Patent Description:
The present disclosure provides apparatus for assessment of a foot of a patient at risk for development of diabetic foot ulcers.

Diabetic foot ulcers are responsible for more hospitalizations than any other complication of diabetes. Nonenzymatic glycation induced by an elevated level of blood sugar causes ligaments to stiffen and increases cross-linking in collagen. These conditions can lead to damage to cellular walls and blood vessels that result in an initial increase the amount of extracellular fluid (ECF). Peripheral neuropathy causes loss of protective sensation and loss of coordination of muscle groups in the foot and leg. The neuropathy can cause an increase in the mechanical stresses within the foot during ambulation and standing that, combined with the weakened tissue induced by the diabetes, will progress to tissue death if the stress is not reduced. The neuropathy also reduces the patient's ability to perceive pain that is normally associated with the stress and tissue damage, thereby allowing the condition to progress.

Every year, approximately <NUM>% of diabetics develop a foot ulcer and <NUM>% will require amputation of a digit or some portion of the foot. Long term, <NUM>% of patients with diabetes will develop a foot ulcer and <NUM>-<NUM>% will require amputation. Diabetes is the leading cause of nontraumatic lower extremity amputations in the United States. <NUM>-<NUM>% of the overall cost of treating diabetes is related to the treatment and healing of foot ulcers after they occur.

The current approach to the prevention of diabetic foot ulcers is patient education, foot skin and toenail care, appropriate footwear selection, and proactive surgical intervention. A means of detecting a pre-ulcer condition would enable implementation of preventive techniques such as offloading and improved hygiene. <CIT> describes apparatuses and computer readable media for measuring sub-epidermal moisture in patients to determine damaged tissue for clinical intervention. <CIT> describes a pressure ulcer detection apparatus and a pressure ulcer determination method for detecting pressure ulcers. An apparatus which implements capacitance measurements for monitoring pressure ulcer developments is described in <NPL>).

The claimed subject matter relates to an apparatus for assessing susceptibility of a patient's foot tissue to forming a diabetic foot ulcer as defined in claim <NUM>. Preferred embodiments of the claimed subject matter are defined in the dependent claims.

Aspects of the disclosure are herein described, by way of example only, with reference to the accompanying drawings. With specific reference now to the drawings in detail, it is stressed that the particulars shown are by way of example and are for purposes of illustrative discussion of aspects of the disclosure. In this regard, the description and the drawings, considered alone and together, make apparent to those skilled in the art how aspects of the disclosure may be practiced.

The present disclosure describes measurement of various electrical characteristics and derivation of SEM values indicative of an increase in the amount of ECF and the application of this information to the assessment of susceptibility to diabetic foot ulcers as well as treatment of ulcers.

Diabetic foot ulcers are known to occur in areas subject to repetitive moderate loads, particularly in areas where bony portions of the foot apply transfer body weight to the adjacent tissue while standing. Damage may initially occur in tissue below the skin and is, therefore, not detectable by visual inspection. The initial damage will release fluid into the extracellular spaces, which can be detected through the measurement of electrical properties of the sub-epidermal tissue, for example the capacitance of the tissue. Monitoring the ECF in at-risk areas will detect deterioration of the tissue that, if left unchecked, will progress to an open ulcer.

This description is not intended to be a detailed catalog of all the different ways in which the disclosure may be implemented, or all the features that may be added to the instant disclosure. For example, features illustrated with respect to one embodiment may be incorporated into other embodiments, and features illustrated with respect to a particular embodiment may be deleted from that embodiment. Thus, the disclosure contemplates that in some embodiments of the disclosure, any feature or combination of features set forth herein can be excluded or omitted. In addition, numerous variations and additions to the various embodiments suggested herein will be apparent to those skilled in the art in light of the instant disclosure, which do not depart from the instant disclosure. In other instances, well-known structures, interfaces, and processes have not been shown in detail in order not to unnecessarily obscure the disclosure. It is intended that no part of this specification be construed to effect a disavowal of any part of the full scope of the disclosure. Hence, the following descriptions are intended to illustrate some particular embodiments of the disclosure, and not to exhaustively specify all permutations, combinations and variations thereof.

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this disclosure belongs. The terminology used in the description of the disclosure herein is for the purpose of describing particular aspects or embodiments only and is not intended to be limiting of the disclosure.

All publications, patent applications, patents and other references cited herein are mentioned for the teachings relevant to the sentence and/or paragraph in which the reference is presented. References to techniques employed herein are intended to refer to the techniques as commonly understood in the art, including variations on those techniques or substitutions of equivalent techniques that would be apparent to one of skill in the art.

<CIT> discloses an apparatus that uses radio frequency (RF) energy to measure the sub-epidermal capacitance using a bipolar sensor similar to the sensor <NUM> shown in <FIG>, where the sub-epidermal capacitance corresponds to the moisture content of the target region of skin of a patient. The '<NUM> application also discloses an array of these bipolar sensors of various sizes.

<CIT> discloses an apparatus for measuring sub-epidermal moisture (SEM) similar to the device shown in <FIG>, where the device emits and receives an RF signal at a frequency of <NUM> through a single coaxial sensor and generates a bioimpedance signal, then converts this signal to a SEM value.

Unless the context indicates otherwise, it is specifically intended that the various features of the disclosure described herein can be used in any combination. Moreover, the present disclosure also contemplates that in some embodiments of the disclosure, any feature or combination of features set forth herein can be excluded or omitted.

The methods disclosed herein (and which do not fall within the scope of the claims) include and comprise one or more steps or actions for achieving the described method. The method steps and/or actions may be interchanged with one another without departing from the scope of the present invention. In other words, unless a specific order of steps or actions is required for proper operation of the embodiment, the order and/or use of specific steps and/or actions may be modified without departing from the scope of the present invention.

As used in the description of the disclosure and the appended claims, the singular forms "a," "an" and "the" are intended to include the plural forms as well, unless the context clearly indicates otherwise.

