An Android Application for Detection and Self-monitoring of the Diabetic Foot Ulcer

Transcription

1 K. Gobin and K. Louison An Android Application for Detection and Self-monitoring of the Diabetic Foot Ulcer 4 ISSN The Journal of the Association of Professional Engineers of Trinidad and Tobago Vol.45, No.1, July 2017, pp.4-10 An Android Application for Detection and Self-monitoring of the Diabetic Foot Ulcer Keri Gobin a and Karen Louison b,ψ Biomedical Engineering Unit, University of Trinidad and Tobago, O Meara Campus, Trinidad and Tobago, West Indies; a keri_gobin@hotmail.com b karen.louison@utt.edu.tt Ψ - Corresponding Author (Received 21 October 2016; Revised 30 January 2017; Accepted 13 February 2017) Abstract: Previous studies have already proven that thermal imaging can be a useful tool in the clinical management of the diabetic foot. This study aims to develop an accurate, easy-to-use, non-intrusive method for self-assessment of the diabetic foot. An affordable infra-red camera attachment for a mobile device allowed the acquisition of thermal and optical lower limb images from a small sample of healthy subjects and diabetic patients with foot ulcers. The data was then utilised in the design, development and testing of an Android application software prototype. Based on the findings, this Android application allows the input and recording of the patient s required information, selection of thermal and optical images and then easy transmission of pertinent information via the method of choice to the designated clinician. This application is designed with the older or novice user in mind and should encourage the more regular home-monitoring of the diabetic foot ulcer necessary to reduce the severe effects of its complications. The work provides a novel method of utilising this promising technology in the provision of necessary telemedicine in Trinidad and Tobago. Keywords: Diabetes mellitus, Foot Ulcer, App, Android, Telemedicine, Thermal Imaging, Monitoring 1. Introduction Diabetes mellitus and its complications are associated with substantial costs and loss of quality of life. In 2014, the global prevalence of diabetes in adults aged 18+ years was estimated to be 9% (WHO, 2015; Wild et al, 2004 ) The same report surmised that diabetes was the direct cause of 1.5 million deaths world-wide and projected that this disease will be the 7th leading cause of death by In Trinidad and Tobago, the 2011 National Risk Factor Survey (MOH, 2011) demonstrated the significant effect of diabetes and its complications on the population by its determinations that: i. Over 60% of all deaths in this country are due to chronic non-communicable diseases including diabetes and its complications. ii. 450 non-traumatic lower limb amputations occurred in people with diabetes in iii. Patients with foot problems accounted for 14% of admissions and 29% of bed occupancy at public hospitals. iv. 60% of persons who have lower limb amputations go into depression and 20% die within two years. For 2015, the number of diabetic cases in Trinidad and Tobago was estimated to be approximately 140,000 patients (WHO, 2015; IDF, 2015), a figure considered grossly underestimated because of inefficiencies in data collection techniques (Nicholls, 2010). The same sources determined the cost per person in that year, both direct in terms of healthcare system expenditure and indirect in terms of loss of earnings, disability payments, loss of time and other factors, to be some US$1,260. The foot ulcer, as the most common complication of diabetes mellitus, is not therefore only a cause of severe disability, which often leads to lower limb amputation, but it can often result in significant physical, psycho-social and economic dysfunction. Additionally, a characteristic feature of this complication is that it is usually painless and therefore not easily subject to self-detection. A common misconception of patients with diabetic neuropathy is that ulceration would be accompanied by pain or that foot damage would be vascular in nature and accompanied by poor circulation and cold feet. There can be a false assurance that feet are healthy and a lack of adherence to recommended treatments. This can result in late detection and lead to difficulty of treatment. Previous studies have found that diabetic foot ulcers can be preventable if detected early and given timely treatment (van Netten et al, 2013). Up to 85% of the footulcer-caused amputations would be prevented (Wylie- Rosett et al, 1995). Early detection, however, depends on frequent assessment, which may be limited for a variety of reasons. Self-examination can be difficult or impossible due to the diabetic health impairment or be social impairment related (van Netten et al, 2013). Frequent examination by health care professionals could be too intrusive or costly and may also be limited by the subjective techniques employed, e.g. use of the human hand for assessment of inflammation-caused temperature

