Swallowing and speech problems in MS: speech therapy exercises that help
Coughing on drinks, food that "sticks", a voice that fades — dysphagia and dysarthria are common in multiple sclerosis and badly under-reported. Here is why they happen, how they are assessed (DYMUS, FEES, VFSS) and a practical set of swallowing, breathing and speech exercises you can do at home.
I keep returning to this subject because a useful answer should be precise without losing sight of everyday life. Swallowing and speech run on the same wiring — the brainstem, cerebellum and corticobulbar tracts. When MS demyelinates those routes you get dysphagia (difficulty swallowing) and dysarthria (slurred, quiet or scanning speech), very often together [1](#ref-1)[2](#ref-2).
Meta-analysis puts swallowing difficulty at roughly one in three people with MS, rising with disability level; speech changes are reported by around 40–50% of people at some point [1](#ref-1)[3](#ref-3).
The good news: this is one of the most treatable MS symptoms. Speech and language therapy, expiratory muscle strength training and texture modification measurably reduce aspiration risk and improve intelligibility [3](#ref-3)[4](#ref-4)[5](#ref-5).
Why they happen in MS
Swallowing is one of the most complex motor acts we perform: more than 30 muscles fire in sequence within about two seconds while the airway is sealed shut. The swallowing centre sits in the brainstem, with cortical and cerebellar control on top.
- Brainstem lesions disrupt the swallow reflex and vocal fold closure → coughing, liquids "going down the wrong way".
- Cerebellar lesions produce mistimed, uncoordinated movement → scanning speech and an unreliable swallow.
- Corticobulbar lesions slow and weaken tongue and lips → slurred speech, food residue in the mouth.
- MS fatigue and respiratory muscle weakness cut airflow pressure → quiet voice, short phrases, a weaker protective cough [4](#ref-4).
- Cognitive slowing affects word finding, which is often mislabelled as a speech problem.
More on the underlying lesions: [Spinal cord lesions in MS](/en/blog/spinal-cord-lesions-multiple-sclerosis-symptoms-mri-diagnosis-modern).
Signs of dysphagia you should not ignore
Coughing or a "wet", gurgly voice during or right after eating and drinking. Food feeling stuck in the throat, or needing several swallows per bite. Liquid or saliva leaking from the corner of the mouth. Meals taking much longer than they used to, or avoiding certain foods. Unexplained weight loss, repeated chest infections or fevers with no clear source.
Silent aspiration is the dangerous variant: food or liquid enters the airway without triggering a cough. Recurrent pneumonia in someone with MS always deserves a swallowing assessment [1](#ref-1)[5](#ref-5).
Signs of dysarthria
A quiet voice that fades away by the end of a sentence. Slurred articulation, especially in the evening or after exertion. Scanning speech — words chopped into syllables with equal stress (classic cerebellar sign). Hoarse, strained or nasal voice quality. Slower rate and frequent breaths mid-sentence.
How it is assessed
- DYMUS questionnaire — a short, validated 10-item screen designed for MS; the easiest first step to raise with your neurologist [6](#ref-6).
- Clinical swallow evaluation by a speech-language therapist — tongue, lip and palate strength, voice quality, and trial sips of different consistencies.
- FEES (fibreoptic endoscopic evaluation of swallowing) — a camera through the nose watches the swallow live and detects silent aspiration.
- VFSS / modified barium swallow — X-ray video of the swallow, the gold standard for timing and airway closure.
Do not wait for it to "settle down". Early assessment is the difference between adjusting your diet and being admitted with aspiration pneumonia.
Swallowing exercises (dysphagia)
Do these only after a therapist confirms they are safe for you — with significant aspiration some of them are not. The rule is short sets, daily, never to exhaustion (MS fatigue applies to throat muscles too).
Effortful swallow
Swallow your saliva while pressing the tongue hard against the roof of the mouth, as if swallowing a large pill. 10 repetitions, 3 times a day. Improves tongue driving force and clears residue from the pharynx.
