multiple sclerosis and may be related to falling [ 5 , 32 , 33 ].

Some articles showed the effects of balance training in stability of MS patients. Improvements in balance assessed by Berg Balance Scale (BBS), are shown following group aquatic and stability training [ 34 , 35 ].

Cattaneo et al. (2007) studied the effects of stability training on multiplesclerosis patients and demonstrated that stability training is effective to reduce the falling and improve stability [ 36 ].

Generally, balance training has small, but statistically significant effect on improving stability and reducing falling risk in MS patients with some degrees of disabilities. There was limited data on patients with severe MS who are not ambulatory [ 33 , 37 ].

Tiredness is greatly seen in MS patients and leads to exacerbation of the neurological and other symptoms of MS such as depression, pain, anxiety and cognitive dysfunction [ 18 , 37 ]. The underlying mechanisms of fatigue are unknown.

Physical inactivity and mental disorders because of MS or comorbidities have been suggested to cause tiredness.

Exercise can cause some changes such as neuroprotection and neuroplasticity, reduction of long-term inactivityand deregulation of hypothalamus-pituitary- adrenal (HPA) axis and then reduction of tiredness in patients [ 38 ].

Evidence has revealed that exercise can manage energy and tierdness levels in healthy peoples. Results are much less conclusive with relation to the exercise and tiedness management in MS patients, although several studies provide support for the potential benefits of exercise in these patients [ 25 , 37 , 39 ].

Cardiorespiratory training and neurorehabilitation, energy storage programs and cooling devices and plans have also been shown as good and effective interventions [ 24 , 40 , 41 ]. Petajan et al. showed that regular aerobic exercisecan reduce fatigue in MS patients, and improve both mood and the QOL(quality of life) [ 42 ].

Kargarfard et al. (2012), revealed that aquatic training is effective on tierdness and QOL of women with MS [ 34 ].

Establishing a safe and effective exercise program may be considered as an important option while planning for treatment of fatigue and should be encouraged [ 37 ].

Quality of life

HRQOL(Health-related quality of life) has diminished in MS patients. The reduced QOL may be related with deterioration of symptoms, walking and cognition in patients [ 14 ].

Stuifbergen (2006) studied the positive effects of regular exercises in general health, liveliness and function of patients [ 43 ]. The results of several studies on patients with MS confirm the effectiveness of exercise on long period improvement in physical and social function and quality of life [ 25 , 42 , 44 ].

In summary, exercise training can cause prominent and positive effects in QOL of persons with MS [ 3 ].

CNS morphology and imaging findings

Until now, no evidence has been foundabout the effects of exercise training on brain structure in multiple sclerosis disease. Any way, some studies revealed the effects of cardiorespiratory training on volume of brain grey matter volume and unity of white matter tract as well as functional connectivity of the hippocampus and cortex in people with MS [ 5 , 45 ]. Despite the limited data on exercise performance on the brain structureon, some studies revealed regular cardiorespiratory training work against brain degeneration in relapsing-remitting type of MS and probably is a protective strategy.

Some studies proposed detection of morphological changes with exercise in the CNS of MS patients by imaging techniques. Although, evidence is still not enoughto demonstrate effects of exercise on brain structure in multiple sclerosis [ 46 ].

Implications for practice

The evidence confirms that individuals with MS are less active than healthy individuals [ 28 ]. This is important when designing effective exercise programs for both increasing the tendency and adherence to exercise and createing potential beneficial effects.

Despite all the limitations, exercise has beneficial effects on individuals with multiple sclerosis. Furthermore, no side effects from exercise have been seen in most studies [ 14 , 23 , 46 – 48 ].

Part II: Exercise recommendations

Growing evidence exists in favour of exercise as an effective treatment for MS patients, and therefore it should be recommended in the rehabilitation process [ 7 , 49 ].

Some general guidelines exist for exercise prescription in the MS population. In this part, we will discuss the practical points for exercise prescription in MS patients.

Pre-exercise evaluation

A comprehensive pre-exercise screening should be considered before designing an individualized exercise program. This should be preferably performed by sports medicine physician, physical medicine and rehabilitation physician, exercise physiologist or physical therapist with proper expertise on MS patients [ 13 , 16 , 18 , 23 , 50 ].

The evaluation should include a thorough physical examination and history, including MS, functional, and exercise histories. A cardiopulmonary function review should also be done [ 6 , 49 ]. Patients should also be screened for risk factors or presence of cardiovascular, respiratory or metabolic disorders [ 51 ].

Some authors have recommended a baseline ECG or submaximal stress test for this review [ 52 ]. However, some others do not always find these tests necessary unless individual cardiovascular risk factors and cardiac history mandate further evaluations [ 23 ]. In these cases, MS patients, stratified as “high risk” for medical problems during exercise should undergo a supervised exercise test before participating in an exercise routine [ 51 ].

Also, some authors recommend fitness evaluations to be used as a baseline for exercise prescription in MS patients. Using these assessments, the physician can formulate an appropriate initial exercise program [ 53 ].

After medical clearance was obtained by physician, exercise professionals should use proper fitness tests to estimate the patient’s cardiorespiratory, musculoskeletal fitness, as well as neuromuscular/functional competence [ 53 ]. These tests should be selected according to the patient’s tolerance and goals [ 18 , 54 , 55 ]. Fitness tests should be performed according to the guidelines of American College of Sports Medicine [ 51 ]. The six minute walk test (6MWT) requiring minimal apparatus, is a valid tool for MS patients, and is applicable for patients who use walkers, canes, and assistive devices [ 56 , 57 ]. Other proper tests consist of arm, leg, or combined leg and arm cycle ergometry and recumbent stepping.

