Sweating in Winter: a serious problem

 

Sweating in summer on a hot day or after a long Sunday jog may feel good, or at least normal. But sweating in winter when the weather is cold or you just come out of the shower can be a nightmare for individuals suffering from a condition called Hyperhydrosis (also spelled Hyperhidrosis).

 

Primary Hyperhydrosis or excessive sweating is in third of the cases a familial condition, which can have various manifestations, depending of the site of the excessive sweating; “primary” means that no obvious cause such as drugs, diabetes, infection etc.. is associated with the excessive sweating. Excessive sweating, in particular starting in adulthood and without family history should be investigated by the GP as it could be secondary sweating.

Armpits sweating:

 In case of Primary Hyperhydrosis affecting  the armpits, it’s often  young adults complaining of sweat marks on their clothes under their arms since their teens. They avoid colourful and white clothes and prefer dark clothes to not show the marks; they feel ashamed and loose their confidence as they are wrongly convinced that the excessive sweating under the arms is associated with excessive body odours. They bring extra clothes at school or at work to change during the day.

Hand sweating:

It can also affect the hands, usually noted when the child learned to write at the age of 5; the pen slipped out the hand; they made wet mark on the paper when writing. then these children don’t dare holding hands of their friends at primary school and later on avoid social contacts; it can also affect  professional manual skills.

Feet Sweating:

The excessive sweating of the feet is usually well tolerated in winter where the socks in the shoes absorb the sweat and I have met patients who were convinced that to have wet socks were normal at the end the day. The worst is in summer when ladies try to wear open sandals, in particular with some heels; the sweaty wet feet slip out and make walking hazardous. I have heard alos young men distress about having wet feet in bed.

Facial sweating:

Facial sweating is also very distressing. The sweat can drip from the scalp, or the forehead along the face, the cheeks and the nose and in back of the neck leaving the hair wet.

Excessive sweating people can benefit from treatment and is not related to excessive shyness or anxiety but it’s a true condition.

Please don’t hesitate to contact support group such as the Hyperhidrosis Support Group at www.hyperhidrosisuk.org

Dr MH Marion is running specialized clinics for all types of primary hyperhidrosis both at St George’s Hospital, London (UK) and at the  London BTX centre.

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Few words about me… Dr Marie-Hélène Marion

Few words about me…

Dr Marie-Hélène Marion, specialist in Botox treatment for 25 years.

My name is Marie-Hélène Marion and I am a consultant neurologist, specialized in the use of Botulinum toxin (also called Botox) in Neurology. I started blogging 2 months ago about Botox, Dystonia and Hyperhydrosis and I enjoyed every minute of it. Of course at the beginning I had some hesitations, but quickly I realized that blogging for patients and talking to patients during a clinic, have a lot in common, except that you don’t know and you don’t see the reactions of your readers.

My training

I studied medicine at the University of Clermont-Ferrand in the heart of the beautiful volcanic region of Auvergne. Then went to Paris to study Neurology as an “ Interne des Hopitaux de Paris” in the most prestigious departments of that time and in parallel studied Neuro-pharmacology (how the drugs work in the brain)

Then I started to have itchy feet and went to London to specialize in movement disorder as a research fellow under Professor David Marsden for 2 years. His passion for Parkinson’s disease, Dystonia and the all field of involuntary movement was contagious and never left me since.

My work as a movement disorder specialist on both sides of the channel

I went back to Paris in September 1986 to work as a Chef de Clinique and pioneer in France the use of Botulinum toxin in Neurology. Then in 1998 I crossed again the channel to follow my Australian husband and worked for 12 years at St George’s hospital, in London, running Movement disorders clinics and various Botulinum toxin clinics. At St George’s I still run a clinic specialized in excessive sweating, in particular facial sweating and hands sweating, and a clinic for voice disorders and severe bent neck.

The London BTX Centre

Now my main clinical activity is at the London BTX Centre in Sloane Square that I founded 6 years ago, dedicated to the treatment of focal dystonia, (Blepharospasm, Cervical dystonia, Jaw dystonia, Writer’s cramp, Musician’s cramp), Hemifacial spasm, Facial palsy, Tremor, Bruxism and excessive sweating.

A special mention for patients with voice disorders who are seen in a joint clinic, unique in London, with an ENT-voice specialist (Ms Lucy Hicklin) and a neurologist (MH Marion).

