The Feasibility and Effectiveness of Wearable Sensor Technology in the Management of Elderly Diabetics with Foot Ulcer Remission: A Proof-Of-Concept Pilot Study with Six Cases

A Scoping Review of Wearable Technologies for Use in Individuals With Intellectual Disabilities and Diabetic Peripheral Neuropathy

BACKGROUND

Individuals with intellectual disabilities (IDs) are at risk of diabetes mellitus (DM) and diabetic peripheral neuropathy (DPN), which can lead to foot ulcers and lower-extremity amputations. However, cognitive differences and communication barriers may impede some methods for screening and prevention of DPN. Wearable and mobile technologies-such as smartphone apps and pressure-sensitive insoles-could help to offset these barriers, yet little is known about the effectiveness of these technologies among individuals with ID.

METHODS

We conducted a scoping review of the databases Embase, PubMed, and Web of Science using search terms for DM, DPN, ID, and technology to diagnose or monitor DPN. Finding a lack of research in this area, we broadened our search terms to include any literature on technology to diagnose or monitor DPN and then applied these findings within the context of ID.

RESULTS

We identified 88 articles; 43 of 88 (48.9%) articles were concerned with gait mechanics or foot pressures. No articles explicitly included individuals with ID as the target population, although three articles involved individuals with other cognitive impairments (two among patients with a history of stroke, one among patients with hemodialysis-related cognitive changes).

CONCLUSIONS

Individuals with ID are not represented in studies using technology to diagnose or monitor DPN. This is a concern given the risk of DM complications among patients with ID and the potential for added benefit of such technologies to reduce barriers to screening and prevention. More studies should investigate how wearable devices can be used among patients with ID.

Sensor-Assisted Wound Therapy in Plantar Diabetic Foot Ulcer Treatment: A Randomized Clinical Trial

BACKGROUND

Offloading is the cornerstone of treatment of plantar diabetic foot ulcers. It limits mobility with consequent psychological and cardiovascular side effects, and if devices are removed, healing is delayed.

METHODS

We developed three non-removable techniques with increasing offloading potential (multilayer felt sole, felt-fiberglass sole, or total contact casts with ventral windows) and sensors built within. Smartwatch and web apps displayed pressure, temperature, humidity, and steps. They alerted patients, staff, and a telemedicine center when pressure limits (125 kPa) were exceeded. Patients were advised to walk as much as they had done before the ulcer episode. To evaluate the potential of this intervention, we enrolled 20 ambulatory patients in a randomized clinical trial. The control group used the same offloading and monitoring system, but neither patients nor therapists received any information or warnings.

RESULTS

Three patients withdrew consent. The median time to healing of ulcers was significantly shorter in the intervention group compared with controls, 40.5 (95% confidence interval [CI] = 28-not applicable [NA]) versus 266.0 (95% CI = 179-NA) days (P = .037), and increasing ulcer area was observed less frequently during study visits (7.9% vs 29.7%, P = .033). A reduction of wound area by 50% was reached at a median of 10.2 (95% CI = 7.25-NA) versus 19.1 (95% CI = 13.36-NA) days (P = .2). Participants walked an average of 1875 (SD = 1590) steps per day in intervention group and 1806 (SD = 1391) in the control group.

CONCLUSIONS

Sensor-assisted wound therapy may allow rapid closure of plantar foot ulcers while maintaining patient's mobility during ulcer therapy.

Data-driven digital health technologies in the remote clinical care of diabetic foot ulcers: a scoping review

Background

The availability and effectiveness of Digital Health Technologies (DHTs) to support clinicians, empower patients, and generate economic savings for national healthcare systems are growing rapidly. Of particular promise is the capacity of DHTs to autonomously facilitate remote monitoring and treatment. Diabetic Foot Ulcers (DFUs) are characterised by high rates of infection, amputation, mortality, and healthcare costs. With clinical outcomes contingent on activities that can be readily monitored, DFUs present a promising focus for the application of remote DHTs.

Objective

This scoping review has been conducted as a first step toward ascertaining fthe data-related challenges and opportunities for the development of more comprehensive, integrated, and individualised sense/act DHTs. We review the latest developments in the application of DHTs to the remote care of DFUs. We cover the types of DHTs in development and their features, technological readiness, and scope of clinical testing.

Eligibility criteria

Only peer-reviewed original experimental and observational studies, case series and qualitative studies were included in literature searches. All reviews and manuscripts presenting pre-trial prototype technologies were excluded.

