Article

Neurodynamique et neuropathie compressive du membre supérieur : revue systématique

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Abstract

Résumé Objectifs Le but de cette revue a été d’analyser l’intérêt des manœuvres neurodynamiques du membre supérieur dans la prise en charge de syndrome de compression neurale. Méthode Une revue systématique a est effectuée de décembre 2016 à avril 2017. Seules les études contrôlées randomisées (ECR), comparant un groupe expérimental avec composante neurodynamique à un groupe témoin, ont été sélectionnées. Résultats Vingt-trois ECR ont été analysées. Les manœuvres neuroméningées en neuroglissements montrent un intérêt dans la prise en charge de syndrome de compression nerveuse. Les neuroglissements semblent aussi efficaces que les traitements conservateurs ayant démontrés leur efficacité et semblent plus efficaces en adjonction d’un autre traitement. Discussion et conclusion Les manœuvres neurodynamiques montrent un effet thérapeutique. Toutes les manœuvres neurodynamiques ne se valent pas et une prise en charge des interfaces tout le long du tissu nerveux semble pertinente compte tenu du phénomène de compressions nerveuses étagées. L’analyse des coûts et de l’efficacité pour une prise en charge du syndrome du canal carpien idiopathique montre la supériorité de la kinésithérapie face à la chirurgie. Niveau de preuve 2.

