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De nouvelles options thérapeutiques sont en cours d'introduction pour les maladies musculaires génétiques telles que les dystrophies musculaires et les myopathies congénitales, maladies jusque là sans traitement causal. Ces développements récents ont suscité un intérêt renouvelé et croissant pour les méthodes atraumatiques en vue de caractériser et de suivre les muscles atteints, en particulier pendant et après une intervention thérapeutique. Dans ce contexte, les modèles animaux sont essentiels pour mieux comprendre les mécanismes des maladies et pour tester des nouvelles thérapies. Récemment, il y a eu des avancées significatives dans l'évaluation atraumatique de modèles murins de maladies musculaires génétiques. Néanmoins, nombre de lignées de souris n'ont pas encore été caractérisées de façon atraumatique et il reste à mettre au point des méthodes plus sensibles pour identifier précocement des altérations subtiles dans le muscle des souris malades. L'objectif de cette thèse est d'appliquer des techniques atraumatiques innovantes à l'étude du muscle de modèles murins de maladies musculaires génétiques avec des phénotypes variés. Trois lignées de souris modèles de dystrophies musculaires (mdx, Large_myd et mdx/Large_myd) et une lignée de souris modèle de la myopathie congénitale (KI-Dnm2_R465W) ont été étudiées par des méthodes de Résonance Magnétique Nucléaire (RMN). Deux lignées dystrophiques (Large_myd et mdx/Large_myd) plus des souris normales après une blessure ont été étudiées par micro-tomographie (micro-CT). En RMN, toutes les souches de souris affectées ont présenté un T2 musculaire augmenté, en relation avec une gamme d'anomalies histologiques, y comprises nécrose et inflammation, mais aussi des groupes de fibres en régénération ou des fibres avec altérations de l'architecture. Avec la combinaison de la RMN et de l'analyse de la texture, il a été possible d'identifier sans ambiguïté toutes les lignées dystrophiques, alors que la seule mesure du T2 ne permettait pas de les différencier. Les souris mdx ont présenté des altérations fonctionnelles et morphologiques du réseau vasculaire musculaire. Pour les souris KI-Dnm2_R465W, des études préliminaires ont révélé une tendance à développer des altérations fonctionnelles musculaires. Finalement, les images de micro-CT n'ont pas pu détecter des différences du contenu musculaire dans les souris dystrophiques. L'ensemble des résultats non seulement enrichit le panel de modèles murins de maladies génétiques musculaires caractérisés de manière atraumatique, il révèle également un certain degré de spécificité des anomalies dans l'imagerie, comme l'a montré l'analyse de texture. Les résultats démontrent aussi que des méthodes de RMN non-invasives peuvent être assez sensibles pour identifier des altérations subtiles dans le phénotype musculaire murin, même à des stades précoces. Cette thèse a été développée dans le cadre d'une co-tutelle internationale entre la France et le Brésil, et elle a comporté un important transfert de compétence, qui a permis de réaliser les premières explorations atraumatiques du muscle murin effectuées au Brésil. / Novel therapeutic approaches are being introduced for genetic muscle diseases such as muscle dystrophies and congenital myopathies, all of them having remained without cure so far. These recent developments have motivated a renewed and augmented interest in non-invasive methods for muscle characterization and monitoring, particularly during and after therapeutic intervention. In this context, animal models are essential to better understand the disease mechanisms and to test new therapies. Recently, significant advances in the non-invasive evaluation of mouse models for genetic muscle diseases have been achieved. Nevertheless, there were still several mouse strains not characterized non-invasively, and it was necessary to develop sensitive methods to identify subtle alterations in the murine affected muscle. The purpose of this thesis was to apply non-invasive techniques in the study of murine models for genetic muscle diseases with variable phenotypes. Three mouse models for muscle dystrophy (mdx, Large_myd, mdx/Large_myd) and one mouse model for congenital myopathy (KI-Dnm2_R465W) were studied with Nuclear Magnetic Resonance (NMR) methods. Two dystrophic strains (Large_myd, mdx/Large_myd) and normal mice after injury were studied through micro-Computed Tomography (micro-CT). On NMR, all affected mouse strains presented increased muscle T2, which could be related to variable features in the histological evaluation, including necrosis and inflammation, but also to clusters of fibers under regeneration or with altered cytoarchitecture. The combination of NMR and texture analyses allowed the unambiguous differential identification of all the dystrophic strains, although it was not feasible when comparing the muscle T2 measurements only. Mdx mice showed functional and morphological alterations of vascular network. In the KI-Dnm2_R465W mice, a pilot study revealed tendencies of functional impairment. Finally, micro-CT images were unable to detect differences in muscle´s content in dystrophic mice. Altogether, these results not only increased the number of murine models for genetic muscle diseases non-invasively characterized, it also demonstrated some degree of specificity of the imaging anomalies, as revealed by texture analysis. It also showed that non-invasive NMR methods can be sensitive enough to identify subtle alterations in murine muscle phenotype, even in early stages. This thesis was developed under an international joint supervision between France and Brazil, and comprised an important transfer of technology, with the first non-invasive studies of murine muscles performed in Brazil.