2 K. Gobin and K. Louison An Android Application for Detection and Self-monitoring of the Diabetic Foot Ulcer 5 rises. At present, early effective management of these ulcers offers techniques which include education, blood sugar control, wound debridement, advanced dressing, offloading, advance therapies and, in some cases, surgery (Wounds International, 2013; Frykberg et al, 2006). These practices can reduce the severity of complications and improve overall quality of life of patients especially if a multidisciplinary team approach is employed (Yazdanpanah, 2015). Early detection and monitoring of the foot ulcer is therefore essential and emphasises the importance of frequent consistent self-assessment to the success of any treatment plan. A method of hindering the development of the diabetic foot ulcer and reducing its harmful effects is therefore required. This must facilitate opportune diagnosis of the developing or present ulcer. Daily inspection by the patient or care-giver is often advised and regular detailed inspection by a physician during medical visits is also demanded. These examinations however usually provide only visual assessment or are based on subjective palpation. A non-invasive, quantitative method of examining the foot would increase the accuracy of ulcer detection and enhance its monitoring. It has been well investigated that areas that are likely to ulcerate, except for traumatic wounds, have been associated with increased local skin temperatures due to inflammation and enzymatic autolysis of tissue (DiPietro, 2010). Early identification of these areas of inflammation would indicate regions of injury and would alert healthcare providers to the need for early treatment (Roback, 2010; Liu et al, 2013). There are, at present, many methods of investigating the skin ulcer, ranging from the relatively low cost methods of skin assessment, skin biopsy and Doppler ultrasound to the more expensive computerised tomography (CT) scans and phlebography (Labropoulos, 2009). Except for skin assessment, these methods are neither used for prediction of the development of an ulcer nor are concurrently low cost and non-invasive. The utilisation of thermographic techniques provides the opportunity of developing a method which is non-invasive, low-cost, and quantitative in nature. Thermal imaging has already been shown to be a useful technique in the clinical management of the diabetic foot (Gatt et al 2015; Liu et al, 2013). Clinical studies were performed by (Lavery, 2004) successfully applying the measurement of infra-red radiation with a hand-held thermometer to determine plantar foot temperatures. They concluded that the disadvantages of low spatial resolution, the necessity for self-assessment and the lack of options for automatic analysis outweighed the advantage of this being a low cost technique. Technological advancements have, however, lessened these limitations. Infra-red detection attachments have been developed for mobile devices which are more affordable and easily available to the home user. The development of specialised applications for data collection and analysis on these mobile devices is also possible through easily accessible web-based or other application developer programs. The tools are therefore available to create a non-invasive, reliable method of evaluating skin surface temperatures so as to provide a quantifiable measurement of inflammation which can then be used as a predictor of the development of an ulcer or for monitoring the present ulcer. Such a technique should encourage the daily self-assessment required of the patient and also enhance home-monitoring capabilities by allowing the transfer of required information to the healthcare provider. This work will utilise a mobile device compatible infrared detector attachment in the provision of an accurate, easy-to-use, non-intrusive method for self-assessment of the diabetic foot. Usage of an interconnected mobile device will allow ease of relay of thermal images and other pertinent information to the chosen clinician. Careful consideration of available technologies is necessary for determination of the attachment most apt for this process. The selected accessory will be utilised, in combination with a mobile device, in the development of a protocol for foot ulcer self-assessment. An easy-to-use Android application for a mobile device, with interface suitable to the typical user, is to be then created for the collection, storage and transmission of pertinent patient information to the healthcare provider. This work not only proposes a new method for home-monitoring of the diabetic patient with a present or developing foot ulcer but also allows and encourages the patient to play a greater role in the management of his or her own healthcare. 2. Method This preliminary study required acquisition of optical and thermal images, analysis of these images and the transmission of selected images to a designated receiver via a specialised mobile application. The selection of an accurate cost-effective infra-red detector which outputs sufficiently high resolution images in a format which enables automatic data analysis and ease of data transfer from one device to another was crucial to this project. It was also necessary that a suitable data acquisition protocol be defined (Hazenberg et al, 2014). 2.1 Selection of Thermal Imaging Device Of the thermal imaging devices available, the FLIR One Thermal Imaging attachment and the Seek Thermal: Infrared Thermal Imaging Camera were chosen for further evaluation because of their relative affordability and availability (FLIR, 2016). A variety of factors were considered and the results of this assessment are presented in Table 1. Factors such as lower cost, ability to also acquire optical images, appropriateness of physical size and sensitivity, ease of use, compatibility to chosen mobile devices, sufficiently large temperature range and detection distance determined that the FLIR One Thermal Imaging Camera Attachment be chosen for this study.

