COMMENTARY

Expert Insight: Technology to Help Tackle Diabetic Foot Problems

Dr Andrew J.M. Boulton, DSc, FRCP

Disclosures

August 07, 2018

Hi, my name is Professor Andrew Boulton, University of Manchester, UK, and today I'm going to say a few words about recent developments hopefully in prevention of recurrent foot ulcers. These are of course my views from expertise and reading the literature and if anybody has any comments or feedback, I'd be delighted to hear from you.

As I'm sure you all know diabetic foot problems in this country and most western countries represent the commonest cause for patients with diabetes being admitted to hospital. And I think there is much we can do about this, and I really think that ulceration, as it's so common and recurrence is so common, we should really redesign what we say when the patient is healed. Healing gives the impression that it's gone away and will never come back. Thus in a recent review article[1] with my good friend David Armstrong, from the USA, and Sicco Bus from the Netherlands, we brought out the term remission rather than heal, because foot ulcers recur up to 40% in the first year and up to 60% after several more years. So we should be talking about the foot being in remission because it may recur.

Now what can we do about the foot in remission to prevent recurrence? And I think there's a lot of exciting data coming through recently. First of all, not recently, it was Dr Paul Brand[2] who worked in leprosy, who observed that the insensitive foot in leprosy, and also in diabetes, tends to heat up before it breaks down. Therefore, the foot warms up because it becomes inflamed before it breaks down. And he showed this using thermography.

Recent studies have shown that a smart bathmat, and this was published by Frykberg and colleagues just a few months ago in Diabetes Care,[3] using a smart bathmat, which the patient can stand on while shaving, or whatever, every day, and this can compare the temperatures between both feet.

In a preliminary study where they observed this, because of course, this is a new technique and they weren't able to do an intervention until anything was proven, they looked at a group of high-risk patients who had a history of ulcers, and if you like were in remission. And what they showed was that the temperature differential of a few degrees between one foot and the other, was a very strong predictor of breakdown, subsequent breakdown, in the warmer foot. So this is something we can do clinically.

Larry Lavery and colleagues[4] using an NIH grant a few years ago showed that patients monitoring skin temperatures at home, if they rested, if one foot was warmer than the other, and sought immediate podiatric help, this reduced recurrence rates by virtually 100%. I think it was 8% recurrence over a year in those patients who were self-temperature monitoring compared to a standard group of around 30% recurrence.

In the future, and it may not be far away, we will have perhaps hosiery, smart socks, that can actually monitor skin temperatures during the day when one is active or inactive. And again, raise alarm before breakdown occurs. So there's much we can do here. Another study that we've been involved in has been looking at, if you like, smart sensors inside the shoes that feed wirelessly to a wristwatch and alert the patient if one area of the foot is being over pressured during walking, and it can help reduce pressure and it’s repetitive pressure in [an] insensitive foot that leads to ulceration.

So I think there's much in the future we can look forward to in terms of prevention of those recurrent ulcers that occur so frequently in our patients in remission.

Much else to follow in the future as well in the diabetic foot. But I think smart technology is going to have a big place in helping us reduce recurrent ulcers that are sadly so common.

We know for example, that education alone does not work. A nice study from my friends and colleagues Frances Game and William Jeffcoate and a group from Nottingham showed that.[5] Intensified education in patients who have had a history of foot ulcers in primary care, randomised, some to intensified education with group sessions and another to standard of care. Despite those in the intensified education group describing better felt foot self-care, they could demonstrate no reduction in recurrent ulcers. So my belief is that we need education plus an intervention. An intervention may be the patient monitoring their own skin temperatures, or in the future, smart technologies such as a smart bathmat, smart socks, smart insoles, that can measure pressure or temperature that will help us to prevent recurrent foot ulcers, which in turn will lead to reduced hospital admissions, and one hopes, reduced amputations.

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