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Neuropathie : L’évaluer en pratique

partie 1

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Par Bryan Littré, MKDE, passionné par les atteintes nerveuses périphériques

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Bonjour, je me présente, Bryan LITTRE MKDE diplômé du CEERRF de Saint-Denis. Depuis mon diplôme, j’ai suivi beaucoup de formations dans le champ musculo-squelettique où j’ai découvert les atteintes nerveuses périphériques (névralgies cervico brachiales, sciatalgies, radiculopathies …) pour lesquelles j’ai un attrait particulier.

Dans ce quatrième article, nous allons parler des tests qui peuvent nous aider à évaluer une neuropathie, puis, nous allons explorer comment les réaliser ou les interpréter au cabinet.
Tous les tests présentés se doivent d’être réalisés en bilatéral comparatif, afin d’éliminer de faux négatifs. Tous les tests décrits dans cet article seront à combiner avec ceux décrits dans le prochain article. Ils évaluent chacun un type de fibre nerveuse. 

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Retrouvez le troisième article ici

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L’évaluation des grosses fibres et des fibres myélinisées (Aα ou Aβ)

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Nous commençons donc par l’évaluation des fibres myélinisées ainsi que les grosses fibres. La fonction de ces fibres est représentée majoritairement par la discrimination tactile, la motricité ainsi que les réflexes. Le meilleur standard de référence pour ce genre d’atteinte est l’électroneuromyogramme (ENMG). L’ENMG évalue la neurophysiologie des fibres nerveuses myélinisées à travers l’amplitude et la vitesse de conduction motrice ou sensitive de la réponse nerveuse à un stimulus. Cependant, la précision diagnostique est plus faible lors d’atteinte radiculaire modérée que lors d’atteinte sévère. 

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 Le Test manuel contre résistance

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L’une des premières étapes est d’observer si nous voyons une amyotrophie ou pas. Cela signifierait une dénervation ou une sous-utilisation du groupe musculaire observé. L’atrophie est souvent due au fait que la dénervation diminue la synthèse des myofilaments. L’absence de stimulation nerveuse est un facteur crucial. Cette observation est à recouper avec l’interrogatoire du patient. Une amyotrophie observée sur peu de muscles est très souvent le signe de neuropathie d’une branche nerveuse (exemple : amyotrophie des muscles thénariens lors d’un syndrome compressif du nerf médian au niveau du canal carpien).

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Le testing par Break Test permet l’évaluation de la fonction des fibres motrices à travers la contraction musculaire. Le but de cette manœuvre est de rechercher un déficit neuromusculaire.

Il existe différentes causes pouvant provoquer une altération de la contraction (lésions musculaires, myopathie, radiculopathie, SLA, Guillain Barré polyneuropathie…). Le testing ne permet pas toujours d’aider à émettre un diagnostic précis sur la cause de cette perte de fonction, car il évalue différents aspects du contrôle neuromusculaire.

Cependant, il reste un outil intéressant qui permet d’évaluer l’évolution de l’état fonctionnel du patient au fil des séances. La positivité de ce test peut augmenter la probabilité de se trouver face à une atteinte nerveuse si la perte de force est significative (en ayant éliminé au préalable une lésion myoaponévrotique). Il est donc recommandé d’effectuer ce test si une neuropathie semble être présente.

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“La positivité de ce test peut augmenter la probabilité de se trouver face à une atteinte nerveuse si la perte de force est significative”

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Distributions des innervations radiculaires :

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Racine Groupe musculaire du membre supérieur Racine Groupe musculaire du membre inférieur

C1/C2

Muscles pour la flexion/extension du cou T1 Muscles pour l’abduction du doigt/adduction du doigt

C3

Muscles pour la flexion latérale du cou L2 Muscles pour la flexion de la hanche

C4

Muscles pour l’élévation de l’épaule L3 Muscles pour l’extension du genou

C5

Muscles pour l’abduction de l’épaule L4 Muscles pour la dorsi-flexion de la cheville