As used herein, "and/or" refers to and encompasses any and all possible combinations of one or more of the associated listed items, as well as the lack of combinations when interpreted in the alternative ("or").

The terms "about" and "approximately" as used herein when referring to a measurable value such as a length, a frequency, or a SEM value and the like, is meant to encompass variations of ± <NUM>%, ± <NUM>%, ± <NUM>%, ± <NUM>%, ± <NUM>%, or even ± <NUM>% of the specified amount.

As used herein, phrases such as "between X and Y" and "between about X and Y" should be interpreted to include X and Y. As used herein, phrases such as "between about X and Y" mean "between about X and about Y" and phrases such as "from about X to Y" mean "from about X to about Y.

As used herein, the term "sub-epidermal moisture" or "SEM" refers to the increase in tissue fluid and local edema caused by vascular leakiness and other changes that modify the underlying structure of the damaged tissue in the presence of continued pressure on tissue, apoptosis, necrosis, and the inflammatory process.

As used herein, a "system" may be a collection of devices in wired or wireless communication with each other.

As used herein, "interrogate" refers to the use of radiofrequency energy to penetrate into a patient's skin.

As used herein, a "patient" may be a human or animal subject.

As used herein, "healthy" may describes tissue that does not exhibit symptoms of damage to cellular walls or blood vessels, where the presence of an increased amount of ECF is an indication of such damage.

As used herein, "extracellular fluid" or "ECF" refers to bodily fluid contained outside of cells, including plasma, interstitial fluid, and transcellular fluid.

As used herein, "susceptible to formation of a diabetic foot ulcer" may describe tissue that exhibit symptoms of damage to cellular walls or blood vessels, such as edema or an increased amount of ECF, yet no open ulcer is present.

As used herein, "time_0" refers to an initial time point, for example, when an open ulcer is first detected.

As used herein, "time_1" refers to a time point later than time_0.

As used herein, "time_2" refers to a time point later than time_1.

<FIG> is a side view of a portion of the anatomy of a foot <NUM>. The areas of the foot that are most likely to develop a diabetic foot ulcer are the heel, located below the calcaneus bone <NUM>, and the pad of the foot, located under the metatarsal bone <NUM>.

<FIG> is an enlarged view of the area "A" of <FIG>. The ends of the metatarsal bone <NUM> and the adjoining phalange bone <NUM> are shown in proximity to the skin <NUM> of the sole of the foot <NUM>. A portion of the body weight of the patient creates a compressive force <NUM> applied by the metatarsal bone <NUM> to the tissue in region <NUM>. Force <NUM> is opposed by resistive force <NUM> applied by the floor to the skin <NUM> under region <NUM> to support the patient. Muscular activity by the patient, for example walking or simply balancing on their feet while standing, creates shear force <NUM> between the metatarsal bone <NUM> and tissue <NUM> as well as the resisting shear force <NUM> between the floor and the skin <NUM>. Thus, the tissue in region <NUM> is simultaneously subject to both compression and shear forces.

It has been observed that a healthy patient will shift their weight from foot to foot as well as shift their center of mass relative to their feet while standing stationary. This limits the duration of time during which forces are applied to any particular region of tissue. Peripheral neuropathy, however, reduces the sensation in the tissue that is created by the patient's weight and, therefore, reduces the unconscious shifting of their weight and patients suffering from peripheral neuropathy are observed to lack the normal motion while standing. This leads to extended period of time of continuous compressive force being applied to local areas of tissue, such as region <NUM>. This extended exposure to moderate levels of force is thought to contribute to the formation of ulcers in these areas.

<FIG>, <FIG> depict the conditions and progression of an open ulcer. <FIG> depicts an initial open ulcer 50A at time_0. The ulcer 50A is surrounded by a ring of increased pressure 52A.

<FIG> shows the pressure profile created in the condition of <FIG>. The force applied by the floor, or by a shoe worn by the patient, is applied as a locally uniform pressure <NUM> to the skin <NUM> of the foot <NUM>. The applied pressure <NUM> is opposed internally by forces <NUM>. No pressure can be applied over the ulcer <NUM>, as the tissue has sloughed away. Thus, the internal forces in the toroidal region 52A increase to a peak <NUM> to pick up the force that would have been applied to the ulcer <NUM>. This peak force <NUM> is high enough to cause further tissue damage in the ring 52A. A callus will commonly form over the region 52A as the body attempts to protect itself from the increased pressure. The tissue below the callus, however, is still being damaged and will exhibit an increase in ECF.

<FIG> depicts the same region of tissue at time_1 that is subsequent to time_0. The increased level of pressure in region 52A led to tissue death in region 52A and the tissue in region <NUM> has sloughed away so that the ulcer 50B is larger than the prior ulcer 50A. The applied pressure <NUM> has not changed, however, so now the tissue in the region 52B around the larger ulcer 50B must pick up even more force. This accelerates the expansion of the ulcer <NUM> as the tissue in are region 52B dies quicker under the higher applied load.

<FIG> depicts the same region of tissue as <FIG> and <FIG>, now at time_2 that is subsequent to time_1. The ulcer <NUM> has grown to size 50C and the region 52C of increased pressure is large than the prior regions 52A, 52B.

In the situation shown in <FIG>, where an ulcer has formed, interventional therapies will be introduced to prevent the growth of the ulcer <NUM> and allow the body to heal the open ulcer <NUM>. Therapies may involve placing pressure-relieving pads around the ulcer to spread the pressure <NUM> over a larger region of healthy tissue and eliminate the peak <NUM> that leads to further damage. Determining whether the therapy is working, however, is only possible by observation over time that the ulcer is not progressing.

<FIG> discloses a toroidal bioimpedance sensor <NUM>. In this exemplary configuration, a center electrode <NUM> is surrounded by a ring electrode <NUM>. Without being limited to a particular theory, the gap between the two electrodes affects the depth of field penetration into the substrate below sensor <NUM>. In one aspect, a ground plane (not visible in <FIG>), is parallel to and separate from the plane of the electrodes and, in an aspect, extends beyond the outer diameter of ring electrode <NUM>. Without being limited to a particular theory, a ground plane may limit the field between electrodes <NUM> and <NUM> to a single side of the plane of electrodes <NUM> and <NUM> that is on the opposite side of the plane of electrodes <NUM> and <NUM> from the ground plane.