Table  1 describes suggestions for testing cardiorespiratory and musculoskeletal fitness, as well as neuromuscular/functional competence.

Recommendations for exercise testing in MS patients [ 53 – 55 ]

BP blood pressure, RPE ratings of perceived exertion, HR heart rate, MS multiple sclerosis; RM, repetition maximum

a RPE is a subjective rating scale ranging from six to 20 that gives an indication of the workout intensity level

Exercise program

The individualized exercise program should be designed to address a patient’s chief complaint or goal—to improve strength, endurance, balance, coordination, fatigue, etc. It should consider a patient’s baseline impairments and capabilities [ 18 , 50 ]. The prescription should include all the necessary components, such as frequency, duration, intensity, modalities to be used, and precautions to be observed [ 50 ].

Exercise staircase model

An exercise staircase model has been proposed for exercise prescription and progression for a broad spectrum of MS patients [ 23 ].

At the base of the staircase is the passive range of motion exercises. This serves as the foundation and is suitable for the most physically and cognitively disabled. These exercises should be done no less than once daily.

The next step up the staircase is the active range of motion exercises. These are proper for less disabled MS individuals and may be carried out with or without gravity eliminationas strength allows. Even when diffused weakness exists, resistance exercises of cautiously chosen muscles, perhaps not more than 2 per limb, may still permit efficient strengthening. In motivated patients with mild MS, focused muscle strengthening with progressive resistive exercises may be effective.

The third and highest step in the staircase is integrated exercises. Integrated exercises use a combination of strength, endurance, flexibility, balance, and coordination exercises [ 16 , 23 ]. Recent studies have also shown that combined exercisetraining may have advantages, especiallyin reducing fatigue perception, and improving someaspects of QOL [ 58 , 59 ]. The exact combination of exercises should be individualized according to patient needs and capabilities. Aquatic exercise is a good example of an integrated exercise, simultaneously incorporating endurance, resistance, flexibility and balance components [ 16 , 23 ].

Aerobic exercises

In general, aerobic training of low to moderate intensity produced improvements in aerobic capacity and in measures of HRQL, mood, and depression in patients with mild to moderate MS (EDSS < 7). Aerobic training is generally safe and well tolerated in these patients [ 13 , 16 ]. Individuals with MS have been shown to make favorable gains in cardiorespiratory fitness within a short span of 4 weeks [ 18 , 60 ].

Bicycle ergometry, arm ergometry, arm-leg ergometry, aquatic exercise, and treadmill walking may all be suggested, although rowing and running are only recommended for MS patients with proper functioning [ 13 , 54 , 55 , 60 – 67 ]. Currently, the use of robot assisted weight supported treadmills has shown promising results in MS patients [ 68 – 71 ]. Exercise frequency of 2–5 weekly sessions is recommended according to the patient’s toleration. It is preferred to set these sessions in non-resistance training days [ 13 , 53 – 55 ]. Starting with intensity of 40%–70% of VO 2 max, 60%–80% of maximal heart rate or 40%–60% heart rate reserve is recommended [ 13 , 18 , 53 , 63 , 64 ]. A rating of percieved exertion (RPE) scale of 11–13 (fairly light to somewhat hard) is another valuable alternative for exercise intensity. As autonomic dysfunction (a common finding in MS patients) may attenuate the HR response to exercise in MS patients, the use of the RPE scale is advised throughout the exercise [ 13 , 53 – 55 ].

Depending on the level of patient’s disability, the initial training duration of 10–40 min is suggested. At first, it may be splitted to three 10-min bouts [ 13 , 53 – 55 ]. During the first 2–6 months, progression should be attained by increasing the duration or frequency of exercise sessions. After this time, it should be checked to find out whether a higher intensity is tolerable. In this condition, one training session may be replaced with interval training (up to 90% of VO 2 max) [ 13 , 18 , 53 – 55 ].

Resistance exercises

It is important that resistance training should be supervized for safety by an experienced staff until the MS patient is contented with the program [ 13 ]. Other than safety concern, it has been shown that supervised is more effective than nonsupervised resistance training [ 13 , 72 ].

In terms of resistance training modalities, the use of weight machines (i.e., closed kinetic chains) is preferred to free weights (i.e., open kinetic chains) for safety, especially in the initial training phase [ 13 ]. If weight machines are not practicable, a home based exercise program using elastic bands and/or body weight as resistance should be considered as a substitute. However, it is not easy to achieve the same benefit from this type of exercises, as it can be achieved using weight machines [ 13 , 18 ].

Training frequency of 2–3 weekly sessions is well tolerated and gives rise to significant progress in patients. Training intensity should be set in the range of 8 to 15 repetition maximum (RM) with 60%–80% of 1RM. Initial starting intensities of approximately 15 RM is suitable [ 53 – 55 ]. This should be gradually increased over several months toward intensities of approximately 8 to 10 RM [ 8 , 18 ]. Resistance can be securely added by 2% to 5% when 15 repetitions are properly carried out in successive training sessions [ 8 , 18 ]. However, day-to-day variability in fatigue will likely justify flexibility in the resistance program. The rate of progression should permit for full recovery between exercise sessions to prevent overuse musculoskeletal injuries [ 13 , 18 ].

The patient should begin with 1 to 3 sets, which can be gradually increased over a few months to 3 to 4 sets of each exercise. Allow rest breaks of 2 to 4 min between sets and exercises [ 16 ].

