“What should a clinician do in regards with thermometry and activity monitoring, when seeing a diabetic patient?”
All the literature out there, suggests that thermometry is useful in “Preventing” foot ulcers and the proven “Delta T” that is considered pre-ulcerous, is 4 Deg F or 2.2 Deg C. However, whether this value of “Delta T” is not validated for newly diagnosed diabetics or diabetics without any history of ulceration. It may stand to reason that, a different “Delta T” value may be true for this population, because thermal receptors are damaged much like mechanical receptors at the onset of neuropathy. Whether, this damage is instant or time driven, needs to be answered in an independent research study. There is some related evidence in this area, but we need to connect the dots through more studies.
To simplify things, it may be better to discuss temperature monitoring with patients based on their duration of diabetes and history of prior ulceration.
1) If there is a history of prior ulceration, there are hand held thermometers and proven “Delta T” that can be used to assess any pre-ulcerous symptoms through serial temperature logs. It must be emphasized that this “Delta T” as a one time measure may not be a cause of concern, however, if there is a clear pattern over 3-4 days of high Delta T, patient should immediately be seen by the physician.
2) On the contrary, if you are managing a newly diagnosed diabetic, with or without neuropathy, the same criterion for “Delta T” can be used at this stage with the additional serial monitoring of neurological damage over time (as the German study suggests).
Physicians must be cautioned when dealing with patients with significant PVD and those who undergo vascular procedures to restore blood supply to the extremities.
This patient group should only be advised above thermometry monitoring, once the perfusion levels are ascertained to be normal.
Regarding physical activity, what we have learned from several studies by Drs. Armstrong & Lavery is that it is not the ABSOLUTE ACTIVITY, rather the VARIABILITY IN ACTIVITY that is a cause of concern. As we do not have validated thresholds of activities currently, we have to advice patients to be consistent in their daily activities and in the event of significant variation at a particular day, be vigilant for the subsequent week. There is a study planned by the SALSA unit to develop and validate this threshold for activity prescription. The underlying vision is to develop a software tool, which potentially can be integrated with patient management tools/EMR’s to recommend physical activity and/or specific exercises depending on past history and patient profile.