<FIG> discloses an idealized field map created by a toroidal sensor of <FIG> when activated by a drive circuit (not shown in <FIG>). When an electric voltage is applied across electrodes <NUM> and <NUM>, an electric field <NUM> is generated between electrodes <NUM> and <NUM> that extends outward from the plane of electrodes <NUM> and <NUM> to a depth of field <NUM>. The diameter of center electrode <NUM>, the inner and outer diameters of ring electrode <NUM>, and the gap between electrodes <NUM> and <NUM> may be varied to change characteristics of the field <NUM>, for example the depth of field <NUM>.

In use, a drive circuit can measure an electrical property or parameter that comprises one or more electrical characteristics selected from the group consisting of a resistance, a capacitance, an inductance, an impedance, a reluctance, and other electrical characteristics as sensed by electric field <NUM>. Depending on the type of drive circuit being employed in an apparatus, a sensor of an apparatus may be a bipolar radiofrequency sensor, a bioimpedance sensor, a capacitive sensor, or an SEM sensor. In an aspect, a measured electrical parameter is related to the moisture content of the epidermis of a patient at a depth that is determined by the geometry of electrodes <NUM> and <NUM>, the frequency and strength of electrical field <NUM>, and other operating characteristics of the apparatus drive circuit. In one aspect, a measured moisture content is equivalent to the SEM content with a value on a predetermined scale. In an aspect, a predetermined scale may range from <NUM> to <NUM>, such as from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>, from <NUM> to <NUM>. In one aspect, a predetermined scaled can be scaled by a factor or a multiple based on the values provided herein. In an aspect, multiple measurements are taken while varying one or more of these operating characteristics between readings, thereby providing information related to the moisture content at various depths of the skin.

One or more regions may be defined on a body. In an aspect, measurements made within a region are considered comparable to each other. A region may be defined as an area on the skin of the body wherein measurements may be taken at any point within the area. In an aspect, a region corresponds to an anatomical region (e.g., heel, ankle, lower back). In an aspect, a region may be defined as a set of two or more specific points relative to anatomical features wherein measurements are taken only at the specific points. In an aspect, a region may comprise a plurality of non-contiguous areas on the body. In an aspect, the set of specific locations may include points in multiple non-contiguous areas.

In an aspect, a region is defined by surface area. In an aspect, a region may be, for example, between <NUM> and <NUM><NUM>, between <NUM> and <NUM><NUM>, between <NUM> and <NUM><NUM>, or between <NUM> and <NUM><NUM>, between <NUM> and <NUM><NUM>, or between <NUM> and <NUM><NUM>.

In an aspect, measurements may be made in a specific pattern or portion thereof. In an aspect, the pattern of readings is made in a pattern with the target area of concern in the center. In an aspect, measurements are made in one or more circular patterns of increasing or decreasing size, T-shaped patterns, a set of specific locations, or randomly across a tissue or region. In an aspect, a pattern may be located on the body by defining a first measurement location of the pattern with respect to an anatomical feature with the remaining measurement locations of the pattern defined as offsets from the first measurement position.

In an aspect, a plurality of measurements are taken across a tissue or region and the difference between the lowest measurement value and the highest measurement value of the plurality of measurements is recorded as a delta value of that plurality of measurements. In an aspect, <NUM> or more, <NUM> or more, <NUM> or more, <NUM> or more, <NUM> or more, <NUM> or more, <NUM> or more, or <NUM> or more measurements are taken across a tissue or region.

In an aspect, a threshold may be established for at least one region. In an aspect, a threshold of <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, or other value may be established for the at least one region. In an aspect, a delta value is identified as significant when the delta value of a plurality of measurements taken within a region meets or exceeds a threshold associated with that region. In an aspect, each of a plurality of regions has a different threshold. In an aspect, two or more regions may have a common threshold.

In an aspect, a threshold has both a delta value component and a chronological component, wherein a delta value is identified as significant when the delta value is greater than a predetermined numerical value for a predetermined portion of a time interval. In an aspect, the predetermined portion of a time interval is defined as a minimum of X days wherein a plurality of measurements taken that day produces a delta value greater than or equal to the predetermined numerical value within a total of Y contiguous days of measurement. In an aspect, the predetermined portion of a time interval may be defined as <NUM>, <NUM>, <NUM>, <NUM>, or <NUM> consecutive days on which a plurality of measurements taken that day produces a delta value that is greater than or equal to the predetermined numerical value. In an aspect, the predetermined portion of a time interval may be defined as some portion of a different specific time period (weeks, month, hours etc.).

In an aspect, a threshold has a trending aspect wherein changes in the delta values of consecutive pluralities of measurements are compared to each other. In an aspect, a trending threshold is defined as a predetermined change in delta value over a predetermined length of time, wherein a determination that the threshold has been met or exceeded is significant. In an aspect, a determination of significance will cause an alert to be issued. In an aspect, a trend line may be computed from a portion of the individual measurements of the consecutive pluralities of measurements. In an aspect, a trend line may be computed from a portion of the delta values of the consecutive pluralities of measurements.

In an aspect, the number of measurements taken within a single region may be less than the number of measurement locations defined in a pattern. In an aspect, a delta value will be calculated after a predetermined initial number of readings, which is less than the number of measurement locations defined in a pattern, have been taken in a region and after each additional reading in the same region, wherein additional readings are not taken once the delta value meets or exceeds the threshold associated with that region.

In an aspect, the number of measurements taken within a single region may exceed the number of measurement locations defined in a pattern. In an aspect, a delta value will be calculated after each additional reading.