Regarding the number of exercises, a whole-body program including 4 to 10 exercises is suitable. As a general rule regarding the exercise order, large muscle group exercises should be performed before small muscle group exercises, and multiple-joint exercises before single-joint exercises [ 13 , 53 , 73 ]. Prioritize lower extremity over upper extremity exercises. In MS patients, the lower extremity strength deficit is greater than that of the upper extremity [ 13 , 74 ].

Balance training of agonist/antagonist muscle groups is also necessary. Particular emphasis should be placed on the posterior shoulder girdle, spine, hip and knee extensors, and dorsiflexor muscles [ 4 – 6 , 9 ]. However, any contraindications based on individual impairments should be addressed [ 16 , 18 ].

Sample exercises include shoulder press, seated scapular row, latissimus pull-downs, chest press, knee extensions, seated leg press, seated hamstring curls, biceps curls, seated triceps extensions, seated back extensions and abdominal crunches, and chair sit to stands [ 53 – 55 ].

In terms of precautions, weight lifting in a seated position (as in most weight machines) is preferred to minimize the risk of falling with free weights. If an individual has impaired proprioception or coordination, the exercise should be done under supervision [ 16 , 18 ]. Also, compared to the endurance exercise, resistance training in heat sensitive patients less frequently cause symptom exacerbations due to increased body temperature [ 18 ].

Flexibility and stretching exercises

Individuals with MS usually have limited range of motion as a result of spasticity and prolonged immobility. Flexibility exercises are recommended to lengthen muscles, offset the effects of spasticity, enhance joint mobility, and improve balance and posture [ 18 ]. These exercises should be performed at least daily for 10 to 15 min [ 18 , 75 , 76 ]. Stretching should be done before and after exercise sessions and must involve both upper and lower body muscle groups used in the program. The neck extensors, anterior shoulder girdle, hip flexors, hamstring, hip adductors and plantar flexors should be especially emphasized [ 53 – 55 ]. Spastic muscles must be particularly targeted. Stretches should be slow, gentle, and prolonged. The stretch should be up to the end of the comfort range and held there for 20 to 60 s. Ballistic stretch or bouncing with the stretch is not recommended. Furthermore, stretching should not be painful. Individuals who need assistance with stretching may use a towel, rope, or partner. For immobilized patients with spasticity, passive stretching may be done by an expert therapist. Passive range of motion above the joint of a paralysed area is recommended. Complementary techniques such as deep breathing, light massage and progressive muscle relaxation techniques may also be beneficial. Supervized yoga or tai chi classes may be suitable for doing stretching exercises in higher-functioning MS patients [ 16 , 18 , 62 ].

Balance and coordination exercises

Particular attention should be paid to include activities for improvement of balance and coordination. In these activities, the MS patient should shift the centre of gravity and respond to external signals. Swiss ball exercise with coordinated movements and bilateral muscle actions may increase coordination and balance, as well. This type of exercise is extremely helpful to increase strength and flexibility, as well. Tai Chi exercises with slow eccentric movements may also be beneficial to maintain balance, strength and range of motion. For patients with insufficient stability or strength to take part in the mentioned activities, coordination and balance drills may be done in shallow pools. In this milieu, the risk of falling or injury due to balance loss is minimised and support of the water will permit the accomplishment of challenging movements, when it is not possible on land. Improvement of posture, flexibility, coordination and muscle tone are potential advantages of water exercise [ 6 ].

Respiratory muscle training

Adaptation of respiratory muscles to training programs can occur similar to skeletal muscles [ 18 ].

In a study, Foglio et al. (1994) examined respiratory muscle function and exercise capacity in MS patients. They concluded that in patients, reduction in exercise tolerance may be associated, at least partially, to diminished respiratory muscle strength [ 77 ].

O’Kroy et al. (1993) showed that respiratory muscle training enhanced maximal inspiratory and expiratory pressures, controlled breathing exercises and increased respiratory muscle endurance in MS patients. The use of ventilatory resistance training devices may be helpful and increase respiratory muscle strength [ 78 ].

Special precautions

MS patients are especially susceptible to exercise-related fatigue, heat intolerance, and falling [ 53 – 55 ]. Furthermore, some problems such as spasticity, neurologic or cognitive deficits, and urinary incontinence may influence the exercise program. So, special measures should be considered in these cases. A summary of these precautions and safety recommendations are listed in Table  2 .

Special considerations and precautions for exercise prescription in MS patients

There are some concerns about the potential effect of exercise on exacerbation of fatigue in MS patients. However, the existing evidence supports the fact that regular exercise training is linked with a small but important reduction in fatigue among persons with MS [ 39 , 63 , 79 ].

Exercise on elliptical machine may result in significant reduction of fatigue among MS patients. So, this type of exercise may be a useful part of MS rehabilitation programs [ 80 ]. Aquatic exercise may also successfully improve fatigue of MS patients and may be considered in the rehabilitation of these patients [ 34 ].