3 K. Gobin and K. Louison An Android Application for Detection and Self-monitoring of the Diabetic Foot Ulcer 6 Table 1. A comparison of selected Thermal Camera attachments Property FLIR ONE SEEK CompactPRO Name FLIR ONE Thermal Imaging Camera (Attachment for Android) Thermal Imaging Camera (Made for Smartphones) Manufacturer FLIR Seek Thermal Inc. Cost $ US $ US Dimensions 2.8 inches (72mm) 1 inch (26mm) 0.7 inches 1 x 1.75 x 1 inches (18mm) Mass 29 grams (~1oz).5 ounces Resolution 120 x 120 pixels 320 x 240 pixels 76,800 pixels) Temperature Range -4 F to 248 F (-20 to 120 C) -40 F to 626 F Thermal Sensitivity 0.18 F (0.1 C) < 70 mk Field of view - 32-degree field of view Detection distance Up to 100 feet 6 inches to 1,800 feet User Interface Mobile App Free Seek Thermal Mobile App 2.2 Choice of Data Analysis Tool The accompanying FLIR Tools+ analysis software can be utilised for capturing, recording and analysis of thermal images (FLIR, 2016). It also allows editing of radiometric images, changing of palettes and adjustment of emissivity and reflective temperature parameters. This proved sufficient for the initial thermogram analysis. 2.3 The Data Collection Protocol The pilot study required only a small population sample size. The initial group of subjects included 1 healthy volunteer and 5 diabetic subjects aged between 21 and 90 years. A healthy subject was chosen who had no history of diabetes or complications of this disease, no pathological conditions or other causes of ill-health and no history of serious injury or surgery to the foot. Criteria for selection of the diabetic subjects included being presently under the care of a physician, having a present diabetic ulcer and having had no amputated foot regions. All subjects provided written informed consent before participation. The data collection process began with an acclimatisation of the patient to the temperature of the room (maintained at 22 ) for the duration of the data collection session. Resting for a period of time in the examination room with its relatively low humidity and controlled temperature allowed the subject to achieve equilibration body temperature with the ambient temperature. To further minimise variables which would affect temperature measurement, patients were removed from contact with hot or cold sources, placed away from convection currents and a minimum number of persons allowed in the room at any time (Bagavathiappan, et al., 2009). Patients with ulcers on the ankle, upper foot surface or sole of the foot were asked to lie in a supine position for 10 minutes. Patients with ulcers above the ankle were seated with their feet planted on the floor for the same period of time. The advantage of the chosen postures over that of a standing position lay in the lack of any further required adjustment to position/ posture for the generally older subjects during the combined patient resting and data collection period. The camera, with attachment in position and mounted on a stand of fixed height, was placed a horizontal distance of 1 m from the ulcer. The placement distance is equivalent to that used in some previous studies (Bagavathiappan, et al., 2009). It allows the imaging of the entire region under analysis and would indicate, if possible, any alternative causes of temperature difference. The camera resolution, thermal sensitivity and detection distance allowed by use of the FLIR camera enabled acquisition of thermograms sufficiently detailed for use in this work. The camera parameters as set for image acquisition are provided in Table 2. Table 2. Set Camera parameters during image acquisition Parameter Set Value Emissivity 0.98 Refl. Temp o C Distance 1.00 m Relative humidity 50.00% Atmospheric Temperature o C Transmission 0.94 IR window temp o C IR window trans Additionally, studies by various researchers (Steketee, 1973; Bagavathiappan, et al., 2009; Chaves, et al., 2015) have indicated that with the skin being an almost perfect blackbody with an emissivity of 0.98 (Farid, et al., 2012; Bernard et al, 2013), the effect of ambient light and any variance in emissivity of normal and ulcerated skin is negligible. Ten optical and thermal images were taken of the ulcer and surrounding tissue. Thermal and optical images were then taken which included both feet. The acquired images were analysed as shown in Table 3. Temperature range and thermal symmetry difference were calculated using the following equations: Temperature range