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Chapter
The nervous system is a continuous system. In fact, Littré [1] talks about a “dynamic interdependency” between its mechanics and its physiology: a mechanical alteration affects the physiology, which can then cause inflammation, peripheral sensitization, and mechano-sensitivity [2].
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The neurodynamic approach created by the author results from progress in nerve mobilization and stretching compared with former methods. Progress has concerned nerve gliding, differences in mechanical pressure, intraneuronal blood flow and sensitivity (physiology) of the nervous tissues. Diagnosis and treatment are seen from the point of view of musculoskeletal functions, particularly concerning the diagnostic categories and selection of therapeutic techniques. Other aspects include structural differentiation and neurodynamic sequencing. Level of evidence: Not applicable
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The diagnosis of entrapment neuropathies can be difficult because symptoms and signs often do not follow textbook descriptions and vary significantly between patients with the same diagnosis. Signs and symptoms which spread outside of the innervation territory of the affected nerve or nerve root are common. This Masterclass provides insight into relevant mechanisms that may account for this extraterritorial spread in patients with entrapment neuropathies, with an emphasis on neuroinflammation at the level of the dorsal root ganglia and spinal cord, as well as changes in subcortical and cortical regions. Furthermore, we describe how clinical tests and technical investigations may identify these mechanisms if interpreted in the context of gain or loss of function. The management of neuropathies also remains challenging. Common treatment strategies such as joint mobilisation, neurodynamic exercises, education, and medications are discussed in terms of their potential to influence certain mechanisms at the site of nerve injury or in the central nervous system. The mechanism-oriented approach for this Masterclass seems warranted given the limitations in the current evidence for the diagnosis and management of entrapment neuropathies.
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Despite the high prevalence of carpal tunnel syndrome and cubital tunnel syndrome, the quality of clinical practice guidelines is poor and non-invasive treatment modalities are often poorly documented. The aim of this cadaveric biomechanical study was to measure longitudinal excursion and strain in the median and ulnar nerve at the wrist and proximal to the elbow during different types of nerve gliding exercises. The results confirmed the clinical assumption that 'sliding techniques' result in a substantially larger excursion of the nerve than 'tensioning techniques' (e.g., median nerve at the wrist: 12.6 versus 6.1mm, ulnar nerve at the elbow: 8.3 versus 3.8mm), and that this larger excursion is associated with a much smaller change in strain (e.g., median nerve at the wrist: 0.8% (sliding) versus 6.8% (tensioning)). The findings demonstrate that different types of nerve gliding exercises have largely different mechanical effects on the peripheral nervous system. Hence different types of techniques should not be regarded as part of a homogenous group of exercises as they may influence neuropathological processes differently. The findings of this study and a discussion of possible beneficial effects of nerve gliding exercises on neuropathological processes may assist the clinician in selecting more appropriate nerve gliding exercises in the conservative and post-operative management of common neuropathies.
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Cervico-brachial pain syndrome is an upper quarter pain condition in which mechanosensitive neural tissue is considered a primary feature. A single-blind randomized controlled trial was conducted to determine the clinical effect of two manual therapy interventions. Thirty subjects (20 females and 10 males) were randomly allocated to one of three groups - one of two manual therapy intervention groups or a control group. One manual therapy intervention group consisted of passive techniques aimed at mobilizing neural tissue structures and the cervical spine. The other involved indirect manual therapy techniques with a focus on articular components of the gleno-humeral joint and thoracic spine. The treatment period lasted 8 weeks in total and was combined with a home exercise programme. Following the 8-week baseline period the control group were crossed over into the specific neural tissue manual therapy group. Pain visual analogue scale (VAS), the short-form McGill pain and Northwick Park neck pain questionnaires were completed before, midway and after the treatment period. The findings suggest that both manual physiotherapy interventions combined with home exercises are effective in improving pain intensity, pain quality scores and functional disability levels. A group difference was observed for the VAS scores at 8 weeks with the neural manual therapy technique having a significantly lower score.
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Both ischemic and mechanical factors are involved in the development of compression neuropathy. Experimental studies suggest a dose response curve such that the greater the duration and amount of pressure, the more significant is neural dysfunction. With changes of axonal injury, significant neurologic dysfunction would be anticipated; however, the vast majority of patients with CTS present with symptoms in association with electrophysiologic findings of demyelination (prolonged latency). Frequently, the prolongation in latency is minimal and some patients may even present with normal electrodiagnostic studies, still complaining of significant symptomatology. This would support the concept that in the majority of patients with CTS, the symptoms relate to problems with the connective tissue "container" of the nerve rather than pathology of the nerve fiber itself. This would be in keeping with the histopathologic findings of fibrosis, with thickening of the external epineurium and perineurium. These changes would interfere with blood flow as the vessels pass through the epineurium and perineurium and produce dynamic ischemia to the nerve fibers. As well, this fibrosis would decrease the excursion of the nerve fibers, resulting in traction, and prevent the nerve fibers themselves from going through a full range of movement without traction and decreased gliding. The importance of neural gliding and movement of the nerve in the extremity has been recently emphasized in the clinical management of patients with multilevel nerve compression. Clinical maneuvers that put the nerve on stretch will provoke patients' symptoms and have been used to diagnose specific compression neuropathies (neural tension test). Similarly, physical therapy modalities to stretch the nerves and restore neural gliding are frequently successful in relieving patients' symptoms [33]. This physical therapy approach is based on the premise that the connective tissue "container" of the nerve is tight and short and needs to be mobilized. This is in keeping with the histopathologic findings of increased connective tissue at the perineurial and epineurial levels. A greater understanding of the pathophysiology of compression neuropathy will have immediate impact on our management of this problem and likely result in emphasis on conservative management and physical therapy rather than surgical intervention.
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In nerve compression syndromes restricted nerve sliding may lead to increased strain, possibly contributing to symptoms. Ultrasound was used to examine longitudinal median nerve sliding in 17 carpal tunnel syndrome patients and 19 controls during metacarpophalangeal joint movement. Longitudinal movement in the forearm averaged 2.62 mm in controls and was not significantly reduced in carpal tunnel syndrome (CTS) patients (mean=2.20 mm). In contrast, CTS patients had a 40% reduction in transverse nerve movement at the wrist on the most, compared to least, affected side and nerve areas were enlarged by 34%. Normal longitudinal sliding in the patients indicates that nerve strain is not increased and will not contribute to symptoms.