Heat intolerance

A common concern with exercise in MS patients is potentially prompting Uhthoff phenomenon. Uhthoff phenomenon is defined as developing transient symptoms such as amblyopia or blurred vision triggered by overheating from exercise [ 6 , 23 ]. The exact mechanism of Uhthoff phenomenon is not determined. It may be the result of heat-worsened conduction across partially demyelinated axons, fatigue of damaged neuronal pathways with repetitive nerve transmission, [ 23 , 81 ] or a hormonal factor produced by cooling [ 16 ]. Exercise-induced Uhthoff phenomenon should not be considered as a contraindication for exercise [ 23 ]. Fortunately, temporary and mild heat stress causes only transient exacerbation of symptoms without apparent remaining impairment after normothermia is achieved [ 18 ]. It often settles within an hour or even sooner with rapid cooling [ 23 ]. Moreover, it is still more common in MS patients to respond to exercise in heat conditions with just general fatigue rather than Uhthoff phenomenon with focal neurologic deficits [ 23 , 82 ]. Studies have demonstrated that usual exercise does not considerably increase core body temperature. A study reported a mean rectal temperature change of 0. 1 ̊ C during land-based exercise and - 0. 1 ̊ C during water-based exercise [ 83 ]. Alternatively, normal thermoregulatory responses (e.g., sweating and peripheral vasodilatation) that preserve a stable core temperature during usual exercise may be impaired in MS patients. In such cases, an increase in core temperature of even less than 1 ̊ C may trigger heat-related symptoms [ 16 , 23 ]. The use of cooling devices such as head-vest liquid cooling garment may provide some modest benefits for MS patients [ 84 , 85 ]. Another study showed the reduced fatigue and improved ambulation for up to 3 h postcooling with the use of either the liquid cooling system or an icepack suit [ 23 , 85 , 86 ]. When engaging in pool-based aquatic exercises, the ideal water temperature for heat sensitive MS patients seems to be between 27 and 29 °C [ 18 , 23 , 87 , 88 ]. Temperatures below 27 ° C can paradoxically enhance spasticity [ 23 , 89 ].

MS patients, especially those who are heat-sensitive, should avoid scheduling exercise sessions in the hottest times of the day or times when they experience greater fatigue. Exercise sessions in the early morning, when there is cooler temperature and lower body temperature, may be more endurable than in the afternoon [ 18 , 90 ]. Moreover, resistance exercise is more tolerable than endurance exercise for heat sensitive MS patients and should be encouraged to incorporate resistance exercises in their routines [ 91 ].

Particularly for individuals with heat sensitivity, several investigators have recommended pre-exercise cooling strategies, such as the use of cooling devices, [ 6 , 18 , 50 , 92 ] cold water lower body immersion, [ 18 ] or taking a tepid bath 20 to 30 min before (and after) exercise [ 23 ]. Individuals should wear light exercise clothing or may even try exercising with a cooling vest. The exercise area temperature should be kept cool through the use of fans or air conditioning [ 16 , 23 ].

Risk of falling

Special attention is needed for patients at high risk of falling due to the balance and coordination problems as well as sensory and proprioceptive deficits. These issues should be particularly considered when planning and supervising exercise sessions in MS patients [ 13 , 16 ].

Exercise should be considered as a safe and effective means of rehabilitation in MS patients. Existing evidence has shown that a supervised and individualized exercise program can improve physical fitness, functional capacity, quality of life and modifiable impairments in MS patients. There are general guidelines that may be followed for exercise prescription for the MS population. These guidelines should be adapted according to the patient’s needs, abilities and preferences.

Acknowledgements

The authors would like to thank Development and Research center of Sina Hospital and Mrs. Pourmand (Urology Research Center, Tehran University of Medical Sciences) for editing the manuscript.

We did not have any sources of funding.

Availability of data and materials

Abbreviations.

Authors’ contributions

HF and AM Wrote the primary draft. SMA Proposed the idea and revised the primary draft. AZ reviewed the literature and approved the primary draft. All authors read and approved the final manuscript.

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10 Essential Exercises for Treating Dysphagia

By Samantha McDaniel, PhD, CCC-SLP

on June 3, 2024

Categories: Speech Pathology

Dysphagia , or difficulty swallowing, is a common issue encountered by speech-language pathologists. Effective management of dysphagia often involves a combination of therapeutic exercises designed to improve swallowing function. In this article, we will explore 10 of these top exercises for dysphagia, including their appropriate use, contraindications, and key considerations for SLPs.

1. Effortful Swallow Exercise

The effortful swallow involves swallowing with maximal effort, squeezing all muscles involved in the swallow as tightly as possible. This exercise is beneficial for patients with reduced tongue base retraction and pharyngeal clearance, helping to increase the strength of the swallow. Ensure patients understand the need to exert maximal effort and practice this exercise under supervision initially. Perform the exercise with food or drink, or with biofeedback as appropriate. This exercise isn’t suitable for patients who can’t follow complex instructions or have significant cognitive impairments.

2. Mendelsohn Maneuver

The Mendelsohn maneuver involves holding the larynx at its highest point during a swallow for a few seconds before releasing. This exercise is appropriate for patients with reduced laryngeal elevation and pharyngeal constriction, helping to improve coordination and prolong UES opening. It requires careful monitoring to ensure correct technique and avoid fatigue. It isn’t recommended for patients with severe cognitive impairments or those who have difficulty with sustained breath holding.

3. Masako Maneuver

Also known as the tongue-hold maneuver, this exercise involves swallowing with the tongue held between the teeth. It’s useful for patients with pharyngeal weakness, as it helps increase posterior pharyngeal wall movement. Emphasize gentle holds to prevent tongue injury and monitor for discomfort. The Masako maneuver shouldn’t be used with patients who have tongue weakness or limited tongue mobility, and shouldn’t be performed with food or liquid.

4. Chin Tuck Against Resistance (CTAR)

CTAR involves tucking the chin to the chest against resistance, often using a rubber ball, towel, or similar prop. This exercise is effective for strengthening suprahyoid muscles, aiding in laryngeal elevation and UES opening. Ensure proper posture and resistance level to prevent neck strain. CTAR isn’t suitable for patients with neck pain or cervical spine issues.