4 K. Gobin and K. Louison An Android Application for Detection and Self-monitoring of the Diabetic Foot Ulcer 7 = Maximum temperature Minimum temperature (Eqn.1) Thermal symmetry difference = Temperature of left foot Temperature of right foot (Eqn. 2) A thermal symmetry difference of more than 2.2 has been shown to be an indicator of pathology (van Netten et al, 2014; Tkáová, 2011). Table 3. Analysis techniques applied to acquired images Optical Images Infra-red Radiation Images Presence of Presence of ulcer as indicated by measured visible ulcer temperature and colour Presence of inflammation as indicated by measured temperature and colour Maximum temperature within area displayed in image Minimum temperature within area displayed in image Temperature range within area displayed in image Thermal symmetry difference one healthy subject. Table 4 shows a comparison of optical and thermal images from diabetic patients with foot ulcers. Table 3. A comparison of optical and thermal images from diabetic patients with foot ulcers Subject Optical Image Infra-red radiation image Discernible foot ulcer Discernible foot ulcer Discernible region of inflammation Patient 1 Y Y Y Patient 2 Y N Y Patient 3 Y N Y Patient 4 Y Y Y Patient 5 Y N Y 2.4 Design of the Mobile Application The flow diagram for the initial application design is shown in Figure 1. App Inventor, the open-source webbased visual blocks programming language for creation of Android applications, was then used to construct and compile the application software (MIT, 2015) Figure 2. Optical image from Patient 1 Figure 3. Thermal image from Patient 1 Figure 1. Initial Application flow chart 3. Results Optical and thermal images were acquired and analysed from 5 diabetic patients with prominent foot ulcers and It can be determined from these results that ulcers which are clearly visible in optical images are not always as easily discerned from the thermal image. Whilst the optical image quite distinctly gives information as to ulcer presence, location, size and state of tissue; the thermal image informs about regions of abnormal temperature and therefore indicates the presence of inflammation and regions of inflammation. In Patient 1, the location of the ulcer was clearly identifiable in the thermogram. These

5 K. Gobin and K. Louison An Android Application for Detection and Self-monitoring of the Diabetic Foot Ulcer 8 findings are corroborated by Figures 2 and 3 which show the optical and thermal images for Patient 1. The ulcer is discernible in both images. A more detailed analysis of the thermograms is given in Table 5. It can be observed that maximum temperatures on the ulcerated feet are an average of 4.3 degrees higher than that on the healthy subject. In addition, the minimum temperature in the region of interest is approximately 2 degrees higher in two out of the 5 subjects. The temperature range observed is also significantly higher in four out of the five subjects. The ability to utilise the thermal image for indication of regions of inflammation is again supported. Subject Table 5. Temperature variations within the thermal images Maximum temperature observed, Minimum Temperature observed, Temperature Range Diabetic Patient Diabetic Patient Diabetic Patient Diabetic Patient Diabetic Patient Healthy Patient A mobile application was then designed using the Android platform. The patient interface was designed to provide an aesthetically pleasing and easy to use access suitable to the older patient or mobile device novice as shown in Figure 4. Simplicity of operation was one of the main goals. Figure 4. Main patient interface screen The Android application was designed with the following functions: i. Entering, editing and recording of patient identifying information ii. Entering, editing and recording of clinician contact information iii. Entering and recording of fourteen glucose levels with their corresponding date of input and patientsubmitted cause of any abnormality iv. Access to graphical display of stored glucose levels and the submitted causes of abnormalities for patient or clinician review v. Access to library of optical and thermal images for reviewing and transmission to designated receiver vi. Access to various methods of transmitting data (via , Dropbox, etc.). 4. Discussion This work provides a preliminary investigation into the utilisation of easily accessible mobile thermal imaging technology in the provision of necessary telemedicine. Researchers have already indicated the usefulness of thermography in the evaluation of ulcers (Chaves, et al., 2015) and have suggested the detection of a positive ulcer temperature gradient (over normal skin) as a predictor of healing and a negative ulcer temperature gradient as an indicator of possible later development of necrosis (Bagavathiappan, et al., 2009; Farid, et al., 2012). The capability of thermal imaging as a non-invasive viable detector of conditions not yet visible to the eye has also been touted. The results obtained in this small initial study corroborated previous findings by showing that the presence of a foot ulcer, which is clearly discernible in the optical image, is also indicated by regions of higher temperature in the acquired thermal images. In this investigation, however, the thermograms were obtained using the mobile phone attachment device. The higher temperature is indicative of inflammation in the ulcerated and surrounding tissue and can be useful in not only ascertaining the occurrence of the ulcer but may also suggest the condition of this tissue