Dr Marie-Helene Marion (neurologist) and MS Lucy Hicklin ( ENT surgeon, Voice specialist)

Academic interests

In parallel, I pursue academic projects in the movement disorders field and published this year on Parkinson’s disease and also on complex cervical dystonia with my junior colleagues at St George’s Hospital. I recently organized the British Neurotoxin Network (BNN)  which gathered all the clinicians over UK who are running Botox services for neurological conditions.

I am a regular invited speaker in international meetings on the field of movement disorders and organized workshops on the use of Botox treatment in neurology, as European expert in the field.

What makes my head turn?

What makes my head turn? Find out with Dr Marion, neurologist which muscles of the neck are responsible of turning the head on one side in neck dystonia

What makes my head turn?

The neck muscles involved in the involuntary posture in cervical dystonia need to be identified for Botulinum toxin injections and physiotherapy. Here are some hints.

See the sketche below.

The head is placed on the top of the cervical spine and can pivot about 90 degrees on both sides. The pivot of the head is possible if one neck muscle is pulling forward and if another one on the other side is pulling backward.

The Sterno-Cleido-Mastoid (SCM) muscle

is the muscle pulling forward and rotating the head to the opposite side (right SCM turns the head to the left).

The Splenius Capitis

is the muscle pulling the head backward and rotating the head to the same side (left Splenius turns the head to the left).

The SCM muscle is a long superficial muscle easy to palpate on the front of the neck, and the Splenius is a deep muscle, difficult to palpate, behind the ear.

The shoulder muscles

In addition, there are 2 muscles which are both neck and shoulder muscles: the Levator scapulae and the Trapezius ; both lift up the shoulder, but the Levator scapulae is a deep muscle,   responsible for the posture “shoulder up and forward “ and works with the Splenius  in turning the head to the same side (the left Levator Scapulae will contribute with the left Splenuis to the rotation of the head to the left, )

The Trapezius is a superficial muscle and can contribute to the rotation of the head to the opposite side, working together with the SCM (the right Trapezius will contribute with the right SCM to the rotation of the head to the left).

These muscles are the most frequent targets for Botulinum toxin injections to control the dystonic rotation of the head. The palpation of these muscles is important, as dystonic muscles feel more bulky under the fingers.

It may sound complex but looking at the drawing should make it simpler to grasp…

Marie-Helene Marion

London BTX centre

 

“With Africa, for Africa”: The World Congress of Neurology

At the XXth World congress of Neurology in Marrakesh, yesterday a group of French neurologists (Dr Christophe Vial from Lyon, Pr Pierre Krystkowiak from Amiens,) with Pr Ouafae Messouak from Fes (Morocco) and I run a workshop of Botulinum toxin injection techniques in Neurology. It was a great success with more than 45 people attending and working with us all day. We had colleagues from Morocco, Tunisia, Ghana, Kenya, Nigeria, Sudan, Syria, Lebanon,  the Emirates, India, Thailand, Belgium, Norway and USA. Mr. Olivier Seguin from the drug company Allergan kindly provided mannequins (called Elvis and Elvira !) which help us to do some “hands on” practices.

It was a very interactive teaching where we met our colleagues in particular from Africa. The BTX services in Africa already exist, in particular in Maghreb where there are very active (Algeria, Tunisia, Morocco). In the other part of Africa, and the Middle East the development of the services is based on individual’s initiative of neurologists, with an interest in movement disorders.

Talking with our African colleagues, we felt the need for setting up an African and Middle East Neurotoxin Network  (AMENN), following the model of the British Neurotoxin Network (the BNN). It will help the neurologists to be less isolated in their practices, and to allow African patients to access services locally without travelling at great cost to Europe for treatment many times a year.

“With Africa, for Africa” was the motto of this world congress.

Picture of the workshop faculty

Dr Marie-Helene Marion  (London BTX centre), Dr Christophe Vial (Lyon, France), Pr Ouafae Messouak (Fes, Marocco), Pr Pierre Krystowiak (Amiens, France)

 

The diagnosis of Blepharospasm is always delayed!

     The diagnosis of Blepharospasm is always delayed!

Blepharospasm is a focal adult- onset dystonia, responsible of an involuntary eye closure. It can start with an increased blinking explained by dry eyes, gritty eyes or intolerance to bright lights. Gradually the patient, more often a woman around her 60’s, complains of difficulty to watch TV, to drive at night or just to walk outdoors on a cloudy day

At that stage, surprisingly the diagnosis is not easily done. Why?