5. Expiratory Muscle Strength Training (EMST)

EMST uses a device to provide resistance during exhalation, strengthening the expiratory muscles. It’s beneficial for patients with reduced cough effectiveness and respiratory support for swallowing. When helping patients perform the exercise, gradually increase resistance and monitor for signs of respiratory distress. Use caution with patients with severe COPD or other respiratory conditions.

6. Shaker Maneuver Exercise

The Shaker exercise involves lifting the head while lying flat on the back, holding it for a set duration, and then lowering it. This exercise helps improve suprahyoid muscle strength, beneficial for patients with reduced UES opening. Start with shorter durations and gradually increase as the patient’s strength improves. Avoid using this exercise with patients who have neck pain or cervical spine issues.

7. Tongue Pressure Resistance

This exercise involves pressing the tongue against a resistance device or the roof of the mouth. It’s suitable for patients with tongue weakness, improving bolus control and pressure generation during swallowing. Use appropriate resistance levels and ensure proper technique to avoid strain. This exercise isn’t ideal for patients with significant oral sensitivity or pain.

8. Pitch Glides

Pitch glides involve gliding the voice from a low to a high pitch. This is useful for patients with reduced laryngeal elevation and vocal fold closure issues. Monitor for vocal strain and encourage gentle, smooth glides. This exercise isn’t recommended for patients with vocal fold pathologies or those who experience pain during phonation.

9. Falsetto Exercise

This exercise involves sustaining a high-pitched “eee” sound, targeting the cricothyroid muscle. It’s beneficial for patients with reduced laryngeal elevation and vocal fold closure. Ensure the patient uses a relaxed vocal technique to prevent strain. Avoid using this exercise with patients who have vocal fold pathologies or discomfort with high pitches.

10. Gargling

Pretending to gargle while holding your tongue back, dry gargling, or gargling with water helps to engage the pharyngeal muscles. This is effective for patients needing increased pharyngeal constriction strength. Supervise patients initially to ensure safe and effective technique. Gargling with liquid is not suitable for patients with aspiration risk or difficulty managing oral secretions.

Final Thoughts

Incorporating these exercises into a dysphagia management plan can help SLPs provide targeted, effective therapy for patients with dysphagia, ultimately improving their swallowing function and quality of life. Always tailor the exercises to individual patient needs, considering their specific impairments, cognitive status, and any contraindications. Regular monitoring and adjustment of the exercises will ensure continued progress and safety.

Looking for more dysphagia resources? Check out our Dysphagia Resource Center , which includes over 60 dysphagia-focused courses plus high-quality home exercises and education to help your patients better manage their condition.

Samantha McDaniel, PhD, CCC-SLP

Samantha is an Assistant Professor and Graduate Program Director at Georgia Southern University in Savannah, GA. She earned an Interdisciplinary Health Sciences Ph.D. and appreciates interdisciplinary collaboration. Samantha has 20 years of clinical experience in speech-language pathology with patients ranging from neonates to centenarians. She teaches courses in disorders of neurogenic communication, motor speech, voice, and cognitive-communication and immensely enjoys supervising graduate students in clinic on campus. Samantha’s current research agenda concerns the difference in cognitive screening outcomes between young and older adults. She aims to translate her research findings into improved practice standards across multiple disciplines.

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Speech Therapy for MS Patients

Multiple sclerosis, or MS, is a disorder characterized by the formation of lesions on the brain and spinal cord. Some of those lesions, either directly or indirectly can affect speech. With as many as 40% of those with multiple sclerosis experiencing some type of speech impairment , the need for speech therapy services is common among MS patients.

How does MS impact speech?

MS can affect patients differently, and even among the group that experiences speech impairments, there is not just one cause. Here is a look at several categories under which MS-related speech impairments are classified.

Speaking is a complicated process, from a physiological point of view. Everything from breathing to voice production in the vocal cords to coordinating the movements of the lips, tongue, jaw and soft palate to produce specific sounds must work in concert.

Dysarthria results from abnormalities in the muscles that control speech , ranging from weakness or paralysis to damage to portions of the brain making it difficult to move the muscles in the right way.

Speech will often become slurred or nasally, and the patient may have difficulty controlling volume and pitch.

Three basic types of Dysarthria are associated with MS :

• Spastic: Muscle stiffness causes slow, harsh speech with some poor articulation
• Ataxic: The loss of muscle movement control can cause a vocal tremor or changes in volume and weak articulation.
• Mixed (most common in MS): Combines features of both, leading to difficulties controlling volume, pitch, and articulation.

Related to dysarthria, dysphonia is an impairment of the voice .

Those suffering from it might have difficulty controlling volume or talk in a monotonous voice. They might also mispronounce or fail to complete words.

This is sometimes caused by weakness in the affected muscles used to speak.

Cognitive difficulties

While Dysarthria and Dysphonia are caused by issues with the muscles used to speak, another set of conditions stem from an inability to produce speech mentally rather than physically.

Dysphasia or aphasia are two such disorders. In these cases the difficulty speaking might manifest itself in the speaker having difficulty recalling words or translating thoughts into phrases .

These disorders are rarer with MS than Dysarthria.

How Speech Therapy Can Help With MS

For those patients with Dysarthria, as with most conditions involving muscles, exercises can help at least control the symptoms.

Exercises can help strengthen and coordinate the muscles in the throat, jaw, tongue, mouth, lips, vocal cords and other parts of the body that impact speech. 