and the region surrounding it. Even without a comparison of optical and thermal image, there is still a clear difference in absolute temperature values when contrasted with those of the healthy sample. Maximum and/or minimum foot temperatures were at least 2 higher than those of the healthy foot in all the diabetic patients in this sample. The validity of using the mobile device acquired thermogram for monitoring the foot ulcer is therefore indicated by this small study. Such temperature increases can be easily detected by a thermal camera attachment of sufficient resolution. Additionally, the occurrence of conditions where the temperature of the ulcerated region is lower than that of surrounding tissue can be used to flag the presence or development of tissue necrosis. The utilisation of an appropriate analytic algorithm and/or suitable colour palette design, within the accompanying application, could be sufficient to inform the patient and the clinician of his or her foot ulcer status and untoward developments. The mobile application, consequentially developed in this study, provides the required simple-to operate patient interface, the patient access to self-monitoring

6 K. Gobin and K. Louison An Android Application for Detection and Self-monitoring of the Diabetic Foot Ulcer 9 information and the ability to transmit data to a clinician for patient-monitoring. Functions available from the main screen enable the user to perform various functions in a few steps: i. Input and storage of patient identification information, clinician contact information, glucose levels and causes of abnormal variations. ii. Selection of thermal and optical images from the device gallery. iii. Transmission of pertinent information to the designated clinician, via a formatted document, using the method of choice. A trial with mobile device savvy users saw quick and easy grasp of the application and its functions. Further trials with the intended population will be required. This software, however, already has the advantages of simplicity, logical flow and low number of controls. Its use is expected to: i. Provide an easy-to-use method of home-monitoring of the diabetic patient by transmitting patient identification, glucose level information and foot ulcer images to the chosen clinician ii. Enhance patient self-monitoring by recording, updating and displaying patient glucose levels over a chosen period iii. Encourage the required regular patient selfmonitoring of the development and healing of foot ulcers by allowing access to optical and infra-red images of the ulcerated foot. Future improvements to this application, to provide automatic and improved image analysis, flagging of negative temperature gradients and multi-user access, will facilitate and enhance its use as a patient monitoring tool. Continual assessment of individuals with diabetic foot ulcers is essential for alleviating the injury and for adjusting the treatment plan as required. Medical thermography, which provides a non-intrusive method of examination and allows the tracking of patients over a long period of time without any injurious effect, can prove to be a very useful tool. Combining these advantages with the technological capabilities of mobile devices can generate a technique which is accessible, affordable, allows real-time analysis and assessment. Additionally, recording of patient data over periods of time can prove to be a valuable source of information to clinicians when developing treatment plans. 5. Conclusion The intention of this study was to develop an easy-to-use Android application, which, when used in conjunction with an affordable thermal camera attachment for a mobile device, will allow acquisition of thermal and optical images of the ulcerated foot, recording of necessary patient information and transmission of all pertinent data to a designated clinician. Initial image analyses have supported the results of previous studies in indicating the validity of using thermal images for detection of areas of inflammation. The accompanying Android application successfully fulfills the required functions and has delivered a novel technique for utilising state-of-the-art technology in the provision of necessary telemedicine services in Trinidad and Tobago. Acknowledgements: The authors thank both the Barrackpore Medical Center and the Tejasvi Medical Center for providing access to their patients and valuable advice about the data collection process for this study. Gratitude also goes to The University of Trinidad and Tobago and the Biomedical Engineering Unit at O Meara, for providing the necessary tools and the encouragement required for this research. References: Bagavathiappan, S., Saravanan, T., Philip, J., Jayakumar, T., Baldev, R., Karunanithi, R., Panicker, T.M.R., Korath, M.P. and Jagadeesan, K. (2009), Infrared thermal imaging for detection of peripheral vascular disorders, Journal of Medical Physics, Vol.34, No.1, pp Bernard, V., Staffa E., Mornstein V., Bourek A. (2013), Infrared