ABSTRACT Rationale: Respiratory insufficiency is one of the most common causes of death in patients with neuromuscular disorders (NMD). Due to weakness and cognitive level, children with NMD often cannot perform required maneuvers to recruit lung volume. Data from cooperative adults suggest that breath stacking with a mask and one-way valve can obtain significantly higher lung volumes. Methods: To study the effectiveness of a breath stacking mask in patients with NMD, we studied 23 children (17 male, 6 female) over 3 years, mean age 11 y (range 3-19 y) and body mass 43.8 kg (range 12-80 kg). Fifteen were cognitively aware and able to communicate verbally. For involuntary breath stacking a one-way valve and pneumotach were attached to a cushioned mask that was held to the face, covering around nose and mouth with a tight seal. Flow signals were acquired to computer (AcqKnowledge BIOPAC Inc.). Tidal volumes (Vt) and minute ventilation (VE) were calculated from the recording for 30 s before and 30 s after 15 s of valve closure during which expiration was prevented. Oxygen saturation (SaO2) was measured. Results: The mean Vt before valve closure was 277 ml (range 29-598 ml). The mean increase in volume by stacking was 599 ± 558 ml (range -140 to 2,916 ml). When normalized to body mass, mean increase above normal end inspiratory level was 14.7 ± 14.7 ml/kg (range -2.7 to 52.2 ml/kg). The mean number of stacked breaths was 4.5 ± 3.6 (range 0-17). VE increased on average by 18% after stacking (p<0.05, paired t-test). There was no change in SaO2 after stacking. Four of the 23 children did not stack. Conclusions: Our findings show that breath stacking with a mask and a one-way valve can achieve breath volumes approximately 3x Vt. The mask was tolerated well, and cooperation of the child was not required.

ABSTRACT Rationale: Respiratory insufficiency is one of the most common causes of death in patients with neuromuscular disorders (NMD). Due to weakness and cognitive level, children with NMD often cannot perform required maneuvers to recruit lung volume. Data from cooperative adults suggest that breath stacking with a mask and one-way valve can obtain significantly higher lung volumes. Methods: To study the effectiveness of a breath stacking mask in patients with NMD, we studied 23 children (17 male, 6 female) over 3 years, mean age 11 y (range 3-19 y) and body mass 43.8 kg (range 12-80 kg). Fifteen were cognitively aware and able to communicate verbally. For involuntary breath stacking a one-way valve and pneumotach were attached to a cushioned mask that was held to the face, covering around nose and mouth with a tight seal. Flow signals were acquired to computer (AcqKnowledge BIOPAC Inc.). Tidal volumes (Vt) and minute ventilation (VE) were calculated from the recording for 30 s before and 30 s after 15 s of valve closure during which expiration was prevented. Oxygen saturation (SaO2) was measured. Results: The mean Vt before valve closure was 277 ml (range 29-598 ml). The mean increase in volume by stacking was 599 ± 558 ml (range -140 to 2,916 ml). When normalized to body mass, mean increase above normal end inspiratory level was 14.7 ± 14.7 ml/kg (range -2.7 to 52.2 ml/kg). The mean number of stacked breaths was 4.5 ± 3.6 (range 0-17). VE increased on average by 18% after stacking (p<0.05, paired t-test). There was no change in SaO2 after stacking. Four of the 23 children did not stack. Conclusions: Our findings show that breath stacking with a mask and a one-way valve can achieve breath volumes approximately 3x Vt. The mask was tolerated well, and cooperation of the child was not required.

