When the muscles of the face, throat, neck and tongue are weakened, you may have difficulty with speaking, chewing, swallowing and controlling mucus and saliva. The onset of ALS with these types of symptoms is known as Bulbar ALS.

Losing your ability to speak is a very significant change for most people. It can be frustrating for both you and your listener. For you, it is the end of off-the-cuff remarks and participating in quick conversation. For your listener it becomes a question of trying to interpret. Some people are much better at it than others. Speech therapy is helpful to determine which muscles are weak and how to best use the muscles still available for speaking.

Speaking problems are generally caused by weaknesses in one or more of the following muscle groups:

• Breathing muscles – resulting in weakened air pressure required to make sound;
• Vocal cords – resulting in soft or monotonous sounds;
• Soft palate and throat muscles - resulting in a nasal sound;
• Tongue and lip muscles - resulting in difficulty forming word sounds.

Conserve energy, speak slowly with short sentences and use non-verbal signals. If forming words is a problem, try using words that are easy to pronounce. Also, it can be very helpful to work out hand signals for frequently used phrases with your immediate family and other caregivers. If you can still use your fingers, it will be helpful to always carry a pad and paper with you so that you can write out your messages.

Patients on ventilation with respirators have to contend with the type of breathing device that has been inserted into their throat. They may be able to speak, but will need to be trained to do so by a respiratory therapist.

Communication devices facilitate sharing information, self-expression, signalling for attention, maintaining contact with others, and problem solving.

What communication equipment is best for you is very much a personal decision. Some people want to avoid electronic equipment while others want the latest, most sophisticated equipment available. Each device should be chosen with the unique needs of the individual in mind. You should also be aware of how long the chosen system will be useful to you. It is most likely that you will need several devices as the disease progresses.

It is also essential that you get advice from an assistive technology clinic, from a speech-language pathologist or from another professional source before purchasing any equipment. You can also visit local suppliers and try out the various options.

Think through what your needs are, and will be in the future.

• Will you need a device mostly for communicating commonly used phrases?
• Are you able to write messages?
• Will you have to make presentations to groups of people?

When choosing a device, some of the following factors may be relevant:

• Level of training needed and the complexity of the system
• Cost
• Portability
• Versatility
• Speed of communication
• Circumstances of use
• Amount of follow-up needed

Microcomputers
If you are willing to use a high-tech communication system, information about systems that meet your preferences, needs and functional abilities should be discussed with a speech-language pathologist. There is a wide range of alternative-input computers available. Some word processors, designed to compensate for specific disabilities, have specialized keyboards that accommodate a limited range of motion or poor hand control. Some software supports a variety of input methods, for example, Morse code. Other systems work in response to laser beams, eye blinks, or other eye movements.

In the later stages of ALS, a system that can be operated by a user trained in switch use and scanning may be more practical. Single-switch systems feature options that allow control of the total environment.

For example, one technique is to have the cursor slowly scan a keyboard displayed on the screen, so the operator just has to press the on/off switch when the cursor is on the key they want. Another assistive technique, called word prediction, will display 10 commonly used words on the screen that start with the letters that the operator is typing in. Each predicted word has a number beside it. If the computer predicts the word the operator wants, the operator can enter the whole word by pressing the switch when the cursor is on the correct number. Some of this software also has a feature which can be used with a computer to turn on and off a TV, VCR, light switches and other electronic equipment. As these machines are highly sophisticated, their cost is considerable.

Voice Synthesizers and Computers
A voice synthesizer allows communication over the telephone with a group of people, as well as in face-to-face interaction. The artificial voice is linked to a computer, and is activated when you type, operate a switch, move a cursor, or use Morse code to translate thoughts into speech. The switching mechanisms are often extremely sensitive, and need minimal user movement to operate; a head turn or eye movement is often adequate.

Voice Amplifiers
These devices enhance the volume of the voice. They may be considered if articulation is adequate, and respiratory weakness is the cause of decreased speaking volume.