Dans le contexte de l’augmentation de l’espérance de vie et de l’obésité ainsi qu’avec les changements environnementaux et culturels, la prévalence du diabète est à la hausse ainsi que ses complications inhérentes tels l’ulcération plantaire diabétique (UPD), l’amputation au membre inférieur (AMI) et les risques d’infection associés. Une façon efficiente de gérer ces complications est la prise en charge en équipe multidisciplinaire (ÉMD) et les soins de pieds intégrés en incluant plusieurs professionnels, dont le podiatre. Dans l’optique d’améliorer les résultats pour la santé de cette population, cette thèse a pour objectifs de développer de nouvelles connaissances pour la compréhension du rôle du podiatre et de ses interventions, réalisées en contexte seul ou en ÉMD, dans la prise en charge de l’UPD et de l’AMI ainsi que d’explorer spécifiquement une nouvelle possibilité de matériel pour la prévention de la colonisation bactérienne des UPDs principalement associée à Staphylococcus aureus. Les travaux de recherche s’insèrent dans une approche intégrative faisant appel aux domaines théorique, pratique et expérimental utilisant différentes approches méthodologiques telles la revue systématique avec méta-analyse, l’étude cohorte comparative et l’étude expérimentale in vitro. Cela a conduit à trois articles scientifiques; les deux premiers traitent spécifiquement des effets des interventions du podiatre en approche d’ÉMD sur les résultats pour la santé (données sur l’UPD, l’AMI et l’utilisation des ressources dans le système de la santé) et le dernier concerne l’effet antibactérien d’un produit potentiel pour la gestion locale des infections des UPDs. Une analyse intégrée des travaux de recherche a permis une perspective des résultats à l’aide du cadre de référence pour la prévention et gestion des maladies chroniques et du cadre d’analyse pour les résultats pour la santé, en relation avec les connaissances actuelles sur la problématique. Cette thèse a contribué à l’avancement des connaissances pour la gestion des UPDs en ÉMD incluant le podiatre et a démontré que cette pratique clinique peut avoir des répercussions sur l’UPD et l’AMI. Elle démontre également l’importance d’optimiser la prise en charge ii en ÉMD incluant le podiatre. Elle a proposé l’aspect novateur d’un matériel biomédical, la cellulose phosphorylée avec l’argent ionisé, ayant le potentiel d’être impliqué dans la prise en charge de l’infection locale de l’UPD puisque les résultats préliminaires sur ses capacités antibactériennes, dans les conditions de laboratoire, ont un effet comparable à des produits de même nature actuellement proposés par l’industrie. Somme toute, que ce soit une UPD qui résulte en une AMI ou non, avec ou sans infection, ce qui importe concrètement, c’est d’en diminuer le nombre et de contribuer à la qualité de vie de ces personnes atteinte de diabète. Les professionnels de la santé, dont les podiatres, doivent donc agir selon les meilleurs pratiques en ÉMD et les décideurs doivent mobiliser les ressources nécessaires. / In the context of increasing life expectancy and obesity rates as well as environmental and cultural changes, the prevalence of diabetes is on the rise, as are its inherent complications such as diabetic foot ulceration (DFU), lower extremity amputation (LEA) and higher infection risks. An efficient way to manage these complications is a multidisciplinary team (MDT) approach along with integrated foot care involving several professionals, including the podiatrist. In order to improve health-related outcomes for these persons, the objectives of this thesis are, first, to develop new knowledge to further understand the role of the podiatrist and his interventions, performed alone or in MDT context, in the management of DFU and LEA, and second, to specifically explore the possibility of new material for the prevention of bacterial colonization of UPDs, mainly associated with Staphylococcus aureus. These research projects adopt an integrated approach involving theoretical, practical and experimental domains and uses different methodological approaches such as systematic review with meta-analysis, comparative cohort study and in vitro experimental study. It has led to three scientific articles; the first two specifically address the effects of podiatrist interventions in the MDT approach on health-related outcomes (data on DFUs, LEAs and the usage of healthcare resources) and the last concerns the antibacterial efficacy of a potential material for local infection management. An integrated analysis of the research projects provides perspective on the results through the use of the framework for prevention and management of chronic diseases and the analytical framework for health-related outcomes, in relation with the latest scientific evidences on this issue. This thesis contributes to the advancement of knowledge for the management of DFUs in MDT approach including podiatrists and demonstrates that this type of clinical management can have significant impacts on LEAs, including decreasing rates of major and total LEAs and improvement of healing time and rate of DFUs. It also establishes the importance of optimizing MDT with the podiatrist. Furthermore, it puts forward the potential of an innovative biomedical material, phosphate cellulose fibers with ionic silver, to be involved in the management of local DFU infection, due to its antibacterial properties which, under laboratory conditions, have an effect comparable to similar products currently offered by the industry. In sum, what truly matters is that whether or not a DFU, with or without infection, results in LEA, the aim is to reduce the number of its occurrences and to contribute to the quality of life of the people it affects. Health professionals including podiatrists must therefore act according to best practices in MDT approach and decision-makers must mobilize the necessary resources.

