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Troubles associés de la locomotion et du contrôle postural des segments axiaux chez les enfants atteints de paralysie cérébrale : impact d’une rééducation centrée sur le tronc

Abstract : The axial segments play an important role in balance control during posturokinetic activities. In children, they are the first reference point around which gait develops. Therefore, an atypical development of postural control of the trunk and the head could adversely affect gait. In children with cerebral palsy (CP), toe-walking defined as the absence of a first pivot associated with flat foot strike is common. While this behavior has often been considered to result from spasticity of the plantar flexors, recent work questions this pathophysiology and opens the way to the search for a more functional causality. Children with CP show greater instability of the axial segments in orthostatic posture and when walking. Toe-walking could then be a form of motor adaptation to compensate for deficient axial control. The first objective of this thesis was to identify axial control disorders in children with CP aged 6 to 12 years after characterizing their typical development (TD) at the same age. By using an unstable sitting position with neutralization of the contribution of the lower and upper limbs in postural control, study 1 shows in TD children an improvement in axial stabilization between the ages of 6 and 12, highlighting the progressive development of axial segments’ control between these ages and its contribution to orthostatic balance. The same method coupled with a functional assessment of the trunk shows in study 2 a deficit in stabilization and functional use of the axial segments in 17 children with CP compared to 17 age-matched TD children – deficits associated with greater standing oscillation. The second objective was to establish functional links between toe-walking and deficient control of the axial segments and to propose to improve gait through a trunk-focused rehabilitation. Study 3 shows that children with CP adapt to wearing negative heel shoes by dorsiflexion allowing the shoes to be placed flat on the ground, while maintaining the same dorsiflexion braking as barefoot during the weight-acceptance (WA) phase, confirming the functional aspect of this braking. Study 4 confirms that this braking is linked with trunk’s forward deceleration and sacrum’s downward deceleration, to compensate for deficits in axial control. We then show that a trunk-focused rehabilitation (TFR) improves control of the axial segments as well as locomotor balance with a decrease in dorsiflexion and trunk braking during the WA phase after a TFR period of 3 months.
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Jonathan Pierret. Troubles associés de la locomotion et du contrôle postural des segments axiaux chez les enfants atteints de paralysie cérébrale : impact d’une rééducation centrée sur le tronc. Médecine humaine et pathologie. Université de Lorraine, 2020. Français. ⟨NNT : 2020LORR0079⟩. ⟨tel-02962810⟩

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