Les maladies neuromusculaires, sont susceptibles d’évoluer vers un syndrome restrictif. La faiblesse des muscles respiratoires ainsi que les déformations rachidiennes et thoraciques associées font entrer les patients dans un cercle vicieux qui aggrave progressivement le syndrome restrictif et mène les patients vers l’insuffisance respiratoire. À cette insuffisance respiratoire peuvent se rajouter d’autres facteurs comme la réduction chronique des mouvements de la cage thoracique, les perturbations du sommeil, le dysfonctionnement bulbaire et l’inefficacité de la toux. En conséquence, la dysfonction du système respiratoire peut être d’origine multiple et impose une évaluation précise et ciblée sur la compréhension des mécanismes physiopathologiques pour chaque maladie non seulement pour proposer pour chacune un traitement adapté mais également pour apprécier les nouvelles thérapeutiques ciblées sur la réparation musculaire en émergence pour certaines pathologies neuromusculaires. Il parait donc nécessaire de mieux connaitre l’évolution de certaines pathologies, avec et sans les traitements classiques, et d’améliorer la compréhension des mécanismes physiopathologiques de l’insuffisance respiratoire en combinant les outils classiques d’évaluation de la fonction respiratoire avec des nouvelles techniques d’évaluation qui pourraient être complémentaires.Cette thèse a, par conséquent, pour objectif de renforcer les connaissances sur les dysfonctions respiratoires de certaines pathologies neuromusculaires en utilisant des outils classiques d’évaluation et de proposer nouvelles méthodes d’exploration de la fonction respiratoire des patients neuromusculaires. Ainsi, nous avons exploité les données de deux filières de patients neuromusculaires suivies régulièrement : la Dystrophie Facioscapulohumérale (DFSH) et la Dystrophie Musculaire de Duchenne de Boulogne (DDB). L’analyse de la DFSH nous paraissait importante car l’insuffisance respiratoire est très peu connue et décrite dans cette pathologie. Si, au contraire, l’évolution de la DDB est bien connue, l’effet de la ventilation noninvasive (VNI) sur l’évolution de la fonction respiratoire a été, en revanche, très peu décrit alors que de nouveaux essais thérapeutiques vont bientôt être proposés à ces patients, dont certains sont déjà sous VNI. Ensuite, pour mieux prédire le degré d’amélioration du syndrome restrictif qu’une thérapeutique de réparation musculaire pourrait potentiellement apporter, nous avons développé une mesure des volumes pulmonaires à l’aide d’une assistance des muscles inspiratoire et/ou expiratoire. Nous avons aussi développé et validé une méthode non-invasive et non-volitionnelle de mesure indirecte de la force du diaphragme, de manière à obtenir des résultats indépendants de la motivation du patient, à partir d’un examen indolore pour le patient.De ce fait, cette thèse a pu faire progresser les connaissances sur l’évolution de la fonction respiratoire de certaines pathologies neuromusculaires grâce à l’analyse des mesures classiques de la fonction respiratoire. Elle a aussi validé des nouvelles mesures d’explorations fonctionnelles indépendantes de la force volontaire du patient. / Neuromuscular disorders are liable to induce a restrictive syndrome. The weakness of respiratory muscles andthe associated spinal deformities lead the patients into a vicious circle, which progressively worsens the restrictivesyndrome and evolves into respiratory failure. This respiratory failure may be associated to additional factors such aschronic reduction of thoracic cage motion, sleep disordered breathing, bulbar dysfunction and ineffective cough. Therefore,dysfunction of respiratory system may have multiples origins and requires precise evaluations targeted on thecomprehension of the physiopathologic mechanisms for each disease, as they may not only allow to adapt specificallytreatment, but also to assess the new therapeutics targeted for muscle restoration that are emerging for some neuromusculardiseases. Accordingly, it is essential to acquire knowledge about the specific evolution of the different disorder, with andwithout classic treatments, and also to improve the understanding of the physiopathologic mechanisms of respiratoryfailure, combining the classic evaluation tools of respiratory function with new evaluation techniques which could provideadditional information.This thesis aims to increase the knowledge of respiratory dysfunction of some neuromuscular disorders using classicevaluation tools and also to propose new exploration methods of respiratory function for neuromuscular patients.Thus, we explored data of two specific neuromuscular disorders patients, regularly followed: FacioscapulohumeralMuscular Dystrophy (FSHD) and Duchenne Muscular Dystrophy (DMD). The analysis of FSHD seemed important asrespiratory failure is not well known and described for this disease. On the other hand, while the evolution of DMD is wellknown, the impact of noninvasive ventilation (NIV) on the evolution of respiratory function has been poorly described,whereas new therapeutic trials will be soon proposed to these patients, some of which are already under NIV.Next, to better predict the improvement of the restrictive syndrome that could be potentially obtained with muscle repairtherapies, we developed a measure of pulmonary volumes, using assistance for inspiratory and/or expiratory muscles.We also developed and validated a painless, noninvasive, non-volitional and indirect method of measurement of thediaphragmatic force, in order to obtain results independent of patients’ motivation.Hence, this thesis was able to advance knowledge of the evolution of respiratory function of some neuromuscular diseases,using traditional evaluation tools of respiratory function. Moreover, it validated new pulmonary function measuresindependent of patient’s voluntary efforts.