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Diabetic foot disease (DFD) is a serious complication of diabetes and, along with critical limb ischemia, significantly exacerbates the prognosis of patients. Peripheral arterial disease in patients with diabetes has an atypical clinical course, its diagnosis is challenging and is one of the most common causes of morbidity and mortality of patients with DFD. The aim of this dissertation focused on the diagnosis and treatment of DFD was to identify a suitable method for evaluating the effect of autologous cell therapy (ACT), to assess options for early diagnosis of Charcot osteoarthropathy (COA) and, possibly, to establish the association between the incidence of cardiovascular disease and DFD. In our studies concerning therapeutic vasculogenesis, we observed a significant increase in the antiangiogenic factor endostatin after ACT in contrast to its unchanged levels after standard percutaneous transluminal angioplasty; the transient increase in endostatin seems to be a marker of therapeutic vasculogenesis after ACT. A benefit of using calf muscle perfusion scintigraphy in the assessment of microcirculation and ACT effect was not clearly demonstrated. By contrast, a promising method for the evaluation of microcirculation and the effect of revascularization after ACT was MR spectroscopy of calf...

Phantom limb pain may occur after the accidental removal or surgical amputation of a limb. Phantom limb pain is the experience of pain in the limb that is no longer present. The clinical management of phantom limb pain is essential in the overall reduction of patient rehabilitation and poor patient outcomes. A patient’s degree of phantom limb pain is influenced by their personal response to loss and pain and can have devastating effects to a person’s social performance, occupational role, family role, relationships, and involvement in activities or hobbies. Like most chronic pain, phantom limb pain decreases the quality of life. Not all amputees who suffer from chronic pain respond to traditional therapies. The purpose of this integrated review of the literature was to explore current research and determine the efficacy of mirror therapy in the treatment of Phantom limb pain in amputees. A database search of CINAHL, PubMed (MEDLINE), and OneSearch was conducted. Mirror therapy had no reported side effects, was inexpensive, and was capable of being practiced at home and at the bedside. Relevant findings in the literature revealed a significant decrease in phantom limb pain when using mirror therapy for more than 4 weeks. Although limited research on the use of mirror therapy as an intervention for amputees, existing research supports the efficacy of mirror therapy for the management of phantom limb pain. Nurses and healthcare providers need education on mirror therapy to advocate for their patients to ensure the best possible outcome and reduction of phantom limb pain. Further research on mirror therapy is needed.