Mendelsohn manoeuvre
Swallow and, at the moment your Adam's apple lifts, hold it up for 2–3 seconds before releasing. 5–10 repetitions, 2–3 times a day. Prolongs opening of the upper oesophageal sphincter.
Shaker (head-lift) exercise
Lie flat on your back with no pillow and raise your head to look at your toes, keeping shoulders on the floor. Hold 10–20 seconds, rest 30 seconds, 3 repetitions; then 20–30 quick lifts. Strengthens the muscles that open the oesophagus. (Skip it with neck problems.)
Masako manoeuvre (tongue-hold)
Gently hold the tip of the tongue between your teeth and swallow your saliva in that position. 5–10 repetitions once a day. Strengthens the back pharyngeal wall. Never with food or drink.
Tongue and lip drills
Stick the tongue out and hold 5 seconds; then left, right, up, down — 5 each. Press the tongue to the palate and hold 5 seconds, 10 times. Alternate exaggerated "ooo — eee" lip shapes, 10 times. Puff the cheeks and hold the air 5 seconds, 10 times.
Expiratory muscle strength training (EMST)
Training with a calibrated expiratory resistance device (e.g. EMST150): 5 breaths x 5 sets, 5 days a week. In MS this has been shown to strengthen expiratory muscles, improve cough strength and support both swallowing and voice loudness [4](#ref-4). A therapist sets the resistance level.
Safe swallowing technique (compensations)
- Sit fully upright at 90° and stay upright for 30 minutes after eating.
- Chin tuck while swallowing slows liquids and protects the airway.
- Small bites, small sips, one at a time; never gulp from a bottle.
- Swallow twice per bite and clear your throat as needed.
- No talking or TV during meals — swallowing needs attention.
- Thickened liquids and moist, soft textures if water makes you cough; avoid mixed consistencies (broth with chunks).
- Mouth care after every meal — the single strongest measure against aspiration pneumonia.
Speech exercises (dysarthria)
Breath support is the foundation
Sit upright, hand on your belly. Inhale through the nose for 4 seconds so the belly expands, exhale through the mouth for 6 seconds on a steady "sss". 10 repetitions, twice a day. Then hold a sustained "aaah" as long as you can on one breath and log the seconds — aim to extend it gradually.
Loudness and effort (the LSVT LOUD principle)
LSVT LOUD-style therapy trains one target — "speak loud" — and improves vocal loudness and intelligibility in neurological hypophonia [7](#ref-7). Home version: say "aaah" as loud and long as you can 15 times, then 10 everyday phrases ("Good morning", "Could you pass me that") deliberately louder than feels necessary.
Articulation precision
- Over-articulate "pa-ta-ka" 10 times slowly, then 10 times fast.
- Read aloud 5 minutes a day, deliberately overdone — like an actor on stage.
- Practise hard word pairs: "sixth sense", "red leather, yellow leather".
Rate and rhythm (for scanning speech)
Tap one beat per syllable on the table and speak in that rhythm. Then read a sentence broken into short chunks with a pause every 3–4 words. Slower equals clearer.
Conversation strategies
Tell people up front: "my voice is quiet, tell me if you can't hear me". Short sentences, one idea each, key word first. Kill background noise (TV, radio) and stay face to face. Save your voice for the conversations that matter; use text and dictation when tired. A personal voice amplifier is a cheap aid that transforms daily life with a quiet voice.
What else helps
- Energy pacing: eat and hold important conversations when you are freshest, usually in the morning. See: [MS fatigue that healthy people don't understand](/en/blog/what-ms-fatigue-feels-like-invisible-exhaustion-healthy-people-not).
- Cooling: heat worsens both speech and swallowing via Uhthoff's phenomenon; a cold drink before meals helps. See: [Why MS symptoms get worse in hot weather](/en/blog/why-ms-symptoms-get-worse-hot-weather-science-protect-yourself).
- Spasticity and tone: treating spasticity can improve speech control — [Spasticity and spasms in MS](/en/blog/ms-spasticity-muscle-spasms-complete-guide-causes-medication-exercises).