Methods

An initial search of three databases (Web of Science, MEDLINE, and Scopus) generated 1,925 English-language papers for screening. 388 papers were assessed as eligible for full-text screening by the review team. 81 manuscripts were found to meet the eligibility criteria.

Results

Only 19% of studies incorporated multiple DHTs. We categorised 56% of studies as 'Treatment-Manual', i.e. studies involving technologies aimed at treatment requiring manual data generation, and 26% as 'Prevention-Autonomous', i.e. studies of technologies generating data autonomously through wearable sensors aimed at ulcer prevention through patient behavioural change. Only 10% of studies involved more ambitious 'Treatment-Autonomous' interventions. We found that studies generally reported high levels of patient adherence and satisfaction.

Conclusions

Our findings point to a major potential role for DHTs in remote personalised medical management of DFUs. However, larger studies are required to assess their impact. Here, we see opportunities for developing much larger, more comprehensive, and integrated monitoring and decision support systems with the potential to address the disease in a more complete context by capturing and integrating data from multiple sources from subjective and objective measurements.

Responsiveness of the Mini-Balance Evaluation System Test in Type 2 Diabetic Patients with Peripheral Neuropathy

Background

Mini-BESTest is an instrument for assessing the balance impairment; however, the use of the Mini-BESTest in type 2 diabetic patients with peripheral neuropathy is not well documented in the literature. The aim of this study was to examine the responsiveness and the minimal important change (MIC) of the Mini-BESTest after four weeks of the balance exercises.

Methods

A prospective single group pretest-posttest design was applied, and forty-eight type 2 diabetic patients with peripheral neuropathy were participated (mean age of 59.04 ± 7.533 years; 3 males and 45 females). All participants were given an intervention program including foot care and balance exercises (50-minute sessions, three times a week for four weeks). The responsiveness of the Mini-BESTest was determined using two approaches: 1) the distribution-based method evaluating the change scores (pre- and post-intervention), the effect size (ES), the standard response mean (SRM), the standard error of measurement (SEM) and the minimum detectable change (MDC₉₅) and 2) the anchor-based method evaluating the MIC using the Global Rating of Change scale (GRC) as an external criterion.

Results

After the balance exercises treatment, the Mini-BESTest scores significantly improved (p < 0.001) with an ES of 3.9 and SRM of 4.32. SEM was 0.73 and MDC₉₅ was 2.03 points. The area under the receiver operating characteristic (ROC) curve corresponded to 81%. The cutoff point of the Mini-BESTest was ≥5 points corresponding to the GRC ≤3 versus >3 for the discrimination of the Mini-BESTest between improvement and no improvement after exercises.

Conclusion

The Mini-BESTest can be demonstrated as high responsiveness according to the determination of the distribution-based and the anchor-based methods. The MIC of the Mini-BESTest was taken as ≥5 points and could be used as an outcome measure for the discriminated evaluation of type 2 diabetic patients with peripheral neuropathy.

Digital Biomarkers of Gait and Balance in Diabetic Foot, Measurable by Wearable Inertial Measurement Units: A Mini Review

People with diabetic foot frequently exhibit gait and balance dysfunction. Recent advances in wearable inertial measurement units (IMUs) enable to assess some of the gait and balance dysfunction associated with diabetic foot (i.e., digital biomarkers of gait and balance). However, there is no review to inform digital biomarkers of gait and balance dysfunction related to diabetic foot, measurable by wearable IMUs (e.g., what gait and balance parameters can wearable IMUs collect? Are the measurements repeatable?). Accordingly, we conducted a web-based, mini review using PubMed. Our search was limited to human subjects and English-written papers published in peer-reviewed journals. We identified 20 papers in this mini review. We found preliminary evidence of digital biomarkers of gait and balance dysfunction in people with diabetic foot, such as slow gait speed, large gait variability, unstable gait initiation, and large body sway. However, due to heterogeneities in included papers in terms of study design, movement tasks, and small sample size, more studies are recommended to confirm this preliminary evidence. Additionally, based on our mini review, we recommend establishing appropriate strategies to successfully incorporate wearable-based assessment into clinical practice for diabetic foot care.