In an aspect, a quality metric may be generated for each plurality of measurements. In an aspect, this quality metric is chosen to assess the repeatability of the measurements. In an aspect, this quality metric is chosen to assess the skill of the clinician that took the measurements. In an aspect, the quality metric may include one or more statistical parameters, for example an average, a mean, or a standard deviation. In an aspect, the quality metric may include one or more of a comparison of individual measurements to a predefined range. In an aspect, the quality metric may include comparison of the individual measurements to a pattern of values, for example comparison of the measurement values at predefined locations to ranges associated with each predefined location. In an aspect, the quality metric may include determination of which measurements are made over healthy tissue and one or more evaluations of consistency within this subset of "healthy" measurements, for example a range, a standard deviation, or other parameter.

In one aspect, a measurement, for example, a threshold value, is determined by SEM Scanner Model <NUM> (Bruin Biometrics, LLC, Los Angeles, CA). In another aspect, a measurement is determined by another SEM scanner.

In an aspect, a measurement value is based on a capacitance measurement by reference to a reference device. In an aspect, a capacitance measurement can depend on the location and other aspects of any electrode in a device. Such variations can be compared to a reference SEM device such as an SEM Scanner Model <NUM> (Bruin Biometrics, LLC, Los Angeles, CA). A person of ordinary skill in the art understands that the measurements set forth herein can be adjusted to accommodate a difference capacitance range by reference to a reference device.

<FIG> provides top and bottom views of a SEM scanner <NUM> that contains electronics that drive sensor <NUM>, which is similar to sensor <NUM> of <FIG>, and measure a capacitance between electrodes <NUM> and <NUM>. This capacitance may be converted to a SEM value that is displayed on display <NUM>.

Aspects of sensor <NUM> and SEM scanner <NUM> are disclosed in <CIT>, from which the <CIT> was filed as a national phase entry.

<FIG> depicts an exemplary electrode array <NUM>, according to the present disclosure. Array <NUM> is composed of individual electrodes <NUM> disposed, in this example, in a regular pattern over a substrate <NUM>. In an aspect, each electrode <NUM> is separately coupled (through conductive elements not shown in <FIG>) to a circuit (not shown in <FIG>) that is configured to measure an electrical parameter. In one aspect, a "virtual sensor" is created by selective connection of predetermined subsets of electrodes <NUM> to a common element of a circuit. In this example, a particular electrode <NUM> is connected as a center electrode, similar to electrode <NUM> of <FIG>, and six electrodes 320A-320F are connected together as a "virtual ring" electrode, similar to electrode <NUM> of <FIG>. In an aspect, two individual electrodes are individually connected to the circuit to form a virtual sensor, for example electrodes <NUM> and 320A are respectively connected as the two electrodes of a sensor. In one aspect, one or more electrodes <NUM> are connected together to form one or the other of the electrodes of a two-electrode sensor.

Any pair of electrodes, whether composed of single electrodes or a set of electrodes coupled together to form virtual electrodes, is coupled to electronics (not shown in <FIG>) that are configured to measures an electrical property or parameter that comprises one or more of a resistance, a capacitance, an inductance, an impedance, a reluctance, or other electrical characteristic with one or more of sensors <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, or other two-electrode sensor. Electronics of the present disclosure may be further configured to compare the measured first capacitance to a reference value and providing a signal if the measured capacitance differs from the reference value by an amount greater than a threshold. In an aspect, one or both of the reference value and the threshold are predetermined.

<FIG> depicts another exemplary array <NUM> of electrodes <NUM>, according to the present disclosure. In this non-limiting example, each of the electrodes <NUM> is an approximate hexagon that is separated from each of the surrounding electrodes <NUM> by a gap <NUM>. In one aspect, electrodes <NUM> are one of circles, squares, pentagons, or other regular or irregular shapes. In an aspect, gap <NUM> is uniform between all electrodes <NUM>. In one aspect, gap <NUM> varies between various electrodes. In one aspect, gap <NUM> has a width that is narrower than the cross-section of each of the electrodes <NUM>. Electrodes <NUM> may be interconnected to form virtual sensors as described below with respect to <FIG> and 10A-10C.

<FIG> depicts an array <NUM> of electrodes <NUM> that are configured, e.g. connected to a measurement circuit, to form an exemplary sensor <NUM>, according to the present disclosure. A single hexagonal electrode <NUM> that is labeled with a "<NUM>" forms a center electrode and a ring of electrodes <NUM> that are marked with a "<NUM>" are interconnected to form a ring electrode. In an aspect, electrodes <NUM> between the center and ring electrode are electrically "floating. " In one aspect, electrodes <NUM> between the center and ring electrode are grounded or connected to a floating ground. In an aspect, electrodes <NUM> that are outside the ring electrode are electrically "floating. " In one aspect, electrodes <NUM> that are outside a virtual ring electrode are grounded or connected to a floating ground.

<FIG> depicts an alternate aspect where an array <NUM> of electrodes <NUM> has been configured to form a virtual sensor <NUM>, according to the present disclosure. In an aspect, multiple electrodes <NUM>, indicated by a "<NUM>," are interconnected to form a center electrode while a double-wide ring of electrodes, indicated by a "<NUM>," are interconnected to form a ring electrode. In one aspect, various numbers and positions of electrodes <NUM> are interconnected to form virtual electrodes of a variety of sizes and shapes.

<FIG> depict an exemplary configuration of an electrode array <NUM> that is capable of forming sensors <NUM> in multiple overlapping locations, according to the present disclosure. In <FIG>, a virtual sensor 430A has been formed with center electrode <NUM> formed by a single electrode <NUM>, indicated by a "<NUM>," and a ring electrode <NUM> formed by a plurality of electrodes <NUM>, indicated by a "<NUM>. " This same array <NUM> is shown in <FIG>, where a new virtual sensor 430B has been formed with a center electrode <NUM>, indicated by a "<NUM>," and ring electrode <NUM>, indicated by a "<NUM>. " The position of virtual sensor 430A is shown by the dark outline. It can be seen that virtual sensor 430B overlaps the position of virtual sensor 430A, this allowing measurements to be made at a finer resolution than the diameter of sensors <NUM>.