Patients can also learn how to adapt, whether it be slowing their speech, overly articulating words or using shorter, easier to say words.

Comprehensive Rehab is here to help

If you are dealing with speech problems caused by Multiple Sclerosis in the Eastern Iowa area, Comprehensive Rehab offers speech therapy at its locations in Clinton and Maquoketa . Call us for more information or to schedule an appointment.

Read More About Speech Therapy Services for Adults

Speech Therapy After a Brain Injury

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Swallowing Disorders in Adults

Swallowing disorders can lead to health issues and social problems, like choosing not to eat meals with others. Speech-language pathologists (SLPs) help people who have trouble swallowing.

On this page:

About Swallowing Disorders

Signs of swallowing disorders, causes of swallowing disorders, testing for swallowing disorders, treatments for swallowing disorders, other resources.

Think about how you eat. First you have to get the food or drink to your mouth. You may use a fork, spoon, straw, or your hands. Next, you have to open your mouth and put the food in. You close your lips to keep the food in your mouth. Then, you chew the food or move the liquid to get ready to swallow.

We all have problems swallowing sometimes. We may have trouble chewing a tough piece of meat. We may gag on food or have to swallow hard to get it down. And we have all had a drink “go down the wrong way,” making us cough and choke. A person with a swallowing disorder will have trouble like this a lot of the time. A swallowing disorder is also called dysphagia (dis-FAY-juh).

Swallowing happens in three stages, or phases. You can have a problem in one or more of these phases. They include:

• Oral phase (mouth)  – sucking, chewing, and moving food or liquid into the throat.
• Pharyngeal phase (throat)  – starting the swallow and squeezing food down the throat. You need to close off your airway to keep food or liquid out. Food going into the airway can cause coughing and choking.
• Esophageal phase  – opening and closing the esophagus (the tube that goes from the back of your throat to your stomach). The esophagus squeezes food down to the stomach. Food can get stuck in the esophagus. You may also throw up a lot if there is a problem with your esophagus or if you have acid reflux (commonly known as indigestion or heartburn).

Signs of a swallowing problem might be any of these:

• coughing during or right after eating or drinking
• clearing your throat often after eating or drinking
• having a wet or gurgly voice during or after eating or drinking
• feeling like something is stuck in your throat or chest after eating or drinking
• needing extra work or time to chew or swallow
• having food or liquid leak from your mouth
• food getting stuck in your mouth
• having a hard time breathing after meals
• losing weight

A swallowing problem might cause you to have these conditions:

• dehydration or poor nutrition
• food or liquid going into the airway, called aspiration
• pneumonia or other lung infections

Some people with swallowing problems feel embarrassed when eating or feel badly about their swallowing problems and want to eat alone.

Many conditions can cause swallowing problems. Some medications can cause dry mouth, which makes it hard to chew and swallow. Other causes include the following:

Damage to your brain or nerves from any of these:

• brain injury
• spinal cord injury
• Parkinson’s disease
• multiple sclerosis
• amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease)
• muscular dystrophy
• cerebral palsy
• Alzheimer’s disease

Problems with your head, neck, or mouth, such as these:

• cancer in your mouth, throat, or esophagus
• head or neck injuries
• mouth or neck surgery
• bad teeth, missing teeth, or dentures that do not fit well

For more information, please see ASHA’s resource on Swallowing Problems From Head and Neck Cancer Treatment .

An SLP can test you to see how you eat and drink. You will want to see an SLP who works with adults with swallowing problems. The SLP will do the following tasks:

• Ask you about your health, past illnesses, surgeries, and swallowing problems.
• See how well your mouth muscles move.
• Watch you eat to see how you sit, how you feed yourself, and what happens when you swallow.
• Do special tests, if needed. The SLP can watch how you swallow using:
• Modified barium swallow  – you eat or drink food or liquid with barium in it. Barium shows up on an x-ray so the SLP can watch where the food goes.
• Endoscopic assessment  – the doctor or SLP puts a tube with a light on the end of it into your nose. This tube has a camera on it, and the SLP can watch you swallow on a screen.

What treatment you need will depend on the problems you have. You may need medical treatment from a doctor, such as medicines for reflux. In severe cases, you may need to get nutrition in other ways. These may include a tube through your nose or in your stomach. Your doctor will work with you if you need tube feeding.

The SLP can work with you to improve how you swallow. They may suggest the following:

• treatment to help you use your muscles to chew and swallow
• instruction on ways you should sit or hold your head when you eat
• strategies to help you swallow better and more safely
• eating softer foods or drinking thicker drinks to help make swallowing easier

Your family or caregivers can help you by doing these things:

• asking questions to understand the problems you have
• making sure they understand what the SLP will work on
• following your SLP’s suggestions
• helping you with exercises
• making food and drinks that you can swallow safely
• keeping track of how much you eat and drink

See ASHA information for professionals on the Practice Portal’s  Adult Dysphagia  page.

This list does not include every website on this topic. ASHA does not endorse the information on these sites.

• Board-Recognized Specialists in Swallowing and Swallowing Disorders
• Medline Plus – National Library of Medicine

To find an SLP near you, visit  ProFind .

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• Parkinson's disease

Parkinson's disease is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves. Symptoms start slowly. The first symptom may be a barely noticeable tremor in just one hand. Tremors are common, but the disorder also may cause stiffness or slowing of movement.

In the early stages of Parkinson's disease, your face may show little or no expression. Your arms may not swing when you walk. Your speech may become soft or slurred. Parkinson's disease symptoms worsen as your condition progresses over time.