C6

Muscles pour la flexion du coude/extension du poignet L5 Muscles pour l’extension du gros orteil

C7

Muscles pour l’extension du coude et des doigts/flexion de poignet S1 Muscles pour la flexion plantaire de la cheville/éversion de la cheville/extension de la hanche

C8

Muscles pour la flexion du doigt S2 Muscles pour la flexion du genou

S3-S4 Muscles pour la contraction anale et sphincter de la vessie

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Réaliser un testing/break test

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Source

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Pour réaliser ce test, il suffit de mettre une résistance manuelle progressive sur la partie distale du segment osseux, ou du membre, auquel est rattaché le muscle ou le groupe musculaire à tester. Il est demandé au sujet de résister au maximum lorsque le thérapeute augmente graduellement sa résistance. Pour les muscles très puissants comme les muscles du membre inférieur, la mise en charge peut être proposée.
Par exemple concernant l’évaluation du nerf tibial innervant le triceps sural, ou l’évaluation de la racine S1 par exemple, nous pouvons demander au patient de monter sur la pointe du pied. L’objectif de ce test est de mettre en évidence une faiblesse significative comparativement à l’autre côté.
De plus, il faudra fréquemment ajouter de la charge lors du test des muscles et groupes musculaires des membres inférieurs afin de faire apparaître un déficit comparatif.

Petit bonus pour l’évaluation des nerfs sacrés : lors de l’interrogatoire, il est recommandé de demander au patient s’il n’a pas d’incontinence ou de fuites urinaires/fécales, qui pourraient être le signe d’une hypotonie des muscles sphinctériens

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De plus, il faudra fréquemment ajouter de la charge lors du test des muscles et groupes musculaires des membres inférieurs afin de faire apparaître un déficit comparatif.

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Retrouvez tous les articles de la série dans ce e-book à télécharger !

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L’évaluation par les réflexes ostéotendineux

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L’évaluation des réflexes ostéotendineux montre une utilité diagnostique lors d’atteinte neurogène. Cependant un test de réflexe négatif ne permet pas d’exclure de neuropathie. Un test positif augmente la probabilité d’être atteint de neuropathie, mais ne permet pas à lui seul, d’émettre le diagnostic de neuropathie. La positivité d’un test de réflexe est décrite comme : une abolition du réflexe, une exagération du réflexe, une extension de la zone réflexogène, un clonus, ou une diminution significative comparativement au côté sain.

La précision diagnostique des réflexes semble utile lorsqu’elle est dans un ensemble précis de données cliniques ou dans l’utilisation d’un cluster. Par exemple il a été mis en évidence que « l’examen réflexe de la cheville combiné à un test sensoriel par vibration ou par piqûre d’épingle (pinprick) est la combinaison la plus sensible pour le diagnostic de la polyneuropathie, et devrait être considéré comme une composante essentielle minimale de l’examen physique chez les patients soupçonnés de polyneuropathie ».

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“La précision diagnostique des réflexes semble utile lorsqu’elle est dans un ensemble précis de données cliniques ou dans l’utilisation d’un cluster.”

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Réaliser et interpréter les résultats d’un test des réflexes

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Pour la bonne réalisation des tests, il faut obtenir un relâchement maximal du patient. Il peut être nécessaire d’utiliser certaines manœuvres de facilitation, comme la manœuvre de Jendrassik qui consiste à demander au sujet d’effectuer une forte traction sur ses mains pendant la recherche du réflexe ou encore en détournant l’attention du sujet.

La percussion brusque du tendon musculaire à l’aide du marteau à réflexes provoque normalement une contraction unique du muscle correspondant.

L’absence d’un réflexe (aréflexie) ou sa diminution (hyporéflexie) est caractéristique d’un syndrome neurogène. L’abolition d’un réflexe a donc une valeur prédictive : le réflexe correspondant à une racine nerveuse subissant un traumatisme ou une maladie est aboli ou diminué.

