Judy Wang

RehabINK Mini Review

Myasthenia Gravis (MG) is a rare chronic autoimmune neuromuscular disorder. MG manifests as unpredictable periods of weakness that worsen with activity and improve with rest (1). Muscle weakness fluctuates minute to minute and can vary in severity day by day. These fluctuations demand constant adaptations to changing energy levels and contribute to feelings of lost control, social isolation, and depression among people living with MG (2,3).

Although the bulk of literature focuses on symptoms relating to visual impairments or generalized body fatigue, bulbar muscles (i.e., muscles involved in speech, swallowing, and breathing) can be affected in over 15% of people (4). However, the true prevalence of bulbar symptoms is likely under-reported due to the disease’s inconsistent presentation, with some studies reporting that up to 90% of people living with the disorder experience speech changes and swallowing difficulties (5). 

 Bulbar weakness can lead to communication difficulties that limit social connection, respiratory complications that result in emergency hospitalizations, and swallowing impairments that contribute to malnutrition or dehydration (3). Breathing difficulties and swallowing problems are among the most bothersome symptoms reported by people living with MG (6). Yet, current treatments for muscle weakness in MG are largely medication or surgery based, which trigger side effects in over 50% of people and can induce respiratory crisis events requiring hospitalization for acute medical care (7). Effective management of bulbar dysfunction in MG requires treatments that not only superficially reduce symptoms, but also address individualized needs for daily function and standard of living. These factors, combined with the doubling of MG prevalence over the last several decades, sparks a growing demand for reformed care (8).

Speech Language Pathologists (SLPs) are specialized therapists in the areas of speech, cognitive-linguistics, and swallowing (9).  Although SLPs are routinely involved in the multidisciplinary care of other neurological disorders, such as amyotrophic lateral sclerosis (ALS) and Parkinson’s disease, evidence suggests their expertise is underutilized in MG care (10). This may be due to MG’s ability to mimic other disorders that present with bulbar weakness, such as ALS, leading to misdiagnosis and delays in treatment (4). Improved engagement of SLPs in MG assessment and care can support physicians’ decisions to prevent misdiagnoses, provide personalized treatment plans that enhance satisfaction with care, and overall improve quality of life in this under-recognized population (11).

Currently, published reviews have examined SLP participation in assessing and treating swallowing issues of MG, but there are no studies investigating interventions across SLP’s broad scope of practice (12). Therefore, this review aimed to map the existing research on SLP involvement in MG care across speech, swallowing, and respiration (airway clearance) functions, describe the roles of SLP interventions in managing bulbar symptoms of MG, and identify current barriers to care. The goal of this review is to inform future priorities for research that facilitates SLP integration into the MG care pathway.

Due to a limited body of literature in this area of study, both peer-reviewed databases and grey literature sources such as professional websites, clinical practice guidelines, conference materials, and textbooks were searched to ensure a comprehensive basis of evidence. From 586 primary records identified across MEDLINE, Embase, CENTRAL and CINAHL databases, and 227 records from grey literature, a total of 49 articles (1956-2025) met the inclusion criteria for this review. These articles only considered adult MG and interventions within SLP scope of practice, excluding physiotherapy and intubation. 

Techniques within SLP scope of practice to assess and treat MG symptoms

SLP assessments for speech difficulties in MG are largely based on auditory-perceptual speech evaluations via continuous counting tasks, passage reading, and interviews (13-23). Specifically, over half of assessments for speech in MG rely on subjective interpretations of speech fatiguability through characteristics such as breathiness (a “whispery” sounding voice), hyperventilation (rapid deep breathing), and articulatory imprecision (slurred or indistinct sounds) (13-23).

