The Bali’s dancers head posture in patients with neck dystonia.

Sometimes the analysis of the posture of a patient with cervical dystonia can be tricky; For instance the horizontal translation of the head is a movement that the dancers from Bali can do side to side so graciously. For us European it’s far from natural to dissociate the movement of the head from the neck in a side to side shift. Dystonic patients sometimes have their head shift to one side ….

The Bali’s dancers head posture in patients with neck dystonia.

The horizontal shift of the head.

Sometimes the analysis of the posture of a patient with cervical dystonia can be tricky; For instance the horizontal translation of the head is a movement that the dancers from Bali can do side to side so graciously. For us European it’s far from natural to dissociate the movement of the head from the neck in a side to side shift. Dystonic patients sometimes have their head shift to one side without a lateral tilt and complained of limitation of their active head and neck movements in daily life. How to analyse this dystonic posture is very important when treating the patient with Botulinum toxin injections.

Professor Reichel from Germany kindly sent me 2 weeks ago the latest English version of his book: Therapy guide spasticity-dystonia, which is a very comprehensive and practical guide of the use of Botuinum toxin in these spasticity and dystonia and reflects his vast clinical experience in these fields.

He illustrates in details the horizontal shift of the head with the underlying principle that the role of the muscles in head and neck posture depends of their insertion either on the cervical spine ( Levator scapulae, Scalenius) or on the head itself , mastoid, linae nuchae ( Sterno-cleido-mastoid, Trapezius, Splenius capitis).

The horizontal shift of the head to the right for instance will occur if at the same time the head is tilt to the left and the neck to the right. Prof Reichel uses the terminology of left laterocaput and right laterocollis.

The right levator scapulae and the right scalenius are responsible of the right laterocollis and the left Sterno-cleido-mastoid muscle, the left cervical portion of the Trapezius, and the left Splenius are responsible of the left laterocaput.

 

It seems complicated to follow but it’s quite obvious when examining the dystonic patient with the Bali’s dancer head posture.

But is this posture a primary dystonic posture or the results of an adaptation of the patient ‘s neck posture with a left laterocaput in order to keep the eye line straight when looking in front? There is a reflex loop between eye movement and neck muscles (the cervico-ocular reflex- COR), which with other reflexes prevents visual slip during head and body motion. But this reflex had been found weak or absent in cervical dystonia.

There is still a lot of unexplained observation in dystonia. Fortunately it does not stop neurologists to treat their patients with cervical dystonia with Botulinum toxin injections, based on a careful analysis of the posture.

Dr Marie-Helene Marion

Therapy Guide Spasticity: Dystonia (Uni-Med Science) G. Reichel

http://www.amazon.co.uk/Therapy-Guide-Spasticity-Dystonia-Uni-Med/dp/389599779X

Cervico-ocular function in patients with spasmodic torticollis

R Stel, M Gresty,T Metcalfe, AM Bronstein.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014296/pdf/jnnpsyc00499-0049.pdf

 

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How much sweat marks can alienate your life?

How much sweat marks can alienate your life?

You may found the word alienated as “excessive” as is the sweating of these patients …I was myself very surprised when one my patient wrote to me after being successful treated, that she felt FREE .. when the excessive sweating stopped.

Patients who presents with excessive sweating suffered from a lot of stigmas.

Daily life problems of a young person with excessive sweating under the arms.

The sweat mark on a colourful T shirt or a blouse or even going through a sweat shirt make the patient ashamed; the patient is scared of being smelly ( which is not the case), and considered as having a poor hygiene; so starts the search for the strongest deodorant which is usually based with aluminiun which make the underarms red and itchy.

The teens avoid the changing room at school and they keep their school blazer on, even in summer to hide the sweat marks.; the mother buys a new shirt uniform every month as the material becomes like a cardboard under the arms.

The adults also in their profession struggle like the teacher who has to write on a blackboard or a sale assistant reaching items from shelves., avoiding at any cost  to lift up their arms

So they have a shower twice a day, bring a change of clothes at work, wear only dark colors and avoid public transports.

Body odour?

It’s important to explain that excessive sweating doesn’t affect the body odour. There is 2 types of sweat glands, called the eccrine nad the apocrine glands.

The eccrine glands secrete an odourless, clear fluid which help to control the body temperature when exercising or in summer by allowing heat loss by evaporation. They are most numerous on the palms, soles of the feet, face, axillae and to a lesser extent the back and the chest. They are active from birth.

It’s very different from the apocrine glands which start to work from puberty and produce a thick fluid and are responsible for the body odour, and which are not involved in primary hyperhydrosis.

Treatment with Botulinum toxin.

Botulinum toxin injections under the arms can stop the excessive sweating for 6 to 9 months with a very good tolerance of the treatment. I draw a grid with a skin pen (or a eyeliner pen!), based on 15 small squares, equally distributed in the armpit. I will inject Botulinum toxin in each square, so 15 sites of injection in each armpit. The injections are not painful as performed with a small needle and very superficial to reach the sweat glands. There is no bleeding or hematoma and the patient can go back to a normal life after the treatment. The dryness will be complete 7 to 10 days after the injections and will last 6 to 9 months, depending of the severity of the condition.