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Η παρουσία σοβαρού ισχαιμικού πόνου πριν από τον ακρωτηριασμό κάτω άκρου πολύ συχνά συνοδεύεται από την ανάπτυξη πόνου φάντασμα. Ερευνήσαμε αν η εντατική περιεγχειρητική αναλγησία μειώνει την ανάπτυξη πόνου φάντασμα 6 μήνες μετά τον ακρωτηριασμό. Μεθοδολογία: Σε συνολικά 65 ασθενείς πραγματοποιήθηκε προγραμματισμένος ακρωτηριασμός κάτω άκρου. Οι ασθενείς τυχαιοποιήθηκαν σε 5 ομάδες αναλγησίας: (1) Οι ασθενείς της ομάδας Επι/Επι/Επι έλαβαν περιεγχειρητικά επισκληρίδια αναλγησία και επισκληρίδιο αναισθησία; (2) Οι ασθενείς της ομάδας PCA/Επι/Επι έλαβαν προεγχειρητικά ενδοφλέβια αναλγησία ελεγχόμενη από τον ασθενή (Patient Controlled Analgesia-PCA), μετεγχειρητικά επισκληρίδιο αναλγησία και επισκηρίδιο αναισθησία; (3) Οι ασθενείς της ομάδας PCA/Επι/PCA έλαβαν περιεγχειρητικά ενδοφλέβια PCA και επισκληρίδιο αναισθησία; (4) Οι ασθενείς της ομάδας PCA/ΓΑ/PCA έλαβαν περιεγχειρητικά ενδοφλέβια PCA και γενική αναισθησία (ΓΑ); (5) Οι ασθενείς της ομάδας ελέγχου έλαβαν συμβατική αναλγησία και ΓΑ. Η επισκηρίδιος αναλγησία ή η ενδοφλέβια PCA ξεκινούσε 48 ώρες προεγχειρητικά και συνεχιζόταν για 48 ώρες μετεγχειρητικά. Τα αποτελέσματα της κλίμακας πόνου VAS (Visual Analogue Scale) και της κλίμακας πόνου McGill καταγραφόταν περιεγχειρητικά και στον 1 και 6 μήνες. Αποτελέσματα: Στους 6 μήνες, η ενδιάμεσες (median) τιμές (ελάχιστη-μέγιστη, minimum–maximum) του πόνου φάντασμα (Phantom Limb Pain – PLP) και οι τιμές P (ομάδες παρέμβασης έναντι ομάδας ελέγχου) για την κλίμακα πόνου VAS (Visual Analogue Scale) ήταν οι ακόλουθες: 0 (0–20) για την ομάδα Επι/Επι/Επι (P = 0.001), 0 (0–42) για την ομάδα PCA/Επι/Επι (P = 0.014), 20 (0–40) για την ομάδα PCA/Επι/PCA (P = 0.532), 0 (0–30) για την ομάδα PCA/ΓΑ/ PCA (P = 0.008), και 20 (0–58) για την ομάδα ελέγχου. Οι τιμές για την κλίμακα πόνου McGill (McGill Pain Questionnaire) ήταν οι ακόλουθες: 0 (0–7) για την ομάδα Επι/Επι/Επι (P = 0.001), 0 (0–9) για την ομάδα PCA/Επι/Επι (P = 0.003), 6 (0–11) για την ομάδα PCA/Επι/PCA (P = 0.208), 0 (0–9) για την ομάδα PCA/ΓΑ/PCA (P = 0.003), και 7 (0–15) για την ομάδα ελέγχου. Στους 6 μήνες πόνος φάντασμα παρουσιάστηκε σε 1 από τους 13 ασθενείς της ομάδας Επι/Επι/Επι, σε 4 από τους 13 ασθενείς της ομάδας PCA/Επι/Επι, και σε 3 από τους 13 ασθενείς της ομάδας PCA/ΓΑ/PCA έναντι 9 από τους 12 ασθενείς της ομάδας ελέγχου (P=0.001, P=0.027, και P=0.009, αντίστοιχα). Ο πόνος κολοβώματος στους 6 μήνες ήταν ασήμαντος. Συμπεράσματα: Η χρήση εντατικήςς αναλγησίας, με χρήση επισκληριδίου ή ενδοφλέβιας PCA, η οποία ξεκινάει 48 ώρες προεγχειρητικά και συνεχίζεται για 48 ώρες μετεγχειρητικά, μειώνει τον πόνο φάντασμα στους 6 μήνες. Trial registration: Clinical Trials.gov, number NCT00443404 / Severe preamputation pain is associated with phantom limb pain (PLP) development in limb amputees. We investigated whether optimized perioperative analgesia reduces PLP at 6-month follow-up. Methods: A total of 65 patients underwent lower-limb amputation and were assigned to five analgesic regimens: (1) Epi/Epi/Epi patients received perioperative epidural analgesia and epidural anesthesia; (2) PCA/Epi/Epi patients received preoperative intravenous patient-controlled analgesia (PCA), postoperative epidural analgesia, and epidural anesthesia; (3) PCA/Epi/PCA patients received perioperative intravenous PCA and epidural anesthesia; (4) PCA/GA/PCA patients received perioperative intravenous PCA and general anesthesia (GA); (5) controls received conventional analgesia and GA. Epidural analgesia or intravenous PCA started 48 h preoperatively and continued 48 h postoperatively. The results of the visual