1-    The GP refers this lady to the eye clinic; the diagnosis of blockage of the lacrymal ducts, or of blepharitis (with an inflamation of the eyelids) are much more common conditions and often the first to be considered.

2-    The patient does not spontaneously mention that the eyes are involuntary closing. They more often talk about their heavy eyelids, or tired eyes, or intolerance to bright light (also called photophobia)

3-    The patient has often the eyes well opened when speaking and the doctor can’t document any forceful eye spasms during the clinic.

This explains that the diagnosis of dystonia (Blepharospasm, Cervical dystonia) is usually made after 5.4 years on average after onset of symptoms and at least after seeing 3 different consultants (Canadian survey of Dr Jog ).

The patient will benefit to come to the first clinic with a relative or a friend who may describe it more accurately as an external observer. I also ask my patients to stop talking and be silent for few minutes, fixing a visual target in the room; the spasms with forceful eye closure will occur 2 to 3 minutes later. It’s worthwhile waiting as it’s a great opportunity not only to make the diagnosis but also to identify the type of Blepharospasm.

 Hope this blog will contribute to an earlier diagnosis of Blepharospasm!

 Reference: Causes of treatment delays in dystonia and hemifacial spasm: a canadian survey. Jog M et al, Can J Neurol Sci 2011: 38:704-11

So many different types of focal dystonia!

So many different types of focal dystonia!

 Depending of the body part affected,

 ·      Eye closure is called Blepharospasm (blepharo means eyelid in Greek).

·      Jaw opening or clenching is called Oro-mandibular dystonia (oro means mouth and mandibular means jaw in Latin).

·      Tongue protrusion is called Tongue dystonia

·      Twisting of the head to one side is called Cervical dystonia (cervic means neck in Latin).

·      Writing difficulty is called Writer’s cramp.

·      Back arching, or trunk bending forward is called Axial dystonia (axial means axis as the spine).

·      Walking or running difficulty is called the “ Crampe du marcheur” in France!

·      Difficulty playing a musical instrument is called Musician’s cramp.

·      Speaking difficulty is called Spasmodic dysphonia (phonia means the speech).

 They usually start in adulthood and remain focal, without spreading to adjacent part of the body.

There is more than one Botulinum toxin!

There are 4 different botulinum toxin brands available in UK; let’s Dr Marion guide you through the pharmaceutical maze of the botulinum toxin.

Various names and abbreviations are attached to Botulinum toxin.    I hope these explanations will make reading and listening about the topic less confusing….

– Botulinum toxin is called a Neurotoxin as it’s a toxin, which is active on the nerve, controlling the action of the muscles or the secretion of the glands.

-Botox is often used in newspaper, magazine and on Internet as a generic name instead of Botulinum toxin. BOTOX is one of the brand names, registered as a trademark, and it uses inappropriately like Kleenex for facial tissue paper.

-There are 3 Botulinum toxins type A (BOTOX, DYSPORT, and XEOMIN) and 1 type B (NEUROBLOC), available in UK for therapeutic uses. The FDA (Food and Drug administration which is a regulatory body for drugs in USA) has decided to give 4 different chemical names to each of these brands, as there is no standard equivalence between the numbers of units of these brands. Ona-botulinumtoxinA for BOTOX, Abo-botulinumtoxinA  for Dysport, Inco-botulinumtoxinA for Xeomin, Rima-botulinumtoxinB for Neurobloc.

-To add to the complexity of the story, the abbreviations are also changing. We used commonly Botox, BTX, and recently we have been asked to use BoNT-A (pronounce Bonte) and BoNT-B by the scientific community!

But don’t worry too much! Despite or because of all these various labels, neurologists communicate well between each other about the treatment of their patients.

H.Oppenheim, 100 years ago was the first to use the word “ Dystonia”…

H.Oppenheim, 100 years ago was the first to use the word “ Dystonia”…what does the word Dystonia means? Dr Marion will take you back 100 years ago…

Dystonia is a neurological condition, characterized by involuntary sustained pulling of the muscles in one part of the body (focal dystonia, mainly in adult) or spread in the all body (generalized dystonia, mainly in children) and associated with abnormal postures.