<FIG> shows how sensors <NUM> may be formed from an array of electrodes <NUM> that is larger than the portion of a patient's skin that is being positioned against the array, according to the present disclosure. In this example, the outline of contact area <NUM> of sole 22R of a right foot of a patient, as seen from underneath the foot, is shown overlaid on array <NUM>. In this example, sensor 430C has been formed in a location where a portion of sensor 430C extends beyond the edge of contact area <NUM>. In such a position, the capacitance or other electrical parameter measured by sensor 430C is lower than the capacitance measured by sensor 430D, which is positioned completely within contact area <NUM>. It can be seen that a sensor <NUM> may be formed at any point within array <NUM> and, depending on the position of sensor <NUM>, may partially overlap the contact area at any level within the range of <NUM>-<NUM>%.

In an aspect, two sensors may overlap <NUM>-<NUM>%, such as <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>%-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, or <NUM>-<NUM>%. In one aspect, two sensors may overlap <NUM>-<NUM>%, such as <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>%-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, or <NUM>-<NUM>%. In one aspect, two sensors may overlap <NUM>-<NUM>%, such as <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>%-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, <NUM>-<NUM>%, or <NUM>-<NUM>%.

In one aspect, an array of sensors <NUM> may further comprise a plurality of contact sensors (not shown on <FIG>) on the same planar surface as, and surrounding, each of the electrodes to ensure complete contact of the one or more virtual sensors to the skin surface. The plurality of contact sensors may be a plurality of pressure sensors, a plurality of light sensors, a plurality of temperature sensors, a plurality of pH sensors, a plurality of perspiration sensors, a plurality of ultrasonic sensors, a plurality of bone growth stimulator sensors, or a plurality of a combination of these sensors. In some embodiments, the plurality of contact sensors may comprise four, five, six, seven, eight, nine, or ten or more contact sensors surrounding each electrode.

<FIG> depict an example of how comparison of SEM values associated with sensors in known relative locations can identify bisymmetric locations, according to the present disclosure. In this example, sensors <NUM> are formed at non-overlapping locations, marked "A" to "H" in <FIG>, across a contact area 450R of a right foot 20R. The SEM values measured at each location are plotted in the graph of <FIG>. In this example, the SEM value of locations "A" and "H" are low or zero, reflecting the non-overlap of sensor <NUM> with contact area <NUM> in those locations. The SEM values associated with locations "B" and "G" are higher, as sensor <NUM> overlaps a portion of contact area <NUM> in those positions. The SEM values for locations C-D-E-F are higher and, in this example, approximately the same, indicating that sensor <NUM> was completely within contact area <NUM> at those locations. In an aspect, an SEM measurement apparatus such as apparatus <NUM> may determine that certain locations, for example locations "C" and "F," are bisymmetric with respect to a centerline 452R of right foot 20R. In one aspect, where a similar set of measurements is made at locations A'-H' on a left foot <NUM>, a location on each foot <NUM> and 20R, for example locations E and E', may be determined to be approximately bisymmetric.

<FIG> depicts an exemplary mat assembly <NUM> that incorporates a plurality of bioimpedance sensors <NUM>, according to the present disclosure not covered by the claims. Although sensors <NUM> are shown as toroidal sensors similar to sensors <NUM> depicted in <FIG>, sensors <NUM> may be any configuration of electrical measurement sensor, including the configurations shown in <FIG>, and <FIG>. Sensors <NUM> are distributed across substrate <NUM>. In an aspect, a portion of substrate <NUM> is flexible. In one aspect, a portion of substrate <NUM> is rigid. In an aspect, electrodes of sensor <NUM> are electrically bare, thereby allowing conductive electrical contact with a patient's foot when a patient stands on mat assembly <NUM>. In one aspect, electrodes of sensor <NUM> are electrically insulated, for example by an insulating cover layer (not shown in <FIG>), thereby allowing only capacitive electrical contact with a patient's foot when a patient stands on mat assembly <NUM>.

In an aspect, mat assembly <NUM> comprises one of more temperature sensors (not shown in <FIG>), that detect the temperature of one or more locations on a foot. In one aspect, a temperature sensor is co-located with SEM sensor <NUM> so as to provide temperature and SEM measurements of a common location.

In one aspect of mat assembly <NUM>, a signal is provided when the measured capacitance differs from a reference capacitance value by an amount greater than a first threshold and the measured temperature differs from a temperature reference value by an amount greater than a second threshold. In an aspect, one or both of the thresholds are predetermined. In one aspect, a first threshold is set at the corresponding reference capacitance value plus at least <NUM>%, such as at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, or at least <NUM>%. In one aspect, a second threshold is set at the corresponding reference temperature value plus at least <NUM>%, such as at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, or at least <NUM>%. In one aspect, one or both of the capacitance and temperature reference values are determined from prior measurements, for example a rolling average of the past <NUM> sequential measurements or by an average of multiple measurements made in an earlier time period, e.g. a month earlier.

In one aspect, one or both of the capacitance and temperature reference values are determined from measurements made when the tissue was in a known healthy state, for example while in a doctor's office when a clinician has made an examination of the tissue and determined that the tissue is healthy, i.e. not susceptible to the formation of a diabetic foot ulcer.

<FIG> depicts another exemplary mat assembly <NUM> not covered by the claims that comprises arrays <NUM> and 530R of electrical sensors <NUM>, where arrays <NUM> and 530R are disposed so as to underlie the left and right feet, respectively, of a patient while standing on mat assembly <NUM>. In an aspect, outlines <NUM> and 540R of the left and right feet are drawn over arrays <NUM> and 530R so as to guide the patient to stand in the proper location.

<FIG> depicts an aspect of a mat assembly <NUM> not covered by the claims that has one or more sensors <NUM> disposed within each of the outlines <NUM> and 540R. In an aspect, a sensors 520A is located in a position corresponding to portions of the foot that are most likely to develop an ulcer, for example the ball of a foot. In one aspect, sensors 520B may be located under the heel or other locations of a foot.