Smart Wearable Systems for the Remote Monitoring of Selected Vascular Disorders of the Lower Extremity: A Systematic Review

This systematic review aims at providing an overview of the state of the art regarding smart wearable systems (SWS) applications to monitor the status of patients suffering from vascular disorders of the lower extremity. Peer-reviewed literature has been analyzed to identify employed data collection methods, system characteristics, and functionalities, and research challenges and limitations to be addressed. The Medline (PubMed) and SCOPUS databases were considered to search for publications describing SWS for remote or continuous monitoring of patients suffering from intermittent claudication, venous ulcers, and diabetic foot ulcers. Publications were first screened based on whether they describe an SWS applicable to the three selected vascular disorders of the lower extremity, including data processing and output to users. Information extracted from publications included targeted disease, clinical parameters to be measured and wearable devices used; system outputs to the user; system characteristics, including capabilities of remote or continuous monitoring or functionalities resulting from advanced data analyses, such as coaching, recommendations, or alerts; challenges and limitations reported; and research outputs. A total of 128 publications were considered in the full-text analysis, and 54 were finally included after eligibility criteria assessment by four independent reviewers. Our results were structured and discussed according to three main topics consisting of data collection, system functionalities, and limitations and challenges.

The Evaluation of Gait and Balance for Patients with Early Diabetic Peripheral Neuropathy: A Cross-Sectional Study

Objective

Falls often occur in patients with diabetic neuropathy due to biomechanical alternation. The implication of diabetic peripheral neuropathy (DPN) on gait and balance remains poorly understood.

Methods

A total of 11 dynamic gait, balance and electrophysiological parameters were evaluated in 176 participants. The biomechanical parameters were compared between groups.

Results

Stride length and stride velocity were significantly lower in all subgroups of DPN compared with healthy subjects (p<0.05). Stance phase and double support phase were significantly higher, but swing phase were significantly lower across all subgroups of DPN than healthy subjects (p<0.05). Under eyes-open standing, the ML and AP range parameters of CoM sway, ankle sway and hip sway, CoM sway index, ankle swing index in both subclinical and confirmed DPN patients were all significantly higher compared to healthy subjects (p<0.05). Under eyes-closed standing, AP range parameters of CoM sway in subclinical DPN and confirmed DPN patients were significantly higher than healthy subjects (p<0.05). The hip sway areas in diabetics were significantly higher compared to healthy subjects (p<0.05).

Conclusion

The abnormal biomechanical parameters existed in the early stages of patients with DPN. The static balance under eyes-open and eye-closed condition is maintained by ankle joint compensation strategy and hip joint protection strategy. An early evaluation and better risk management is essential for diabetic patients with a history of more than 5 years even without DPN clinical symptoms and signs.

Clinical Trial Registration Number

No. ChiCTR1800019179, www.chictr.org.cn.

Custom-Molded Offloading Footwear Effectively Prevents Recurrence and Amputation, and Lowers Mortality Rates in High-Risk Diabetic Foot Patients: A Multicenter, Prospective Observational Study

BACKGROUND

Recurrence of high-risk diabetic feet, after wound, healing is a common challenge among diabetic patients. Continuous use of an offloading device significantly prevents recurrence of high-risk diabetic feet, although patient adherence is imperative to ensuring this therapy's clinical efficacy. In this study, we explored clinical outcomes of patients with a high-risk diabetic foot who had been prescribed with custom-molded offloading footwear under different adherence conditions.

METHODS

A total of 48 patients (17 females and 31 males) with high-risk diabetic feet, who had been with prescribed offloading footwear in 13 medical centers across 4 cities, were enrolled in the current study. The patients were assigned into either continuous offloading therapy (COT, n = 31) or interrupted offloading therapy (IOT, n = 17) groups, according to their adherence to the therapy. All patients were followed up monthly, and differences in recurrence, amputation, and deaths between the groups were analyzed at 4 months after therapy.

RESULTS

Forty-eight patients met our inclusion criteria and were therefore included in the final analysis. Among them, 31 were stratified into the COT group and adhered to offloading therapy throughout the study period, whereas 17 were grouped as IOT and exhibited interrupted adherence to offloading therapy. We found statistically significant differences in recurrence rates (0 vs 38.46%, p < 0.01), amputation (0 vs 11.76%, p < 0.01), and deaths (0% vs 5.88%, p < 0.01) between the groups during follow-up.

CONCLUSION

Patients' adherence is imperative to efficacy of custom-molded offloading footwear during treatment of high-risk diabetic foot. Further studies are needed to elucidate the role of improved design of the offloading device and the need for enhanced patient education for improved adherence.