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Neuropathie : L’évaluer en pratique

partie 2

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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.

Préambule : Tous les tests présentés se doivent d’être réalisés en bilatéral comparatif, afin d’éliminer de faux négatifs. Tous les tests décrits dans ce cinquième article sont à combiner avec ceux du précédent article et ceux du suivant. Ils évaluent chacun un type de fibre nerveuse. Après une rapide description des tests, nous allons explorer comment les réaliser ou les interpréter au cabinet.

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Retrouvez le quatrième article ici

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Suite et fin de l’évaluation des grosses fibres et des fibres myélinisées (Aα ou Aβ)

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La pallesthésie

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La pallesthésie est l’étude de la perception vibratoire par un diapason appliqué sur des surfaces osseuses (patella, calcanéum, olécrane). L’évaluation de la sensibilité vibratoire est habituellement mesurée par des diapasons de 64Hz (Rydell Seiffer) ou de 128Hz.

Ce test n’est pas utile pour exclure une neuropathie. Afin d’inclure une neuropathie l’utilité clinique de ce test est modérée (RV+ = 2,08). Il semblerait que plus l’atteinte neurologique est sévère et altérant plusieurs fonctions, plus la spécificité du test augmente. La positivité du test est décrite comme la diminution de la capacité de signaler quand la vibration a été appliquée et quand la vibration s’est atténuée alors qu’elle était encore appliquée. Ce test clinique a majoritairement été étudié sur une population diabétique atteinte de polyneuropathies.

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Kinesthésie et proprioception

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La proprioception est le sens qui indique si le corps bouge avec l’effort approprié et où les différents segments du corps sont situés les uns par rapport aux autres. C’est le sens de la position relative des segments du corps par rapport aux autres segments du corps.

Pendant que le patient ferme les yeux, le thérapeute met le segment du patient en position de flexion dorsale ou plantaire, et demande au patient dans quelle position se trouve sa cheville. La positivité du test est décrite comme l’impossibilité du patient à répondre correctement 8 fois sur 10 lorsque le thérapeute teste le patient.

[/fusion_text][/fusion_builder_column][fusion_builder_column type=”1_3″ layout=”1_3″ spacing=”” center_content=”no” link=”” target=”_self” min_height=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” background_color=”” 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=”” padding_right=”” padding_bottom=”” padding_left=”” margin_top=”” margin_bottom=”30px” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=”” last=”no”][fusion_imageframe image_id=”18135|medium” max_width=”” style_type=”none” blur=”” stylecolor=”” hover_type=”none” bordersize=”” bordercolor=”” borderradius=”” align=”none” lightbox=”no” gallery_id=”” lightbox_image=”” lightbox_image_id=”” alt=”” link=”” linktarget=”_self” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=””]https://pp.kobusapp.com/wp-content/uploads/2018/12/3-300×225.jpg[/fusion_imageframe][/fusion_builder_column][fusion_builder_column type=”2_3″ layout=”2_3″ spacing=”” center_content=”no” link=”” target=”_self” min_height=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” background_color=”” background_image=”” background_position=”left top” background_repeat=”no-repeat” hover_type=”none” border_size=”0″ border_color=”” border_style=”solid” border_position=”all” padding_top=”” padding_right=”” padding_bottom=”” padding_left=”” 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=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=””]

L’un des défis de l’examen de la kinesthésie est la reproductibilité du test. En effet, il faudrait une homogénéisation des pratiques dans l’évaluation clinimétrique de ces tests. Pourtant quelques données viennent montrer un intérêt clinique à cette évaluation. Ces tests ont montré une utilité au diagnostic de neuropathies du membre inférieur.

Nous retrouvons  lors du dépistage de neuropathies, ces ratios de vraisemblance : RV+ 2,83 / RV- 0,17 pour l’évaluation de la kinesthésie du gros orteil (https://lh4.googleusercontent.com/2jz1I5PQPy9JdVcqiD6AxTCT76K5JjJUcfeFS3k93myOT0Glut8ho2v4YE0qTiUcBhcZanK_c3Fpu3oRIRsoZ30NU5QI7EGhIp3aAd5c8rtmriD6s6O-B1hBS3JsMMqbP2IUWE5Dhttps://lh4.googleusercontent.com/2jz1I5PQPy9JdVcqiD6AxTCT76K5JjJUcfeFS3k93myOT0Glut8ho2v4YE0qTiUcBhcZanK_c3Fpu3oRIRsoZ30NU5QI7EGhIp3aAd5c8rtmriD6s6O-B1hBS3JsMMqbP2IUWE5D classement Kobus). Pour l’évaluation de la kinesthésie de la cheville, ils sont de : RV+ 25 / RV- 0,76 (https://lh4.googleusercontent.com/2jz1I5PQPy9JdVcqiD6AxTCT76K5JjJUcfeFS3k93myOT0Glut8ho2v4YE0qTiUcBhcZanK_c3Fpu3oRIRsoZ30NU5QI7EGhIp3aAd5c8rtmriD6s6O-B1hBS3JsMMqbP2IUWE5Di classement kobus).

