L’orthésiste et le patient diabétique

Patient diabetique - Rive Sud - OrthoAction

Que ce soit pour la marche en ville ou en montagne, le golf, le jogging ou simplement pour le travail et la maison, le choix de vos souliers peut vraiment influencer votre bien-être. Au delà de la marque, la chaussure doit convenir à l’activité pour laquelle elle est destinée, à la physiologie de vos pieds, ainsiqu’aux divers troubles biomécanique que vous pourriez présenter. Il y a plusieurs années, acheter des chaussures se résumait à s’assurer qu’il y ait assez de place au bout des orteils.  Les chaussures d’aujourd’hui sont beaucoup plus complexes et spécialisées, il est donc important de connaître vos pieds et vos besoins avant d’aller magasiner.

L’orthésiste peut faire une différence
On sait tous que le diabète entraîne une atteinte des artères et des nerfs qui fragilisent les pieds et que l’infection peut venir compliquer ces deux atteintes. Mais il est très important de souligner que dans plus de la moitié des cas, ces trois facteurs n’aboutissent à des plaies de pieds que par l’entremise de facteurs déclenchants.

Quels sont ces principaux facteurs déclenchants
Et bien, sachez que les troubles de la statique, les chaussures mal ajustées ainsi que les supports plantaires inadéquats figurent en tête de liste, représentant à eux seuls plus de 50% des facteurs déclenchant de plaies aux pieds.

Le rôle de l’orthésiste
L’importance de faire vérifier les pieds du diabétique par un orthésiste qualifié est primordiale. Cette vérification permet non seulement de prévenir l’apparition de plaies, mais aussi de faire une analyse biomécanique complète. Cette analyse personnalisée permet d’informer et d’éduquer le patient sur sa façon de se chausser. Elle permet aussi de vérifier ses habitudes de vie dans la maison, d’analyser les points de pression à risque de ses pieds et surtout, d’éviter qu’il ne tente par lui-même de contrôler ses pieds avec des supports préfabriqués ou autres éléments à insérer dans la chaussure ce qui est complètement à proscrire dans leur condition. L’orthésiste vérifiera l’usure des chaussures portées, fera ses recommandations et effectuera des suivis périodiques.

Prévenir vaut mieux que guérir
L’atteinte des nerfs des muscles du pied peut entraîner un moins bon fonctionnement de ces muscles et amener comme conséquences :

  • des déformations des orteils, en marteaux ou en griffes
  • des affaissements des arches plantaires (internes et métatarsiennes) modifiant la répartition des points d’appuis.L’atteinte artérielle pour sa part nous préoccupe par la peau qui devient amincie, sèche, fragile aux fissures et aux conflits entre le pied et la chaussure. Mais surtout par son manque d’apport en oxygène et en nutriments affectant la capacité de guérison.

L’orthésiste est qualifié pour vérifier l’évolution du pied diabétique
Chez le patient diabétique, il y a une diminution de l’information en provenance des pieds. Lorsqu’il y a une atteinte des nerfs et des artères, on ne peut plus se fier à la sensibilité ni à l’absence de douleur. Une couture saillante, un pli dans le cuir de la chaussure, une semelle fendue ne seront pas perçus comme des éléments douloureux. De plus, le cerveau ne reçoit pas les informations nécessaires pour activer les muscles du pied afin de changer les points d’appuis inadéquats. Il est donc difficile pour le diabétique de se rendre compte par lui même de cette diminution de sensibilité. Pourtant, plus cette atteinte est importante, plus le risque de plaie est élevé.

On informe les personnes diabétiques qu’elles doivent vérifier leurs pieds et leurs chaussures tous les jours. Dans les faits, on constate malheureusement que la diminution de la sensibilité et l’absence de douleur amènent souvent le patient diabétique à sous-estimer la gravité d’une rougeur, d’une petite entaille ou d’une callosité. De plus, la vue, la mobilité, la sensibilité des mains et la capacité du diabétique d’interpréter et de réagir à toutes les informations recueillies par l’examen visuel et tactile sont tous des facteurs importants dont on doit tenir compte.

 

L’orthésiste joue un rôle important dans la prévention d’apparition de plaies chez le patient diabétique. Son travail consiste à vérifier la répartition des points d’appuis plantaires, détecter et décharger les zones d’hyperpressions à risques de plaies, vérifier et éduquer les patients sur l’ajustement de leurs chaussures, faire des suivis préventifs, évaluer la perte de sensibilité et la mobilité articulaire.

Les matériaux à privilégier

  • Base semi-rigide pour un bon contrôle des déviations;Avec un revêtement absorbant sur le dessus pour augmenter la répartition de la charge et diminuer l’appui sur les points de pression présents ou à venir (une orthèse trop molle serait trop instable et déséquilibrante et une orthèse trop rigide risquerait de créer des conflits avec le pied fragile du diabétique.
  • La forme de la chaussure doit correspondre à la physiologie de chacun des pieds (pointus ou carrés, larges ou étroits, fins ou épais).