analog scale and the McGill Pain Questionnaire were recorded perioperatively and at 1 and 6 months. Results: At 6 months, median (minimum–maximum) PLP and P values (intervention groups vs. control group) for the visual analog scale were as follows: 0 (0–20) for Epi/Epi/Epi (P _ 0.001), 0 (0–42) for PCA/Epi/Epi (P = 0.014), 20 (0–40) for PCA/Epi/PCA (P = 0.532), 0 (0–30) for PCA/GA/ PCA (P = 0.008), and 20 (0–58) for controls. The values for the McGill Pain Questionnaire were as follows: 0 (0–7) for Epi/Epi/Epi (P = 0.001), 0 (0–9) for PCA/Epi/Epi (P = 0.003), 6 (0–11) for PCA/Epi/PCA (P = 0.208), 0 (0–9) for PCA/GA/PCA (P = 0.003), and 7 (0–15) for controls. At 6 months, PLP was present in 1 of 13 Epi/Epi/Epi, 4 of 13 PCA/Epi/Epi, and 3 of 13 PCA/GA/PCA patients versus 9 of 12 control patients (P=0.001, P=0.027, and P=0.009, respectively). Residual limb pain at 6 months was insignificant. Conclusions: Optimized epidural analgesia or intravenous PCA, starting 48 h preoperatively and continuing for 48 h postoperatively, decreases PLP at 6 months. Trial registration: Clinical Trials.gov, number NCT00443404

At the Ottawa Hospital in Ontario, Canada, clinicians use full body immersion virtual reality to treat a variety of health conditions, including: traumatic brain injuries, post- traumatic stress disorder, acquired brain injuries, complex regional pain syndrome, spinal cord injuries, Guillain-Barré syndrome, and lower limb amputations. The system is shared between military and civilian patient populations. Viewed by clinicians and the system’s designers as a value neutral medical technology, clinical virtual reality’s sights, sounds, movements, and smells reveal cultural assumptions about universal patient experiences. In this dissertation I draw from reflexive feminist research methodologies, visual anthropology and sensory ethnography in a hospital to centre the body in current debates about digital accessibility in the 21st Century. 40 in-depth interviews with practitioners and patients, 210 clinical observations, and film and photography ground research participant experiences in day-to-day understandings of virtual reality at the hospital. In this dissertation I address an ongoing absence of the body as a site of analytical attention in anthropological studies of virtual reality. While much literature in the social sciences situates virtual reality as a ‘post-human’ technology, I argue that virtual reality treatments are always experienced, resisted and interpreted through diverse body schemata. Furthermore, virtual reality cannot be decoupled from the sensitivities, socialities and politics of particular bodies in particular places and times. The Ottawa Hospital’s Computer Assisted Rehabilitation Environment (CAREN) system features a digitally enhanced walk-in chamber, treadmills on hydraulic pistons, surround sound audio, advanced graphics and user feedback utilizing force plates and a dynamic infrared motion capture system. The CAREN system utilizes hardware and software reliant on specific assumptions about human bodies. For example, these assumptions are echoed in depictions of race, gender, class, and indigeneity. Patients using virtual reality technologies can experience more than one disability or health condition at a time, further disrupting the idea of universal user experiences. As clinicians and patients confront the limitations of body normativity in the CAREN system’s interface design, they improvise, resist, and experience virtual reality in ways that defy design agendas, ultimately shaping patient treatments and unique paths to healing and health. / Graduate