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La sensibilité mécanique et tactile

[/fusion_title][fusion_imageframe image_id=”18140|medium” max_width=”” style_type=”” blur=”” stylecolor=”” hover_type=”none” bordersize=”” bordercolor=”” borderradius=”” align=”none” lightbox=”no” gallery_id=”” lightbox_image=”” lightbox_image_id=”” alt=”” link=”” linktarget=”_self” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=””]https://pp.kobusapp.com/wp-content/uploads/2018/12/BIO-VF-M_it-300×153.jpg[/fusion_imageframe][fusion_separator style_type=”none” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” sep_color=”” top_margin=”5px” bottom_margin=”10px” border_size=”” icon=”” icon_circle=”” icon_circle_color=”” width=”” alignment=”center” /][fusion_text columns=”” column_min_width=”” column_spacing=”” rule_style=”default” rule_size=”” rule_color=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=””]

La sensibilité tactile mécanique est mesurée en partie en produisant des pressions graduelles avec des monofilaments en plastique « von Frey hairs ». La positivité du test est décrite comme l’incapacité de ressentir la stimulation qui est appliquée au patient. Les ratios de vraisemblance sont de RV+ 4,56 / RV- 0,53 (https://lh4.googleusercontent.com/2jz1I5PQPy9JdVcqiD6AxTCT76K5JjJUcfeFS3k93myOT0Glut8ho2v4YE0qTiUcBhcZanK_c3Fpu3oRIRsoZ30NU5QI7EGhIp3aAd5c8rtmriD6s6O-B1hBS3JsMMqbP2IUWE5D). Le test de référence est une étude de la conductivité nerveuse. Ce test est utile dans l’aide au diagnostic de neuropathies.

Concernant la sensibilité tactile du toucher fin ou « light touch » il y a actuellement une remise en question sur comment effectuer et interpréter ce test. En effet il est fastidieux et long de proposer au patient un examen complet de ses dermatomes étant donnée la faible validité diagnostique de l‘évaluation de ces derniers. Il semblerait que l’évaluation des grosses fibres soit meilleure pour l’aide au diagnostic de neuropathie. Le « light touch » serait utile en complément afin d’évaluer s’il y a une perte totale ou partielle de cette sensibilité, ou si une allodynie est présente.

[/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=”10px” border_size=”” icon=”” icon_circle=”” icon_circle_color=”” width=”” alignment=”center” /][/fusion_builder_column][fusion_builder_column type=”1_3″ layout=”1_3″ spacing=”” center_content=”no” link=”” target=”_self” min_height=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” background_color=”” 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=”” padding_right=”” padding_bottom=”” padding_left=”” margin_top=”” margin_bottom=”30px” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=”” last=”no”][fusion_imageframe image_id=”18141|medium” max_width=”” style_type=”” blur=”” stylecolor=”” hover_type=”none” bordersize=”” bordercolor=”” borderradius=”” align=”none” lightbox=”no” gallery_id=”” lightbox_image=”” lightbox_image_id=”” alt=”” link=”” linktarget=”_self” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” animation_type=”” animation_direction=”left” animation_speed=”0.3″ animation_offset=””]https://pp.kobusapp.com/wp-content/uploads/2018/12/2013_05_22_11_48_46__15_nc12775_14b_w_12-300×300.jpg[/fusion_imageframe][/fusion_builder_column][fusion_builder_column type=”2_3″ layout=”2_3″ spacing=”” center_content=”no” link=”” target=”_self” min_height=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=”” background_color=”” background_image=”” background_position=”left top” background_repeat=”no-repeat” hover_type=”none” border_size=”0″ border_color=”” border_style=”solid” border_position=”all” padding_top=”” padding_right=”” padding_bottom=”” padding_left=”” 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=”” hide_on_mobile=”small-visibility,medium-visibility,large-visibility” class=”” id=””]

La boule de coton est majoritairement utilisée, car c’est l’un des éléments qui stimule la sensibilité tactile légère avec le moins de force possible (2-4 mN), un pinceau pourrait également faire l’affaire (200-400 mN). Certains experts mondiaux comme Annina Schmid recommandent également l’utilisation d’un mouchoir.

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La semaine prochaine nous allons continuer de nous intéresser aux tests permettant d’augmenter la probabilité de dépister une neuropathie. Nous nous intéresserons cette fois-ci aux fibres non myélinisées et fibres peu myélinisées de petits calibres (fibres Aδ et C).

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