- Nutrition and hydration: dysphagia carries a real risk of dehydration and weight loss — [Nutrition and multiple sclerosis](/en/ishrana-i-multipla-skleroza).
- Disease control (DMT): the best long-term protection for bulbar function is fewer new lesions — [MS treatments ranked by efficacy](/en/blog/the-most-effective-ms-treatments-ranked-strongest-weakest-2026).
- Botulinum toxin into the salivary glands for severe drooling, under neurologist supervision.
Key studies mapped to claims
- Prevalence of dysphagia in MS: systematic review and meta-analysis [1](#ref-1).
- Pathophysiology, assessment and management: overview, Frontiers in Neurology 2024 [2](#ref-2).
- Non-pharmacological approaches (exercises, compensations, stimulation): systematic review [5](#ref-5).
- EMST and speech/respiratory outcomes in MS: Chiara et al., 2007 [4](#ref-4).
- Communication and swallowing in MS — current update: De Biagi and Heikkola, IJMSC 2020 [3](#ref-3).
- DYMUS screening tool: validation study [6](#ref-6).
When to seek urgent help
Choking, bluish lips, or inability to swallow your own saliva. Fever with coughing after meals (suspected aspiration pneumonia). Rapid weight loss or signs of dehydration. Sudden worsening of speech or swallowing lasting more than 24 hours without fever — this may be a relapse.
Swallowing and speech problems in MS are neither inevitable nor something you simply have to live with unaided. Screening takes five minutes, a therapist assessment identifies the exact mechanism, and the targeted exercises — effortful swallow, Mendelsohn, Shaker, EMST, loudness and articulation work — have evidence behind them. The biggest mistake is silence: most people only mention the symptom once pneumonia shows up, by which point the easiest window for therapy has passed.
Sources and references
1. {#ref-1} *Prevalence of dysphagia in patients with multiple sclerosis: a systematic review and meta-analysis.* J Clin Neurosci. 2023. [sciencedirect.com](https://www.sciencedirect.com/science/article/abs/pii/S0967586823000061).
2. {#ref-2} Restivo DA, Quartarone A, Bruschetta A, et al. *Dysphagia in multiple sclerosis: pathophysiology, assessment, and management — an overview.* Front Neurol. 2024;15:1514644. [frontiersin.org](https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2024.1514644/full).
3. {#ref-3} De Biagi F, Heikkola LM. *Update on Recent Developments in Communication and Swallowing in Multiple Sclerosis.* Int J MS Care. 2020;22(6). [ijmsc.org](https://www.ijmsc.org/view/update-on-recent-developments-in-communication-and-swallowing-in-multiple-sclerosis).
4. {#ref-4} Chiara T, Martin D, Sapienza C. *Expiratory muscle strength training: speech production outcomes in patients with multiple sclerosis.* Neurorehabil Neural Repair. 2007;21(3):239–249. [journals.sagepub.com](https://journals.sagepub.com/doi/10.1177/1545968306294737).
5. {#ref-5} Kesik G, Özdemir L. *Non-pharmacologic approaches to dysphagia in patients with multiple sclerosis: a systematic review.* Turk J Neurol. 2021;27(2). [tjn.org.tr](https://www.tjn.org.tr/full-text/186/eng).
6. {#ref-6} Printza A, et al. *The modified DYMUS questionnaire is a reliable, valid and easy-to-use tool in the assessment of dysphagia in multiple sclerosis.* Eur J Neurol. 2020. [onlinelibrary.wiley.com](https://onlinelibrary.wiley.com/doi/10.1111/ene.14219).
7. {#ref-7} National Multiple Sclerosis Society. *Speech and swallowing problems.* [nationalmssociety.org](https://www.nationalmssociety.org/understanding-ms/what-is-ms/ms-symptoms).
This article is educational and does not replace assessment by a speech-language therapist, neurologist or rehabilitation physician. Start swallowing exercises only after a safety assessment.