The word “Dystonia” is composed of Dys (meaning abnormal) and Tonia ( meaning the tone ) . The tone represents how flexible or stiff is a part of the body. Oppenheim coined the word “Dystonia” in 1911 to describe an abnormal muscle tone, different from what was observed following stroke (spasticity). Oppenheim described children, from Ashkenazi Jewish descent, affected with generalized dystonia and called this condition “ Dystonia musculorum deformans”. In 1989, Laurie Ozelius established that a gene (called DYT1) on chromosome 9 was responsible of the ‘Oppenheim dystonia”.

 http://en.wikipedia.org/wiki/Hermann_Oppenheim

http://brain.oxfordjournals.org/content/97/1/793.extract

http://www.ncbi.nlm.nih.gov/pubmed/2576373

Cervical dystonia: what does the examination look for?

Cervical dystonia: what does the examination look for? Dr Marion tells you how the clinical examination is important to optimise the Botox treatment.

Cervical dystonia: what does the examination look for?

 Patients with cervical dystonia described at onset an intermittent feeling of pulling in the neck muscles; over the months, the head take an abnormal posture. Torticollis is defined by the head (the chin) turned to one side; laterocollis by the head tilt toward one shoulder; retrocollis by the head pulled backward in extension, chin up; antecollis by the  head  flexed downward, chin down to the chest. These abnormal postures are due to the involuntary movement of the neck on the trunk. There is also the possibility of abnormal movement of the head on the neck, the head going forward like a goose or going backward giving a double chin posture.

The diagnosis of cervical dystonia is made on the involuntary movement and the abnormal posture of the head, and often delays by many years from the onset of symptoms. They are other rare causes of abnormal posture of the head that a neurologist can exclude by a neurological examination and investigations.

 But like the BSP, every patient is different and need to be examined carefully to document precisely the abnormal dystonic posture to know which muscle is pulling too much! Then these muscles, which are responsible of the pulling, will be the one to inject with Botulinum toxin.  The difficulty comes from the action of the neck muscles which are often mixed (rotating the head on one side and tilting on the other side), resulting in mixed abnormal posture of the head (predominant rotation with a degree of tilt and extension).

It’s best to see the patient at his worst!

The patient is asked to walk, to stand up, to write or to lie down depending of the triggering factors. Usually the worst posture is achieved standing, eyes closed. The fixation of the eyes on an object helps the person to keep the head straight; when closing the eyes, the head lost the visual cue and shift to its maximal abnormal posture. Then to write down the degrees of the rotation, tilt, extension and flexion to be able at the next visit to assess the improvement under treatment.

It’s also important to see the patient at his best!

I ask the patient if he has a “geste antagoniste” (French expression also used by the Anglo-Saxons neurologists!); for instance stopping the pulling in rotation by touching with one finger the cheek without exerting an opposing force to the movement. What’s count is the improvement of the pulling by simply touching a part of the head or neck. It’s also called sensory trick and it’s a hallmark of the dystonic phenomenon.

Then when the posture is clearly documented, identifying which are the leading muscles behind, is based on surface anatomy (palpation) and functional anatomy (which muscle is doing what!).

Are all the blepharospasms the same?

Are all Blepharospasms the same?

 BSP can vary from one patient to another and also change overtime after few sessions of Botulinum toxin injections.In daily life, we can close our eyes in different ways; for instance when we are in the shower and we get shampoo into our eyes (by the way I am not sure that shampoo are still stinging), we spontaneously frown, screw and close our eyes very tight. On the other hand when we go to sleep, we pulled down very gently our eyelids, which feel heavy. In case of a patient with BSP, there is the same diversity; the eyes can closed very tight with a forceful spasm of or closed with only the eyelids pulling down, despite sometimes one finger trying to hold it up.

The orbicularis oculi muscle which is the muscle responsible of closing the eyes are organized in 3 circular parts: an inner circle (the pretarsal part responsible of the eyelid going down), a middle circle (the preseptal part) and an external circle (the orbital part); these 3 parts can contract independently.In the situation of the shampoo in the eyes, it’s the orbital part, which is contracting. When sleeping, it‘s only the pretarsal portion of the orbicularis oculi, which is involved, pulling down the eyelid.

When treating the patient with injection of Botulinum toxin, the sites of the injections have to be placed in the right portion of the orbicularis oculi muscle depending of the type of BSP.  The treatment needs to be customized for each individual, not very far from the world of the haute couture!