Harnessing Digital Health Technologies to Remotely Manage Diabetic Foot Syndrome: A Narrative Review

Abstract

About 422 million people worldwide have diabetes and approximately one-third of them have a major risk factor for diabetic foot ulcers, including poor sensation in their feet from peripheral neuropathy and/or poor perfusion to their feet from peripheral artery disease. The current healthcare ecosystem, which is centered on the treatment of established foot disease, often fails to adequately control key reversible risk factors to prevent diabetic foot ulcers leading to unacceptable high foot disease amputation rate, 40% recurrence of ulcers rate in the first year, and high hospital admissions. Thus, the latest diabetic foot ulcer guidelines emphasize that a paradigm shift in research priority from siloed hospital treatments to innovative integrated community prevention is now critical to address the high diabetic foot ulcer burden. The widespread uptake and acceptance of wearable and digital health technologies provide a means to timely monitor major risk factors associated with diabetic foot ulcer, empower patients in self-care, and effectively deliver the remote monitoring and multi-disciplinary prevention needed for those at-risk people and address the health care access disadvantage that people living in remote areas. This narrative review paper summarizes some of the latest innovations in three specific areas, including technologies supporting triaging high-risk patients, technologies supporting care in place, and technologies empowering self-care. While many of these technologies are still in infancy, we anticipate that in response to the Coronavirus Disease 2019 pandemic and current unmet needs to decentralize care for people with foot disease, we will see a new wave of innovations in the area of digital health, smart wearables, telehealth technologies, and “hospital-at-home” care delivery model. These technologies will be quickly adopted at scale to improve remote management of diabetic foot ulcers, smartly triaging those who need to be seen in outpatient or inpatient clinics, and supporting acute or subacute care at home.

Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers

“…Such a plantar tissue stress threshold could be used in future to enable the development of more personalised offloading treatments for patients, clinicians and researchers, safe in the knowledge that any mix of treatments they choose that keeps their plantar tissue stress levels under a certain threshold should improve their DFU healing [ 9 , 114 ]. Secondly, the ability to continuously measure individual plantar pressure, activity and adherence outcomes, along with DFU healing, have already been incorporated into “smart boots” designed to offload DFU, i.e., knee-high devices incorporated with sensors that measure these outcomes in real time and display them to patients and clinicians on smart watches [ 9 , 115 , 116 , 117 , 118 ]. These smart boots are being armed with alarms to flag the smart watches of patients and clinicians when their plantar pressure, activity or adherence thresholds are exceeded and further treatment is required to improve healing [ 115 , 116 , 117 , 118 ].…”

“…Secondly, the ability to continuously measure individual plantar pressure, activity and adherence outcomes, along with DFU healing, have already been incorporated into “smart boots” designed to offload DFU, i.e., knee-high devices incorporated with sensors that measure these outcomes in real time and display them to patients and clinicians on smart watches [ 9 , 115 , 116 , 117 , 118 ]. These smart boots are being armed with alarms to flag the smart watches of patients and clinicians when their plantar pressure, activity or adherence thresholds are exceeded and further treatment is required to improve healing [ 115 , 116 , 117 , 118 ]. Thirdly, three-dimensional scanning and printing using smart materials is already available in footwear and closer to also becoming a reality for offloading devices [ 116 , 118 , 119 , 120 ].…”

“…These smart boots are being armed with alarms to flag the smart watches of patients and clinicians when their plantar pressure, activity or adherence thresholds are exceeded and further treatment is required to improve healing [ 115 , 116 , 117 , 118 ]. Thirdly, three-dimensional scanning and printing using smart materials is already available in footwear and closer to also becoming a reality for offloading devices [ 116 , 118 , 119 , 120 ]. Such solutions should deliver lighter weight, cooler and less bulky knee-high devices that are more easily customizable to patients wherever they reside.…”

“…Such solutions should deliver lighter weight, cooler and less bulky knee-high devices that are more easily customizable to patients wherever they reside. In addition, new smart materials are becoming available that automatically register and redistribute high plantar pressures in real time rather than having to wait to modify devices when patients return to a clinic [ 20 , 116 , 118 , 119 , 120 ]. All these novel solutions are aimed at further reducing high plantar tissue stress, improving patient satisfaction and inturn adherence, and eventually, significantly reducing DFU healing times in future.…”

Patient and Provider Perspective of Smart Wearable Technology in Diabetic Foot Ulcer Prevention: A Systematic Review

“…As we live in the era of rapidly improving medical technologies, smart wearable devices are being developed for ongoing monitoring of DFU risk factors, with the aim of DFU prevention through monitoring parameters, including foot pressure [19]. These technologies are highly effective in reducing DFU recurrence through improved foot selfmonitoring [20]. Wearable devices have also been developed for monitoring wound healing and inflammatory biomarkers (i.e., cortisol, glucose, and interleukin-6), promoting them as a tool for managing diabetes and DFU [20].…”