Assessments for swallowing in MG within SLP scope of practice include more objective, tool-based techniques (over 80%), such as fibreoptic evaluations of swallowing (FEES) and modified barium swallows (MBS). FEES uses a thin flexible scope inserted through the nose into the pharynx, while MBS uses an x-ray that can visualize the passage of barium-containing food down a patient’s throat during swallowing. Together, these tools can identify residual food in the swallowing pathway, saliva pooling, and nasal regurgitation (20,21,24-32). Some perceptual assessments, such as bedside swallow assessments, are also common practice, where SLPs use water swallowing and chewing tests to observe choking or incomplete swallows (15,28,33).

 For both speech and swallowing concerns in MG, treatments focus on behavioural changes through strategies to improve communication and reduce choking risk, respectively (5,15,18,23-26,29,34-38). Both peer-reviewed and grey literature include suggestions such as speaking slowly, using shorter phrases, and eating smaller meals to reduce fatigue during conversation and mealtimes (5,15,18,23-26,29,34-38).

SLPs were not found to be involved in respiratory assessments for airway clearance in MG, which are under the scope of respirologists assessing pulmonary function. However, regarding intervention, variations of respiratory muscle training within SLP scope of practice can increase muscle strength and lung volume, which is vital to support adequate coughing and prevent choking in participants with mild to moderate MG (39-48). In conjunction with aerobic exercise prescribed by physiotherapists, SLPs can support interval-based respiratory training using a handheld breathing device. Improvements in respiratory strength are observed after approximately three months (39–48). Notably, these muscle-strengthening interventions are delivered alongside standard pharmacological treatments for MG to support strength gains while minimizing the risk of overfatigue (39–48).

Types of studies conducted

The majority of evidence to support SLP services for speech and swallowing in MG consists of professional recommendations, observational studies, and case studies from which intervention effectiveness cannot be determined (13-38). Although higher-quality randomized controlled trials have examined respiration and cough in MG, none explicitly identify SLPs as the clinician performing the treatment, despite these interventions falling within their scope of practice (39–48).

Perception of SLP services

 Only two studies investigated patient/provider perspectives on SLP care in MG. From the perspective of healthcare professionals, surveyed neurologists indicate a need for a more multidisciplinary approach to managing swallowing in MG, as care is currently physician-led (24). Similarly, SLP involvement in MG is limited by many barriers. Over half of people living with MG describe a lack of awareness of SLP roles (5). Enhancing knowledge of SLPs’ scope of practice through education represents a critical initial step; however, it does not address all existing challenges (5). One survey found that even after education on SLP services, 40% of participants would still not seek help from an SLP due to clinic accessibility concerns, cost of services, and perceived discord between clinician and patient priorities for care (5).

Implications

This review highlights several key gaps in literature on SLP management of bulbar symptoms of MG. First, there is a need for more objective and accessible alternatives to standardized perceptual assessments. The accuracy of perceptual clinician assessments relies

on individualized training level and accumulated experience, with greater expertise associated with higher judgement reliability and validity (49). This can create variation in clinician assessments and lead to diagnostic delays that hinder timely referrals to care (49). 

Secondly, future research should prioritize high-quality randomized controlled trials with measurable outcomes to evaluate the effectiveness of SLP interventions, particularly for speech and swallowing, as current evidence in these areas of bulbar function is largely limited to lower-quality, recommendation-based, or case-based studies. Respiratory muscle training was used to improve coughing strength to expel food during choking, yet treatments suggested to mitigate communication difficulties and choking risk in MG focused mainly on compensatory behavioural changes. Thus, it remains unclear whether muscle-strengthening exercises may be effective in improving speech and swallowing control alongside standard medical treatments, and is another target for future studies. 

Finally, integrating patient and provider opinions into the development of interventions can lead to more personalized treatments that address individual needs and bridge the therapeutic discord currently perceived by MG clients. Care for complex neuromuscular disorders such as MG is multidisciplinary and involves a team of professionals. Addressing the issues highlighted in this review can provide clearer definitions of SLP scope in the context of MG and support improvements in bulbar symptoms across key aspects of daily functioning.

References

References

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