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Assessment in patients with NMD consists principally of measures of motor impairment since they are well known by clinicians and their measures do not require much equipment. The conventional treatments in patients with NMD are above-all focused on the diminution of motor impairments by maintaining or improving joint mobility, muscle strength and endurance. Nevertheless, a reduction of motor impairments does not directly lead to a higher ability in performing daily activities. Therefore, activity limitations should be measured specifically. A new scale of activity limitations was first developed in children and adults with NMD. The use of the Rasch model provided a scale to assess the fundamental psychometric qualities. Secondly, relationships between motor impairments and activity limitations were investigated to verify the assumption that reduced motor impairments do not necessarily lead to higher activity levels. Finally, to complete the investigation of psychometric qualities, a longitudinal study of the developed questionnaire was carried out to evaluate its sensitivity to change. Chapter 1 presents the development of ACTIVLIM, a Rasch-built measure of activity limitations and its validation in children and adults with NMD. ACTIVLIM is a self-reported questionnaire that assesses the difficulties adult patients and parents of affected children perceive when they or their children perform daily activities. This questionnaire originally included 126 daily activities and was submitted to 369 patients. The Rasch model selected 22 daily activities to define a linear and unidimensional measure of activity limitations in patients with NMD. The validity and the reproducibility of the results were also studied. A second section of Chapter 1 demonstrates why the measure of activity limitations in children with NMD as assessed using the ACTIVLIM questionnaire is based upon the perception of their parents. A third section of Chapter 1 compares the difficulties self-perceived by the patients with the difficulties observed by external examiners. The agreement between both measures is very good, indicating that the use of ACTIVLIM as a self-reporting questionnaire is a valid method to assess activity limitations in patients with NMD. Chapter 2 investigates the relationships between motor impairments and activity limitations as measured with the ACTIVLIM questionnaire. As the anatomical basis and pathophysiology are different from one NMD to another, the relationships between impairments and activity limitations were investigated in six main diagnostic groups and in the whole sample without diagnostic distinction. Gait speed and muscle weakness in proximal and flexor muscle groups were significantly but moderately correlated to the activity limitations, indicating that the latter cannot simply be inferred from motor impairments but should be independently measured and treated. Chapter 3 investigates the sensitivity to change of the ACTIVLIM questionnaire. As NMD are progressive disorders, it is important that the ACTIVLIM questionnaire be able to assess the change over time in the activity level of patients with NMD in order to characterize the disease course and to quantify the effects of new treatments on activity limitations in these patients. Finally, the last section discusses the results of the different chapters and presents perspectives for future research.

Les maladies neuromusculaires sont des maladies souvent très sévères et très handicapantes, et un fardeau pour les patients, leurs familles, ainsi que pour le système de santé. Le but de ce projet était de mettre au point et de valider une approche de capture de séquence et de séquençage haut débit pour identifier les mutations en cause chez les patients atteints de maladies neuromusculaires et également trouver les nouveaux gènes qui sont impliqués dans une sous-classe de myopathies, les myopathies centronucléaires. Nous avons montré que l’approche de capture de séquence et de séquençage haut débit peux être utile dans le domaine des maladies neuromusculaires car elle est moins coûteuse que les approches conventionnelles « gène par gène » mise en oeuvre dans les laboratoires de diagnostics génétiques.Cette stratégie devrait élargir les spectres cliniques connus et identifier de nouvelles maladies alléliques (des mutations dans un gène causant différentes maladies). De plus, cela sera utile pour l’élargissement des connaissances sur les corrélations génotypes-phénotypes qui sont nécessaires à une prise en charge plus adaptée et au développement de stratégies thérapeutiques. / Neuromuscular disorders (NMD) are genetic diseases affecting muscles, nerves and neuromuscular junctions. They are rare and often severe with different age of onset from childhood to adulthood with significant burden to the patients, their families and public health system. For testing the possibility of using massively parallel sequencing as a routine technique in molecular diagnosis of neuromuscular disorders, the first aim of my PhD project was to use massively parallel sequencing technique in patients with different NMDs for disease-causing mutation detection. The second aim of my PhD project was to find novel gene(s) implicated in centronuclear myopathies (CNM). CNM are inherited neuromuscular disorders and a type of congenital myopathies, characterized mainly by presence of central and one or more internalized nuclei in muscle fibers with different severities and age of onset, using massively parallel sequencing. About 20% of CNM patients don’t have any mutations in four implicated genes. Disease- causing mutation(s)/ gene(s) in these patients need to be identified. We could show that next generation sequencing is a robust technique for gene identification if a homogenous cohort of patients is available and also is useful to use as a routine technique in molecular diagnosis as it istime and cost effective technique.