Dear Doctor Dear Doctor Do you need a second opinion about one of the symptoms of your M.E.? While we regret that our medical advisers cannot respond to individual enquiries, we will try to cover a range of problems in these pages. Speech problems how to produce sounds, as it depends on feedback from sensation. CFS/M.E. can also affect the function Speaking for only a couple of minutes leaves my tongue feeling swollen and of the speech control centre in the my lips numb. People mention their speech slurring, but not what I experience brain, much as it can cause ‘brain fog,’ when I strain to speak for too long; when the body shuts down and you can’t memory difﬁculty, sleep disturbance, or produce a sound. Not being able to communicate or socialise is incredibly poor temperature control. This may be distressing. This has been my worst symptom for almost a decade now and yet at the level of instruction to the voice there is hardly any literature on this problem. box, giving rise to stammering or stuttering. Or it can be at the level of Sharon word and sentence formation, which can cause word-ﬁnding problems, jumbled words and sometimes spoonerisms (in which letters or syllables are swapped eg. saying “a lack of pies” instead of “a pack of lies” – After receiving this letter, InterAction Our principal Ed). Wider problems with brain fatigue asked Noticeboard readers if anyone else had experienced speech problems. medical may mean that the whole process of putting together and producing speech Shirley told us: “I had major problems adviser, Prof is too much. A migraine aura (before being understood – speech was very Tony Pinching the headache) can indeed affect slow and badly slurred. Only close comments: speech too. family understood what I was trying to Finally, I should mention that sore say. My speech still changes according Your correspondents outline a range of throat is of course quite a common to energy, stress etc.” speech problems, which are among the symptom in CFS/M.E. This may be an Jeanette said: “My voice becomes less common, but yet more troubling, echo of the triggering infection, or very weak and faint, and my voice symptoms of CFS/M.E. The additional could be a bad dose of whatever is breaks up, so I have to stop talking. impact of speech difﬁculty to the going around. I have seen a few The only thing that helps is to rest isolation of CFS/M.E itself can be people whose illness has been more, and gradually my voice will understood. While word-ﬁnding triggered by viral laryngitis, with loss of return to a more normal level. It usually problems are common, serious voice as an early feature; for them, occurs during a relapse or when I am difﬁculty with actual speech production relapses may show up with voice very tired, or when I try to talk for is surprisingly uncommon; it is most problems. longer than usual. I also have trouble likely to occur in those who are more Each person with CFS/M.E. will have with swallowing and chewing. severely affected. their own version of the illness. If Sarah added: “I tend to experience Speech represents one of the most speech problems are a feature for you, speech loss when my muscles are complex functions of brain and body they should determine how you plan having ‘muscle fatigue phase’ – the and this illness can impact at different that activity, just like any other energy sensation is that my tongue seems to levels. At the ‘voice-box’ end, the very resource. Apply the principles of become too large for my mouth, and ﬁne muscle control and coordination pacing, including true rest and my jaw muscles become sluggish. I on which we rely for ﬂuent speech can relaxation breaks, to speech just as you have to get the words out quickly be affected, much like muscles in the would to anything else. If function is before my jaw gradually becomes arms and legs. Even quite subtle limited, make sure that you use it to slower and slower and then stops changes in function can affect the best effect. Save your voice for saying working. The other type of speech volume, tone and accuracy of speech things that make a difference for you problem I get is part of a migraine production. Swallowing is sometimes as a person (maybe recite a haiku that ‘aura’, usually when I have had to affected as related muscle and nerve you have been composing for overdo things. I tend to feel as though groups are involved. weeks?!). Asking for a cup of water, or words get stuck behind my teeth – I If sensations in and around the for someone to turn the TV down, begin stuttering and stammering, and mouth and throat are affected (again, could be done by pointing at a pre- it becomes increasingly difﬁcult to as sensations often are elsewhere), written request list, for example. Find a talk.” then speech can be harder. This is signal system that suits your situation. because the brain gets confused about 