Although Parkinson's disease can't be cured, medicines might significantly improve your symptoms. Occasionally, a health care professional may suggest surgery to regulate certain regions of your brain and improve your symptoms.

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Parkinson's disease symptoms can be different for everyone. Early symptoms may be mild and go unnoticed. Symptoms often begin on one side of the body and usually remain worse on that side, even after symptoms begin to affect the limbs on both sides.

Parkinson's symptoms may include:

• Tremor. Rhythmic shaking, called tremor, usually begins in a limb, often your hand or fingers. You may rub your thumb and forefinger back and forth. This is known as a pill-rolling tremor. Your hand may tremble when it's at rest. The shaking may decrease when you are performing tasks.
• Slowed movement, known as bradykinesia. Over time, Parkinson's disease may slow your movement, making simple tasks difficult and time-consuming. Your steps may become shorter when you walk. It may be difficult to get out of a chair. You may drag or shuffle your feet as you try to walk.
• Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles can be painful and limit your range of motion.
• Impaired posture and balance. Your posture may become stooped. Or you may fall or have balance problems as a result of Parkinson's disease.
• Loss of automatic movements. You may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk.
• Speech changes. You may speak softly or quickly, slur, or hesitate before talking. Your speech may be more of a monotone rather than have the usual speech patterns.
• Writing changes. It may become hard to write, and your writing may appear small.

When to see a doctor

See a health care professional if you have any of the symptoms associated with Parkinson's disease — not only to diagnose your condition but also to rule out other causes for your symptoms.

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In Parkinson's disease, certain nerve cells called neurons in the brain gradually break down or die. Many of the symptoms of Parkinson's are due to a loss of neurons that produce a chemical messenger in your brain called dopamine. When dopamine levels decrease, it causes irregular brain activity, leading to problems with movement and other symptoms of Parkinson's disease.

The cause of Parkinson's disease is unknown, but several factors appear to play a role, including:

Genes. Researchers have identified specific genetic changes that can cause Parkinson's disease. But these are uncommon except in rare cases with many family members affected by Parkinson's disease.

However, certain gene variations appear to increase the risk of Parkinson's disease but with a relatively small risk of Parkinson's disease for each of these genetic markers.

• Environmental triggers. Exposure to certain toxins or environmental factors may increase the risk of later Parkinson's disease, but the risk is small.

Researchers also have noted that many changes occur in the brains of people with Parkinson's disease, although it's not clear why these changes occur. These changes include:

• The presence of Lewy bodies. Clumps of specific substances within brain cells are microscopic markers of Parkinson's disease. These are called Lewy bodies, and researchers believe these Lewy bodies hold an important clue to the cause of Parkinson's disease.
• Alpha-synuclein found within Lewy bodies. Although many substances are found within Lewy bodies, scientists believe that an important one is the natural and widespread protein called alpha-synuclein, also called a-synuclein. It's found in all Lewy bodies in a clumped form that cells can't break down. This is currently an important focus among Parkinson's disease researchers. Researchers have found the clumped alpha-synuclein protein in the spinal fluid of people who later develop Parkinson's disease.

Risk factors

Risk factors for Parkinson's disease include:

• Age. Young adults rarely experience Parkinson's disease. It ordinarily begins in middle or late life, and the risk increases with age. People usually develop the disease around age 60 or older. If a young person does have Parkinson's disease, genetic counseling might be helpful in making family planning decisions. Work, social situations and medicine side effects are also different from those of an older person with Parkinson's disease and require special considerations.
• Heredity. Having a close relative with Parkinson's disease increases the chances that you'll develop the disease. However, your risks are still small unless you have many relatives in your family with Parkinson's disease.
• Sex. Men are more likely to develop Parkinson's disease than are women.
• Exposure to toxins. Ongoing exposure to herbicides and pesticides may slightly increase your risk of Parkinson's disease.

Complications

Parkinson's disease is often accompanied by these additional problems, which may be treatable:

• Thinking difficulties. You may experience cognitive problems, such as dementia, and thinking difficulties. These usually occur in the later stages of Parkinson's disease. Such cognitive problems aren't usually helped by medicines.

Depression and emotional changes. You may experience depression, sometimes in the very early stages. Receiving treatment for depression can make it easier to handle the other challenges of Parkinson's disease.

You also may experience other emotional changes, such as fear, anxiety or loss of motivation. Your health care team may give you medicine to treat these symptoms.

• Swallowing problems. You may develop difficulties with swallowing as your condition progresses. Saliva may accumulate in your mouth due to slowed swallowing, leading to drooling.
• Chewing and eating problems. Late-stage Parkinson's disease affects the muscles in the mouth, making chewing difficult. This can lead to choking and poor nutrition.

Sleep problems and sleep disorders. People with Parkinson's disease often have sleep problems, including waking up frequently throughout the night, waking up early or falling asleep during the day.

People also may experience rapid eye movement sleep behavior disorder, which involves acting out dreams. Medicines may improve your sleep.

• Bladder problems. Parkinson's disease may cause bladder problems, including being unable to control urine or having difficulty in urinating.
• Constipation. Many people with Parkinson's disease develop constipation, mainly due to a slower digestive tract.

You may also experience:

• Blood pressure changes. You may feel dizzy or lightheaded when you stand due to a sudden drop in blood pressure (orthostatic hypotension).
• Smell dysfunction. You may experience problems with your sense of smell. You may have trouble identifying certain odors or the difference between odors.
• Fatigue. Many people with Parkinson's disease lose energy and experience fatigue, especially later in the day. The cause isn't always known.
• Pain. Some people with Parkinson's disease experience pain, either in specific areas of their bodies or throughout their bodies.
• Sexual dysfunction. Some people with Parkinson's disease notice a decrease in sexual desire or performance.