L’importance de la chaussure

  • Elle doit être en cuir ou avec empeigne extensible, lacées, et ne comporter aucune couture sur le devant de l’empeigne afin d’éviter des frictions indésirées.
  • Lorsqu’on se tient debout dans notre chaussure, il doit y avoir un jeu d’environ 1cm entre le bout de la chaussure et l’orteil le plus long, pas plus, pas moins.
  • La semelle doit être stable, absorbante et ne doit permettre aucune torsion au centre
    du pied.

Savoir se chausser
C’est le rôle de l’orthésiste d’apprendre à chaque personne comment choisir la chaussure la plus appropriée pour sa condition et sa forme de pied. Ce qui est confortable pour un peut être completement inadéquat pour un autre.

Qu’est-ce que la chaussure orthopédique ?
Il arrive parfois que les pieds nécessitent une attention plus particulière. Un hallux valgus (oignon), des orteils marteaux, des pieds très fins ou très larges, très courts ou très longs sont touts autant de bonnes raisons de se faire ajuster, par un orthésiste qualifié, des chaussures offrant différentes possibilités de formes, de largeurs, de profondeurs. De plus, l’orthésiste est la personne qualifiée pour modifier ou adapter les chaussures en fonction des déviations qui se présentent sous une forme asymétrique (un pied plus large ou plus court que l’autre, un hallux valgus prononcé d’un coté seulement…

Qu’est-ce que la chaussure moulée ?
Lorsque les déviations ou les asymétries sont trop importantes, nous pouvons ajuster une chaussure fabriquée à partir d’un moule des pieds. Ces chaussures sont spécifiquement conçues et fabriquées afin de répondre à tous les besoins particuliers de chacun des pieds du patient. Hauteur de l’empeigne, type de cuir, de doublure, de couture, d’ouverture, de laçage, type de semelle (hauteur, texture, wedge ou talon séparé), couleur du cuir et des coutures, rigidité et longueurs des contreforts. Tous ces éléments de conception seront choisis spécifiquement pour le patient.

 

Malheureusement, trop souvent la perte de sensibilité et le débalancement musculo-squelettique entraînent des points de pression sous les pieds, qui peuvent être à l’origine d’ulcérations, d’infections, de déformations et parfois même d’amputation partielle ou complète du pied. À ce stade, la limitation des activités quotidienne, la réduction de la pression sous le pied et la limitation ou contrôle des mouvements des principales articulations du pied (métatarse, médio-tarse, sous-astragalienne et cheville) sont les principaux objectifs.

La botte de décharge
Lorsqu’on est en présence d’une ulcération ou d’un mal perforant, la botte de décharge est le type d’orthèse la plus appropriée. Elle peut être moulée ou préfabriquée selon la gravité des déformations, de l’œdème, des troubles de la proprioception, de la sévérité de l’ulcération et de son emplacement. L’objectif de cette orthèse est de répartir la charge du pied sur la plus grande surface possible et d’empêcher tout mouvement du complexe pied cheville. Elle permet une meilleure supervision des plaies, est hygiénique, facile d’entretien, s’accommode des variations de volumes causées par l’œdème, par les différents bandages ou pansements. La semelle berceau est toujours présente et permet de compenser la perte de mobilité de la cheville et de l’articulation métatarso-phalangienne. Elle assure un déroulement normal du pas sans solliciter ces dernières.

La chaussure
Dès que la plaie est stabilisée, l’importance d’ajuster adéquatement une bonne chaussure devient capitale. Elle ne doit créer aucun conflit avec le pied et son ajustement doit être vérifié par un orthésiste car la perte de sensibilité ne nous permet plus de se fier aux sensations du patient. L’orthésiste enseigne au patient comment vérifier ses chaussures mais il s’assure lui-même de l’état des chaussures lors des suivis (doublure intérieure abimée, présence de corps étrangers, usure de la semelle.) Il s’assure aussi que le patient comprend l’importance de ne jamais marcher sans ses chaussures (donc pas de pantoufle) La chaussure doit répondre à tous les critères mentionnés plus tôt à la page 6. si le pied est trop déformé ou trop difficile à chausser, une chaussure moulée sera envisagée.

L’orthèse plantaire
Puisque même la meilleure chaussure n’a pas de fond moulé, le patient qui a eu une ulcération devrait toujours avoir une orthèse plantaire moulée aux pieds à l’intérieure de ses chaussures. Une couche de plastazote ou d’un matériel souple à faible mémoire sera privilégiée sur le dessus pour leur capacité à se conformer rapidement à la forme du pied. La compression du matériel assure un contact total et maximise la répartition des charges. L’inconvénient de ces matériaux est directement relié à leur qualité. C’est-à-dire que leur compression rapide nous oblige malheureusement à effectuer de fréquents ajustements.

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