L’exagération d’un réflexe (hyperréflexie) est caractéristique d’une atteinte centrale médullaire ou corticale. L’exagération de la réponse se manifeste par un réflexe :
– d’une trop grande amplitude,
– polycinétique (clonus : plusieurs réponses évoquées par une seule stimulation) 
– diffus (contraction diffusée aux autres muscles et zone réflexe élargie)

Il faut savoir que chez des personnes saines, les réflexes peuvent être de vivacité variable. De plus lorsqu’un sujet a eu une diminution ou abolition de ses réflexes monosynaptiques, nous ne savons pas si la récupération est possible.

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“Il faut savoir que chez des personnes saines, les réflexes peuvent être de vivacité variable.”

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Principaux réflexes ostéotendineux

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Réflexes Technique de recherche Réponse attendue si test normal Niveau radiculaire
Bicipital Avant-bras demi-fléchi. Pouce de l’examinateur sur le tendon du biceps. Percussion du pouce Flexion par contraction du biceps C5 (C6)
Stylo-radial Avant-bras demi-fléchi, bord radial vers le haut. Percussion de la styloïde radiale Flexion de l’avant-bras sur le bras, par contraction du long supinateur C6
Tricipital Bras en abduction, avant-bras pendant. Percussion du tendon du triceps au-dessus de l’olécrâne Extension de l’avant-bras sur le bras par contraction du triceps C7
Cubito-pronateur Avant-bras demi-fléchi, légère supination. Percussion de la styloïde cubitale Pronation de la main C8
Flexion des doigts Percussion de l’index de l’examinateur posée sur l’articulation interphalangienne distale Flexion distale des dernières phalanges C8
Rotulien Au lit : genou demi-fléchi. Assis : jambes pendantes ou croisées. Percussion du tendon rotulien Extension de la jambe sur la cuisse par contraction du quadriceps L4
Achilléen Position à genoux : percussion du tendon d’Achille Extension du pied par contraction du triceps sural S1

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La semaine prochaine nous allons continuer de nous intéresser aux tests permettant d’augmenter la probabilité de dépister une neuropathie.

[/fusion_text][fusion_separator style_type=”none” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” sep_color=”” top_margin=”5px” bottom_margin=”5px” border_size=”” icon=”” icon_circle=”” icon_circle_color=”” width=”” alignment=”center” /][fusion_button link=”https://pp.kobusapp.com/blog/evaluation-neuropathie-2/” text_transform=”” title=”” target=”_self” link_attributes=”” alignment=”” modal=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” color=”default” button_gradient_top_color=”” button_gradient_bottom_color=”” button_gradient_top_color_hover=”” button_gradient_bottom_color_hover=”” accent_color=”” accent_hover_color=”” type=”” bevel_color=”” border_width=”” size=”” stretch=”default” shape=”” icon=”” icon_position=”left” icon_divider=”no” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=””]LA SUITE ICI[/fusion_button][/fusion_builder_column][/fusion_builder_row][/fusion_builder_container][fusion_builder_container hundred_percent=”no” equal_height_columns=”no” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” background_position=”center center” background_repeat=”no-repeat” fade=”no” background_parallax=”none” enable_mobile=”no” parallax_speed=”0.3″ video_aspect_ratio=”16:9″ video_loop=”yes” video_mute=”yes” border_style=”solid” padding_top=”20px” padding_bottom=”20px” admin_label=”Inscription Newsletter” admin_toggled=”yes”][fusion_builder_row][fusion_builder_column type=”1_1″ layout=”1_1″ spacing=”” center_content=”no” link=”” target=”_self” min_height=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” background_color=”#ffffff” background_image=”” background_position=”left top” undefined=”” background_repeat=”no-repeat” hover_type=”none” border_size=”0″ border_color=”” border_style=”solid” border_position=”all” padding_top=”6″ padding_right=”20″ padding_bottom=”6″ padding_left=”20″ margin_top=”” margin_bottom=”” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=”” last=”no”][fusion_text columns=”” column_min_width=”” column_spacing=”” rule_style=”default” rule_size=”” rule_color=”” class=”” id=””]

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