In one aspect, substrate <NUM> is partially transparent and mat <NUM> comprises a second substrate <NUM> on which are mounted one or more optical sensors <NUM>. In an aspect, optical sensor <NUM> is a camera capable of imaging the underside of a foot of a patient standing on mat <NUM>. In one aspect, optical sensor <NUM> is sensitive to visible light. In an aspect, optical sensor <NUM> is sensitive to infrared light.

The use of mat assemblies <NUM>, <NUM>, <NUM> and the like on a regular basis by patients can serve to detect changes in the health of their feet. For example, a baseline will be established by measurement of electrical characteristics, such as capacitance, of each foot at the time of examination by a clinician who verifies that there is no ulcer or indication of damage that would lead to formation of an ulcer in a patient. The patient then places the mat <NUM>, <NUM>, <NUM> in a readily accessible location in their home, for example in front of the bathroom sink. On a regular basis, such as daily while brushing their teeth, the patient triggers a measurement of their feet by the sensors <NUM>. If the patient is standing on the same location, for example being guided by outlines <NUM> and 540R, then each sensor <NUM> and <NUM> is measuring the same position for each repeated measurement. In an aspect, a temperature measurement is made by an infrared sensor <NUM> or one of more temperature sensors (not shown in <FIG>) in mat assembly <NUM>, <NUM>, <NUM>. In one aspect, an image is captured by an optical sensor <NUM> in mat assembly <NUM>. This information is stored in a local memory or transmitted to a remote storage location, such as the doctor's office. Each daily measurement is compared to reference derived from previous measurements, for example a measurement made in a clinician's office or an average of last week's measurements. If the most recent measurement deviates from the reference, the patient is informed of the deviation. The patient can then consult a clinician for further evaluation and possible intervention. In an aspect, a change in the measured SEM value larger than the threshold triggers a notification. In one aspect, a change in the measured SEM value larger than a first threshold and a change in the measured temperature larger than a second threshold together trigger a notification. In an aspect, either a change in the measured SEM value larger than a first threshold or a change in the measured temperature larger than a second threshold triggers a notification. In one aspect, a first threshold is set at the corresponding reference SEM value plus at least <NUM>%, such as at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, or at least <NUM>%. In one aspect, a second threshold is set at the corresponding reference temperature value plus at least <NUM>%, such as at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, at least <NUM>%, or at least <NUM>%. In an aspect, information such as an image of the underside of a patient's foot is always sent to a clinician for review.

In an aspect, measurements of the left and right foot are compared to each other. For example, with reference to <FIG>, locations E and E' are compared to each other. In one aspect, a difference between the left and right measurements is compared to a reference and the patient notified if the difference exceeds a threshold.

<FIG> discloses a foot cover <NUM> that incorporates bioimpedance sensors <NUM> as shown in the cut-away view of <FIG>, according to the claimed subject matter. In an aspect, foot cover <NUM> comprises a sock or other flexible, conforming garment <NUM> into which a foot can be inserted. In one aspect, a flexible, conforming garment <NUM> may be a flexible shoe, similar to a "water shoe," made from a flexible, elastic material such as rubber. In an aspect, a flexible, conforming garment <NUM> may be a conventional shoe, for example a leather dress shoe or a sneaker. Sensors <NUM> are located in one or more locations that correspond to areas of concern for development of ulcers. According to the claimed subject matter, sensors <NUM> are located under or around the heel of a flexible, conforming garment <NUM>. In an aspect, sensors <NUM> are located on the sole of a flexible, conforming garment <NUM>. In one aspect, sensors <NUM> are located in the area around the toes (not visible in <FIG>) of a flexible, conforming garment <NUM>.

<FIG> discloses a sandal <NUM> that incorporates bioimpedance sensors <NUM>, according to the present disclosure. One or more sensors <NUM> are disposed on a sandal in locations that correspond to areas of potential ulcer development.

<FIG> depict configurations of addressable electrodes of <FIG> that vary the performance capabilities of a sensor, according to the present disclosure. <FIG> depicts an exemplary first configuration <NUM>, where electrodes <NUM> are connected so as to form a center electrode <NUM> and a ring electrode <NUM>, similar to electrodes of <FIG>. Sensor configuration <NUM> has a gap <NUM> of a single row of electrodes <NUM>, which results in a first field depth <NUM>, with reference to <FIG>.

<FIG> depicts a second exemplary configuration <NUM> of the same array of sensors <NUM>, where one electrode is connected to form a center electrode <NUM> while a plurality of electrodes <NUM> are connected to form a ring electrode <NUM> that is larger in diameter than ring electrode <NUM> and having a gap <NUM> that is larger than gap <NUM>. Sensor configuration <NUM> will have a second field depth <NUM> that is larger than that of sensor configuration <NUM>.

<FIG> depicts a third exemplary configuration <NUM> of the same array of sensors <NUM>, where one electrode is connected to form a center electrode <NUM> while a plurality of electrodes <NUM> are connected to form a ring electrode <NUM> that is larger in diameter than ring electrodes <NUM> and <NUM> and having a gap <NUM> that is larger than gaps <NUM> and <NUM>. Sensor configuration <NUM> will have a third field depth <NUM> that is larger than either of sensor configurations <NUM> or <NUM>.

In an aspect, a mat assembly <NUM> comprises an array of electrodes <NUM> distributed across a portion of substrate <NUM>. At a location of an array that corresponds to an area of concern on a patient's foot, mat assembly <NUM> is configured to form a sensor configuration <NUM> and make a first measurement, then reconfigure electrodes <NUM> to form a sensor configuration <NUM> and make a second measurement. The first and second measurements provide information about the difference in ECF at different depths below the skin of a foot, thereby providing improved knowledge of the tissue condition within the foot. In one aspect, mat assembly <NUM> is configured to then form a sensor configuration <NUM> and take a third measurement. Comparison of the three measurements provides even greater resolution of the internal tissue condition.