40 InterAction 59 March 2007 Dear Doctor Various patients have found that Speech disorders can either be Dr Sarah particular solutions or therapies can present at birth or acquired as a result help them, through trial and error. As of stroke, head injury, or illness. Many Myhill, is often the case with other difﬁculties, are temporary, some transient because M.E./CFS these may be particular to them and of the nature of the condition. The specialist, may not work for the next person. If production of intelligible speech is the responded to speech problems are major, it would be result of very complex interactions wise to seek help, if necessary a originating in the brain. Sharon’s letter referral to a speech therapist. Whilst In trying to provide a form of as follows: they may not have seen many people management for this symptom there Speech is a complicated process with CFS/M.E., they are expert in the have been a few suggestions in requiring intense neuro-muscular ways in which illness can affect speech literature and from anecdotal sources co-ordination. Speech, together with production, and will have valuable skills in my patient cases. One suggestion is balance and short term memory are that can assist adjustment and based on an ENT (Ear, Nose, Throat) highly energy-dependant processes recovery, regardless of the cause. surgeon’s approach that when speech going on in the brain. Let us face it, becomes sore the tendency is to rest it. when somebody partly switches off However this often prolongs the Keith Anderson, speech loss and it is then better to ‘use their brain with alcohol, the ﬁrst things to go are speech, balance and short- M.E./CFS Clinical it or lose it’ and continue trying to term memory! This is because they are Nurse Specialist, speak. This would be inclusive of highly energy-dependant processes. In increased ﬂuid intake, gargles with Fife, says: soluble asprin (where appropriate), order to speak there are several mechanisms that have to go in place – As if M.E./CFS was not reducing or stopping smoking and ﬁrst of all the brain has to formulate the cause of enough breathing and speech therapy exercise. the thought to create speech, this disabilities, imagine not Other methods used by some include thought then moves to the speech being able to tell a doctor how you a pro-active rest approach that includes centre where the necessary messages feel because you have lost the power speech, as an activity that is paced in are created, which pass down the to speak. Speech loss is one of the the same way as any physical activity, spinal cord to the mouth and throat. more rare of M.E./CFS symptoms but it such as walking, would be. Important Just think of all the muscular activity is frightening for those who experience discussions or communications with with respect to ones lips, tongue, jaw, it as it robs them of another potential people like bank staff or DLA which are necessary to shape the air coping resource. administration are planned into the day ﬂow that is created by the vocal cords. More common are communication as a single tiring activity with little or All these movements require very ﬁne difﬁculties such as losing the thread of nothing planned around the rest of the control of the muscles. conversations, being unable to recall a day. Regularly review any approach you word or tiredness at the point of an choose as your condition changes important discussion – ‘brain fog’ if often enough to render certain you like that term. Very often these methods obsolete. events are strongly associated with the Even the 2002 Chief Medical onset of increasing fatigue and as Ofﬁcer’s Report into M.E./CFS ofﬁcially better spells come these symptoms are recognised that a number of serious less common. However other forms of and unusual neurological symptoms speech disorder are more prolonged. and signs do sometimes occur in more Speech disorders belong to a broad severely affected people with M.E./CFS. category of disorders called These can include double vision, communication disorders that also blackouts, atypical convulsions/ﬁts, loss include language and hearing of speech, and loss of swallowing. disorders. Communication disorders When these neurological symptoms affect about one person out of every and/or signs occur, it is always ten. Speech disorders refer to important to exclude the possibility of difﬁculties producing speech sounds or the cause being another neurological problems with voice quality. They may disorder. In these cases consult your be characterised by an interruption in doctor or GP for further guidance. the ﬂow or rhythm of speech such as stuttering, or by problems with the way sounds are formed, also called articulation or phonological disorders, or they may involve voice problems such as pitch, intensity or quality. Often, there is a combination of several different problems.