Because the cause of Parkinson's is unknown, there are no proven ways to prevent the disease.

Some research has shown that regular aerobic exercise might reduce the risk of Parkinson's disease.

Some other research has shown that people who consume caffeine — which is found in coffee, tea and cola — get Parkinson's disease less often than those who don't drink it. Green tea also is related to a reduced risk of developing Parkinson's disease. However, it is still not known whether caffeine protects against getting Parkinson's or is related in some other way. Currently there is not enough evidence to suggest that drinking caffeinated beverages protects against Parkinson's.

Parkinson's disease care at Mayo Clinic

• Loscalzo J, et al., eds. Parkinson's disease. In: Harrison's Principles of Internal Medicine. 21st ed. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed April 4, 2022.
• Parkinson's disease: Hope through research. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Parkinsons-Disease-Hope-Through-Research. Accessed April 4, 2022.
• Ferri FF. Parkinson disease. In: Ferri's Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed April 4, 2022.
• Chou KL. Diagnosis and differential diagnosis of Parkinson disease. https://www.uptodate.com/contents/search. Accessed April 4, 2022.
• Hornykiewicz O. The discovery of dopamine deficiency in the parkinsonian brain. Journal of Neural Transmission Supplementum. 2006; doi:10.1007/978-3-211-45295-0_3.
• Spindler MA, et al. Initial pharmacologic treatment of Parkinson disease. https://www.uptodate.com/contents/search. Accessed April 4, 2022.
• Relaxation techniques for health. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/stress/relaxation.htm. Accessed April 4, 2022.
• Taghizadeh M, et al. The effects of omega-3 fatty acids and vitamin E co-supplementation on clinical and metabolic status in patients with Parkinson's disease: A randomized, double-blind, placebo-controlled trial. Neurochemistry International. 2017; doi:10.1016/j.neuint.2017.03.014.
• Parkinson's disease: Fitness counts. Parkinson's Foundation. http://www.parkinson.org/pd-library/books/fitness-counts. Accessed April 4, 2022.Green tea. Natural Medicines. https://naturalmedicines.therapeuticresearch.com. Accessed April 4, 2022.
• Green tea. Natural Medicines. https://naturalmedicines.therapeuticresearch.com. Accessed April 4, 2022.
• Tarsy D. Nonpharmacologic management of Parkinson disease. https://www.uptodate.com/contents/search. Accessed April 4, 2022.
• Caffeine. Natural medicines. https://naturalmedicines.therapeuticresearch.com. Accessed April 4, 2022.
• Jankovic J. Etiology and pathogenesis of Parkinson disease.
• Thomas A. Allscripts EPSi. Mayo Clinic. April 22, 2022.
• Post B, et al. Young onset Parkinson's disease: A modern and tailored approach. Journal of Parkinson's Disease. 2020; doi:10.3233/JPD-202135.
• Bower JH (expert opinion). Mayo Clinic. May 16, 2023.
• Robbins JA, et al. Swallowing and speech production in Parkinson's disease. Annals of Neurology.1986; doi:10.1002/ana.410190310.
• Hauser RA, et al. Orally inhaled levodopa (CVT-301) for early morning OFF periods in Parkinson's disease. Parkinsonism and Related Disorders. 2019; doi:10.1016/j.parkreldis.2019.03.026.
• Dashtipour K, et al. Speech disorders in Parkinson's disease: Pathophysiology, medical management and surgical approaches. Neurodegenerative Disease Management. 2018; doi:10.2217/nmt-2018-0021.
• Mishima T, et al. Personalized medicine in Parkinson's disease: New options for advanced treatments. Journal of Personalized Medicine. 2021; doi:10.3390/jpm11070650.
• Jenner P, et al. Istradefylline — A first generation adenosine A2A antagonist for the treatment of Parkinson's disease. Expert Review of Neurotherapeutics. 2021; doi:10.1080/14737175.2021.1880896.
• Isaacson SH, et al. Blinded SAPS-PD assessment after 10 weeks of pimavanserin treatment for Parkinson's disease psychosis. Journal of Parkinson's Disease. 2020; doi:10.3233/JPD-202047.
• Al-Shorafat DM, et al. B-blocker-induced tremor. Movement Disorders Clinical Practice. 2021; doi:10.1002/mdc3.13176.
• Haahr A, et al. 'Striving for normality' when coping with Parkinson's disease in everyday life. A metasynthesis. International Journal of Nursing Studies. 2021; doi:10.1016/j.ijnurstu.2021.103923.
• Mehanna R, et al. Age cutoff for early-onset Parkinson's disease: Recommendations from the International Parkinson and Movement Disorder Society task force on early-onset Parkinson's disease. Movement Disorders Clinical Practice. 2022; doi:10.1002/mdc3.13523.
• Siderowf A, et al. Assessment of heterogeneity among participants in the Parkinson's Progression Markers Initiative cohort using alpha-synuclein seed amplification: A cross-sectional study. The Lancet Neurology. 2023; doi:10.1016/S1474-4422(23)00109-6.
• Berg D, et al. Alpha-synuclein seed amplification and its uses in Parkinson's disease. The Lancet Neurology. 2023; doi:10.1016/S1474-4422(23)00124-2.

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• Empowering Lives: Navigating Parkinson's disease with hope June 11, 2024, 04:30 p.m. CDT
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