<FIG> depict an exemplary aspect of a sensor assembly <NUM> configured to be placed in a known position on a patient's skin, according to the present disclosure. In this example, sensor assembly <NUM> has a shaped substrate <NUM> that is configured to conform to posterior and bottom surfaces of the heel of a foot <NUM>. In one aspect, shaped substrate <NUM> is suitable for use with both a left foot <NUM> and a right foot 20R. Sensor assembly <NUM> comprises one or more sensors <NUM> disposed on the inner surface of shaped substrate <NUM>. In this example, sensors <NUM> are configured as toroidal sensors as shown in <FIG>. In an aspect, the inner surface of shaped substrate <NUM> is lined with an array <NUM> of electrodes <NUM>, with reference to <FIG>, such that virtual sensors may be formed at any location. In one aspect, sensors of other shapes and configurations are provided on the inner surface of shaped substrate <NUM>. In an aspect, shaped substrate <NUM> is a flexible panel (not shown in <FIG>) that can be conformed to a patient's skin, for example wrapped around the back of an ankle. In one aspect, sensor assembly <NUM> comprises a cable <NUM> to connect sensors <NUM> to one or more of a power source, a circuit configured to measure one or more of capacitance or other electrical property, a processor, a communication subsystem, or other type of electronic assembly (not shown in <FIG>).

<FIG> depicts an exemplary configuration of sensor assembly <NUM> where multiple sensors <NUM> disposed on shaped substrate <NUM> such that, for example when sensor assembly <NUM> is placed against the skin of a patient around the back, sides, and bottom of the right heel center. This enables multiple SEM measurements to be taken in repeatable location on the heel with sensor assembly <NUM> in a single position. In one aspect (not shown in <FIG>), sensor assembly <NUM> is configured to be placed on a portion of the back of a patient thus providing the capability to make measurements at bisymmetric locations on the back. In an aspect, shaped substrate <NUM> is configured to match anatomical features of the target area of a patient. In one aspect, shaped substrate <NUM> comprises markings or other indicators that can be aligned with features of a patient's body, so as to enable measurements to be taken at the same location at time intervals over a period of time in the general range of hours to weeks. In one aspect, sensor assembly <NUM> is integrated into a lining of a garment or shoe or other article of clothing. In an aspect, sensor assembly <NUM> is integrated into a sheet, blanket, liner, or other type of bed clothing. In one aspect, sensor assembly <NUM> comprises a wireless communication capability, for example a passive radio frequency identification (RFID) or an inductive coupling, to allow actuation of sensors <NUM> without physically connecting to sensor assembly <NUM>.

In an aspect, sensors <NUM> are coupled to electronics (not shown in <FIG>) that are configured to compare a current set of measurements to each other and to past measurements made in the same location. In an aspect, electronics of the present disclosure may provide a signal if one or more of certain conditions are met. Such conditions may include, but are not limited to, a change in the difference between measurements made at two locations when compared to the difference in measurements made at the same two locations at a previous time, and a change in the measured value at a particular location from prior measurements at the same location that is greater than a threshold amount.

<FIG> depicts a schematic depiction of an integrated system <NUM> for measurement, evaluation, storage, and transfer of SEM values, according to the present disclosure. In this example, system <NUM> comprises a SEM measurement apparatus <NUM>, for example a SEM scanner <NUM>, that comprises the capability to wirelessly communicate with a WiFi access point <NUM>. Apparatus <NUM> communicates with one or more of a SEM application running on a server <NUM>, an application running on a laptop computer <NUM>, a "smart phone" <NUM>, or other digital device. In an aspect, laptop computer <NUM> and smart phone <NUM> are carried by the user of apparatus <NUM>, for example a nurse, and the application provides feedback and information to the user. In an aspect, information received from apparatus <NUM> for a patient is stored in a database <NUM>. In one aspect, information received from apparatus <NUM> for a patient is stored in a database <NUM>. In an aspect, information received from apparatus <NUM> is transferred over a network <NUM> to another server <NUM> that stores a portion of the information in an electronic medical record (EMR) <NUM> of the patient. In one aspect, information from apparatus <NUM> or retrieved from database <NUM> or EMR <NUM> is transferred to an external server <NUM> and then to a computer <NUM>, for example a computer at the office of a doctor who is proving care for the patient.

In an aspect, apparatus <NUM> is one of a mat assembly <NUM>, a foot cover <NUM>, or other measurement device and one or both of smart phone <NUM> and laptop <NUM> are used by the patient to receive information and notifications related to measurements made by mat assembly <NUM>.

<FIG> depicts a sensing band <NUM>, according to the present disclosure. In one aspect, a SEM sensor as described herein, for example sensor <NUM> or sensor <NUM>, is embedded in a band <NUM> that can be wrapped around a calf <NUM> as shown in <FIG>. In an aspect, band <NUM> comprises sensors configured to measure one or more of oxygenation of the tissue, which may comprise measurement of one or both of oxyhemoglobin and deoxyhemoglobin, temperature of one or more points on the skin, pulse rate, blood volume and blood pressure. In one aspect, the combination of measurements made by band <NUM> provides information regarding the flow of blood to the foot, where reduced blood flow is a possible indication of susceptibility to formation of DFUs. In an aspect, this information comprises measurement of blood volume and refill times on the portion of the calf <NUM> that is proximate to band <NUM>.

