Altération des stratégies musculaires chez des patients post-AVC : conséquences sur la marche et en condition de fatigue

Abstract : Hemiparesis is one of the most frequent deficits after stroke. It is accompanied by an abnormal muscle co-contraction pattern and an altered force production that significantly contribute to reduced gait performance. These alterations lead to a reorganization of muscle coordination patterns to ensure stability and adjust the propulsion of the center of mass during walking. However, less is known about muscle actions in the paretic and non-paretic lower limbs during walking. In addition, co-contraction patterns were evaluated from only EMG data in post-stroke patients. Furthermore, post-stroke patients manifest higher levels of fatigability than healthy individuals. While several factors are involved in fatigue, the role of co-contraction remains poorly understood. The main objective of this thesis was to characterize the alterations of the muscle strategies of the lower limbs in post-stroke hemiparetic patients during walking and during fatigue induced by isokinetic concentric maximal contractions. This thesis introduces the novel use of an EMG-driven modelling approach to measure muscle forces generated around the knee and ankle joints of the paretic and non-paretic lower limbs during gait in post-stroke patients. In addition, we have shown that quantification of co-contraction from muscle moments is preferable compared to EMG measurements. The results showed that the reduced forces exerted by the plantar-flexors and the knee-extensors on the paretic side, gives a possible explanation for hemiparetic gait abnormalities. Increased forces generated by the knee-flexor and knee-extensor muscles on the non-paretic side, as well as increased force generated by the knee flexors on the paretic side, compared to healthy subjects, during the stance phase would be a behavioral reorganization to better support body weight and properly adjust the forward center of mass. This reorganization of muscle coordination patterns is also reflected by the increased levels of co-contraction (based on muscle moments) observed on the paretic and non-paretic side during walking. This seems to be an adaptive, compensatory strategy to ensure postural stability. However, increased co-contraction during walking can contribute to an increased energy cost in patients and lead to a more rapid fatigue development. The study of neuromuscular fatigue in post-stroke patients showed less fatigability compared to healthy subjects, in the presence of a higher level of co-contraction (based on EMG data). Decreasing agonist EMG during repeated concetric contractions, occurred in parallel with decreasing antagonist EMG, reducing the relative opposing force and resulting in a less decline in net torque. This seems to be a potential mechanism by which net torque output is preserved in post-stroke patients who are inherently weaker. The results of these studies underline the importance of developing rehabilitation programs focused on the strengthening of plantar flexors and knee extensors and on the selectivity of movement control, such as power training.
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Hiba Souissi. Altération des stratégies musculaires chez des patients post-AVC : conséquences sur la marche et en condition de fatigue. Education. Université Côte d'Azur, 2018. Français. ⟨NNT : 2018AZUR4213⟩. ⟨tel-02273108⟩

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