Brian Lepow, DPM, Assistant Professor of Surgery, Baylor College of Medicine
With current and upcoming medical technologies on the horizon, medical providers are able to establish a new standard of care to empower patients to become more proactive in their care, especially when it comes to the diabetic population. According to the American Diabetes Association, more than 30 million Americans are diagnosed with Diabetes (1). A diabetic foot ulceration (DFU)on one's foot is a common complication due to long standing diabetes, along with other comorbidities such as peripheral vascular disease, which can be as high as 25% (2). Diabetes has become a worldwide epidemic and diabetics are placed at a significantly higher risk of amputation than those patients without diabetes (3). The Podiatric Physician’s role in a multidisciplinary approach for the diabetic patient is key in diagnosing, treating and preventing diabetic foot ulcers (4). Leading experts have established guidelines in the management of DFUs and have stressed the importance of offloading to adequately reduce the pressure to bottom surface of the foot, which is a causative factor in the development of foot ulcerations (5). Offloading can be a challenge for patients however since it ultimately requires lifestyle modifications. The following technologies are designed help to engage patients in becoming more proactive in offloading as they become increasingly aware and self-educated about their own health and its impact.
Smart socks and intelligent floor textiles are playing a significant role in the area of health monitoring. Foot temperature has been shown to precede tissue breakdown (7, 8). Studies have reported 97% of non-traumatic DFUs can be detected by a foot temperature monitoring system (9, 10). Self-care and daily visual examination of the foot can be difficult for patients when they are not aware of microtrauma to their feet, especially if they are neuropathic or have lost the ability to feel their feet. Embedded sensors within “smart socks” are placed in areas of high pressure which are known to lead to ulceration are designed to measure skin temperature. Wireless transmission of this data can be viewed on a smart phone via a mobile app, which has the potential for receiving notifications and alerts when a temperature change is detected (11).
Akashdeep Singh, DPM, Podiatric Surgical Resident PGY II, St. Joseph Medical Center
Plantar foot pressure can also be measured by a telemedicine foot mat, which allows patients to check for asymmetric temperatures routinely. A difference in 2.5 degrees Celsius between each foot has shown to predict 97% of DFUs before clinically present (9). Textile floor mats are water-resistant and easy to use, allowing for daily monitoring as well. Continuous temperature monitoring gives patients the opportunity to engage in their care, allowing for increased compliance and adherence to the offloading protocol before the onset of tissue breakdown.
As medical technologies expand to mobile devices for monitoring chronic disease to promote healthy behavior interventions, it may be helpful to provide data to clinicians as well for non-compliant high-risk patients. Having bidirectional communication between patients and their provides can help patients have a more positive outlook in managing their DFUs and adherence to offloading protocols (12,13). Motus Smart boot is a viable alternative to the non-removable cam boot walker and total contact cast (TCC). TCC has been a gold standard treatment in offloading of the forefoot up to 87%. However, it can be uncomfortable wearing it for long periods of time (6). Furthermore, it can be difficult to apply and manage and is not ideal for infected wounds. Motus Smart boot integrates pressure analyzing technology and provides patients and providers with real time data (13). All parties have access to data on mobile app and web interface, which allow providers to council, provide recommendations and intervene every step of the way. Patients compliance and usage patterns are also recorded to provide optimal treatment. Visualizing the impact of the Motus Smart boot daily will help to encourage patients to adhere to the provider’s treatment protocol.
"According to the American Diabetes Association, more than 30 million Americans are diagnosed with Diabetes"
Recently, pressure-sensitive insoles have become an area of interest for providing patients real-time feedback via their smart watches. This system can supplement patients who are insensate, as their protective threshold mechanism has been lost due to Diabetic Peripheral Neuropathy (DPN). Traditionally, custom orthotics can be made to reduce high-pressure areas on the plantar foot (14). However, these orthotic devices cannot adapt to the changes in pressure when the patient’s activity level changes, such as with running. The Orphyx Medical Technologies Inc. smart shoe insoles with smart watch interface provides the individual with alerts when high pressure is detected, allowing for immediate activity modification (15). Notifications regarding plantar pressure changes can help to increase awareness for high-risk patients to change or decrease their level of activity. Smart insoles could be a promising innovation as technology-based health intervention becomes more popular.
Medical technologies are also helping to create healthcare platforms where healthcare providers are receiving objective health data on a routine basis. Having data over long periods of time enables remote patient monitoring. MR3 Health provides patients with a mobile app which guides and directs patients on how to measure skin temperature daily (16). Providers have access to their patients’ temperature data in real-time and can inform their patients if the change in skin temperature is related to a precursor to ulcer formation. If so, preventative measures can be taken swiftly before complications arise. Medical technologies like MR3 Health are now assisting physicians in managing high-risk patients.
Armstrong and colleagues showed that ulcer recurrence is as high as 40% within the first year (17). DFUs have an enormous economic burden on not only the healthcare system but also to the families of those who are affected by the disease, with expenditures 2.3 times greater than patients without diabetes (18). The next generation in treating DFUs aims to engage patients in becoming active participants in their care and increasing compliance and adherence with their providers. Current medical technology has helped to create a new standard of care for the diabetic population.