<FIG> depicts an integrated sensor and stimulator assembly <NUM> suitable for treatment of a pressure ulcer, according to the present disclosure. In an aspect, an integrated sensor and stimulator assembly <NUM> is provided to a patient in need thereof. Assembly <NUM> has a substrate <NUM> with a plurality of sensors <NUM> disposed on a first surface. Sensors <NUM> are configured to measure sub-epidermal moisture (SEM) as an indication of tissue health at the location of the respective sensor <NUM>. In an aspect, there are two electrodes 212A and 212B that are in conductive contact with the skin of a patient (not shown in <FIG>) when the assembly <NUM> is placed on the skin. These electrodes 212A, 212B are connected to an external controller (not shown in <FIG>) that is configured to apply a therapeutic electrical stimulus to the tissue between the electrodes 212A, 212B, with the stimulus applied for periods having a time duration and a time interval between the periods. In an aspect, low level voltage and/or currents may enhance the healing of a pressure ulcer. Sensors <NUM> are individually connected to an external controller (not shown in <FIG>) that is configured to measure the capacitance of the respective sensors <NUM>. In an aspect, the capacitance is measured in a time interval between the stimulus periods. In one aspect, a time interval can be in the general range of hours to weeks. In an aspect, assembly <NUM> comprises an absorbent pad and a non-stick layer (not shown in <FIG>) overlaid upon sensors <NUM> and electrodes 212A, 212B. In an aspect, assembly <NUM> comprises a layer of adhesive (not shown in <FIG>) overlaid upon a portion of substrate <NUM> so as to allow assembly <NUM> to be adhesively attached to the skin of a patient. In an aspect, substrate <NUM> may be permeable to gas while impervious to fluid.

The combination of a standard bandage (the absorbent pad, non-stick layer, and covering substrate) with a therapeutic instrument, such as electrodes 212A, 212B and the associated external controller, with one or more sensors <NUM> provides a means of protecting the wound, improving the healing process, and monitoring the healing without disturbing the assembly <NUM>.

<FIG> depicts the sole of a foot <NUM> of a patient having a pressure ulcer <NUM>.

<FIG> depicts an assembly <NUM> adhered to the sole of foot <NUM> over the pressure ulcer <NUM>. In an aspect, assembly <NUM> is placed over ulcer <NUM> and left in place for several days. In an aspect, assembly <NUM> comprises a toroidal pad that relieves the pressure on the pressure ulcer <NUM>. The external controller of electrodes 212A, 212B is periodically attached to electrodes 212A, 212B to apply a therapeutic stimulus. During the interval between these stimuli, the external controller of the sensors <NUM> is attached to one or more of the sensors <NUM> to make a SEM measurement.

In an aspect, assembly <NUM> comprises a battery and wireless communication capability that enables the external controller to cause the stimulus to be applied through electrodes 212A, 212B without a wired connection to the assembly. Similarly, the assembly may be configured to allow the external controller to communicate with the sensors <NUM> to make and receive SEM measurements without a wired connection. In an aspect, the assembly <NUM> comprises a microcontroller configured to apply the therapeutic stimulus and make SEM measurements and wirelessly transmit information, such as the SEM values.

It will be apparent to those of ordinary skill in the art that the concept of combining therapeutic instruments and SEM sensors can be applied to other types of wounds and to other locations on the body besides the sole of the foot, such as an ankle, or a bony prominence.

<FIG> depicts a bandage assembly <NUM> adapted for placement over a pressure ulcer on the sacrum of a patient in need thereof. The assembly <NUM> comprises substrate <NUM> that is porous to gas while impervious to fluid. The assembly <NUM> comprises a pad <NUM> (seen from the external side in <FIG>) that provides both protective padding and absorption. In this example, a single sensor <NUM> is positioned on the underside of the pad <NUM> such that the sensor is directly over the pressure ulcer when the assembly is applied over an early-stage pressure ulcer with unbroken skin. The electrodes 214A, 214B are location adjacent to the sensor <NUM> and on the same underside so that they will be in contact with the skin of the patient. In this configuration, the assembly <NUM> can be placed over an early-stage ulcer and protect, improve the healing process, and monitor the progress of the healing with removal of the assembly <NUM> or disturbance of the wound.

Having now generally described the disclosure, the same will be more readily understood through reference to the following examples that are provided by way of illustration, and are not intended to be limiting of the present disclosure, unless specified.

SEM measurements were taken at the foot using one of three methods below to ensure complete contact of an electrode with the skin of a human patient.

<FIG> illustrates a method not covered by the claims used to take SEM measurements starting at the posterior heel using an apparatus according to the present disclosure. First, the forefoot was dorsiflexed such that the toes were pointing towards the shin. Second, a bioimpedance sensor <NUM> was positioned at the base of the heel <NUM>. The electrode was adjusted for full contact with the heel, and multiple SEM measurements were then taken in a straight line towards the toes, including the ball of the foot <NUM>. The ball of the foot is one of the primary locations of diabetic foot ulcer.

<FIG> illustrates a method used to take SEM measurements starting at the lateral heel using an apparatus according to the present disclosure. First, the toes were pointed away from the body and rotated inward towards the medial side of the body. Second, an electrode was placed on the lateral side of the heel <NUM>. A bioimpedance sensor <NUM> was adjusted for full contact with the heel, and multiple SEM measurements were taken in a straight line towards the bottom of the foot. The ball of the foot <NUM> is also shown in <FIG>.

Claim 1:
An apparatus (<NUM>) for assessing susceptibility of a patient's foot tissue to forming a diabetic foot ulcer, said apparatus comprising:
a plurality of electrodes (<NUM>, <NUM>) embedded on a shaped substrate, wherein pairs of said plurality of electrodes (<NUM>, <NUM>) each are capable of forming one or more capacitive sensors (<NUM>) configured to measure a first capacitance of a first region of foot tissue proximate to said capacitive sensor, thereby forming a plurality of capacitive sensors and wherein said shaped substrate is a flexible conforming garment (<NUM>) into which a foot can be inserted, and
wherein the plurality of capacitive sensors (<NUM>, <NUM>) are located under and around the heel of the flexible, conforming garment (<NUM>),
a drive circuit electronically coupled to said electrodes,
a processor electronically coupled to said drive circuit, and
a non-transitory computer-readable medium electronically coupled to said processor and comprising instructions stored thereon that, when executed on said processor, perform the steps of:
receiving information regarding said measured first capacitance from said drive circuit,
comparing said measured first capacitance to a first reference value, and
providing a signal if said measured first capacitance differs from said first reference value by an amount greater than a first predetermined threshold.