camera assessment of skin surface temperature: Effect of emissivity, Physica Medica, Vol.29, No.6, pp Chaves, M.E.A., da Silva, F.S., Soares, V.P.C., Ferreira, R.A.M., Gomes, F.S.L., de Andrade, R.M. and Pinotti, M. (2015), Evaluation of healing of pressure ulcers through thermography: a preliminary study. Research on Biomedical Engineering, Vol.31, No.1, pp DiPietro, L.A. and Guo, S. (2010), Factors affecting wound healing, Journal of Dental Research, Vol.89, No.3 pp Farid, K.J., Winkelman, C. and Jones, A.R. (2012), Using temperature of pressure-related intact discolored areas of skin to detect deep tissue injury: An observational, retrospective, correlational study, Ostomy Wound Management, Vol.58, No.8 pp FLIR (2016), FLIR One, Accessed 21 October 2016 from: Frykberg R.G.1., Armstrong, D.G., Driver, V.R., Giurini, J.M., Kravitz, S.R., Landsman, A.S., Lavery, L.A., Moore, J.C., Schuberth, J.M., Wukich, D.K., Andersen, C. and Vanore, J.V. (2006), Revision: Diabetic foot disorders A clinical practice guidelines, The Journal of Foot and Ankle Surgery, Vol.45, No.5 Supplement, pp.1-66 Gatt, A., Formosa, C., Cassar, K., Camilleri, K.P., de Raffaele, C., Mizzi, A., Azzopardi, C., Mizzi, S., Falzon, O., Cristina, S. and Chockalingam, N. (2015), Thermographic patterns of the upper and lower limbs: Baseline data, International Journal of Vascular Medicine, Article ID , 9 pages Hazenberg, C.E., Netten, J.J. and Bus, S.G. (2014), Assessment of signs of foot infection in diabetes patients using photographic foot imaging and infrared thermography, Diabetes Technology and Therapeutics, Vol.16, No.6, pp.1-8 IDF (2015), International Diabetes Federation, Accessed 21 October 2016, from: Labropoulos, N and Spentzouris, G. (2009), The evaluation of lower-extremity ulcers, Seminars in Interventional Radiology, Vol.26, No.4, pp Lavery, L.A., Higgins, K.R., Lanctot, D.R., Constantinides, G.P., Zamorano, R.G., Armstrong, D.G., Athanasiou K.A. and Agrawal, C.M. (2004), Home monitoring of foot skin temperatures to prevent ulceration, Diabetes Care, Vol..27,

7 K. Gobin and K. Louison An Android Application for Detection and Self-monitoring of the Diabetic Foot Ulcer 10 No.11, pp Liu, C., van der Heijden, F., Klein, M.E., van Baal, J.G., Bus, S.A. and van Netten, J.J. (2013), Infrared Dermal Thermography on Diabetic Feet Soles to Predict Ulcerations: a Case Study, Advanced Biomedical and Clinical Diagnostic Systems XI. Vol.8572, pp.1-9 MIT (2015), MIT App Inventor, Massachusetts Institute of Technology, Accessed 21 October 2016, from: MOH (2011), World Diabetes Day, Ministry of Health Trinidad and Tobago, Accessed 21 October 2106, from: Nicholls, K. (2010), The diabetes epidemic in Trinidad and Tobago, Blood Glucose Monitoring, Accessed 21 October 2016, from: Roback, K. (2010), An overview of temperature monitoring devices for early detection of diabetic foot disorders, Expert Review of Medical Devices, Vol.7, No.5 pp Steketee, J. (1973), Spectral emissivity of skin and pericardium, Physics in Medicine and Biology, Vol.18, No.5, pp Tkáová, M., (2011), Thermographic atlas of the human body, Proceedings of the 15th International Conference on Intelligent Engineering Systems, Poprad Slovakia, June 23-25, pp van Netten, J.J., van Baal, J.G., Liu, C., van der Heijden, F. and Bus, S.A. (2013), Infrared thermal imaging for automated detection of diabetic foot complications, Journal of Diabetes Science and Technology, Vol.7, No.5, pp van Netten, J.J., Prijs, M., van Baal, J.G., Liu, C., van Der Heijden, F. and Bus, S.A. (2014), Diagnostic values for skin temperature assessment to detect diabetes-related foot complication, Diabetes Technology and Therapeutics, Vol.16, No.11, pp WHO (2015), Diabetes, World Health Organisation, Accessed 21 October 2016, from: Wild, S., Roglic, G., Green, A., Sicree, R. and King, H. (2004), Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030, Diabetes Care, Vol.27, No.5, pp Wounds International (2013), International Best Practice - Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers, Accessed 21 October 2016, from Wylie-Rosett, J., Walker, E.A., Shamoon, H., Engel, S., Basch, C. and Zybert, P. (1995), Assessment of documented foot examinations for patients with diabetes in inner-city primary care clinics, Archives of Family Medicine, Vol.4, No.1, pp Yazdanpanah, L., Nasiri, M. and Adarvishi, S. (2015), Literature review on the management of diabetic foot ulcer, World Journal of Diabetes, Vol.6, No.1, February, pp Authors Biographical Notes: Keri Gobin is undergraduate student in Biomedical Engineering at The University of Trinidad and Tobago. She is interested in improving the quality of health for diabetic patients. More specifically, her work examines the concept of the practical applications of Thermography. Karen Louison is Senior Instructor at the Biomedical Engineering Unit, University of Trinidad and Tobago, O Meara Campus. Her research interests include assistive technology and other applications of rehabilitation engineering.