This post was commissioned by University of Manchester’s Sensing, Imaging and Signal Processing group in the school of Electrical and Electronic Engineering. We interviewed Dr Alex Casson, and FutureEverything’s Tom Higham – a type 1 diabetic and insulin pump user – to investigate the devices, behaviours and future of wearable medical technology. Article photo courtesy of Tom Higham, which shows the kit needed for one set change of his equipment.
It’s hard to keep up with the rate at which new wearable technologies are developed, from implantables, to ingestibles, to smart fabric and clothing. It’s overwhelming, and often confusing for us to make sense of the data that is thrown back at us. However, in research labs across the world, this technology is being used innovative ways to improve patient care. So what are the main applications and issues when we look at wearables in clinical situations, and is technology the answer?
First things first. It’s important to distinguish between the technology used in medicine and healthcare, and that used to help encourage a healthy lifestyle. I’m reminded of this as I talk to Alex Casson, a lecturer in the Sensing, Imaging and Signal Processing group in the school of Electrical and Electronic Engineering at the University of Manchester.
Alex’s team are working on a potentially revolutionary new technology for clinical wearables – conformals – discrete sensors placed directly onto the skin which can be used to create a much needed feedback loop for patients. By being attached directly to a patient’s skin there are fewer artefacts due to strap movements. The conformals can follow the contours of the skin to give a larger surface area in contact with the body which increases the strength of the collected signal. Both of these factors lead to much more accurate results than current devices. The aim, Alex says, is for conformals to give very very timely feedback, potentially leading to automated, and far more accurate, interventions. ‘At the moment you might take a drug two times a day at six pm, and six am, but that’s not based upon when your body is more likely to absorb it or any sort of information as to what sort of state you’re in. But in order to find the best time successfully you’ve often got about 15 milliseconds to do the feedback looping and that presents some very interesting technical challenges, which we hope conformals and advanced low power signal processing will solve.’ Conformals are also far less invasive, particularly for those that might not particularly welcome a cumbersome device attached to their body, and particularly for those that might need a bit of help adapting to a potentially sudden change in their health such as children.
This kind of dynamism is important, as we know, not everybody is the same and therefore in need of exactly the same treatment. This is one of the great problems not only in clinical wearables, but in ‘healthy living’ wearables too, a shared frustration that perhaps could signal a push towards better customisation. Technology Critic Sara Watson argues for this dynamism in the connected technologies that we use in our attempts to be healthier, particularly after observing that her fitbit complained when she didn’t take 10,000 steps after a hip operation. This is something that Dr Casson’s team have already identified as being a significant step towards between clinical wearables, particularly in the field of printed devices, which can make custom electrodes for individuals. Although it takes about half an hour per print, it’s still progress towards addressing customised healthcare.
However, consideration into how they actually fit into our lives is important, how will we feel having nearly invisible sensors attached to our bodies? What is it like to adjust our behaviour, and awareness of our own body, and will we ever feel fully comfortable with it? And do we have everything in place to make sense of it once the data is available to us?
One of the areas where this constant feedback, and continuous relationship with monitoring technology, is those that live with type 1 diabetes. Talking to colleague and FutureEverything’s Executive Director Tom Higham about his experiences with Type 1 diabetes and the devices he has used and interacted with, it’s often not about the technological advancements themselves, but rather all of the infrastructure and behaviours around it.
In order to manage his own diabetes, Tom wears an insulin pump, a revolutionary piece of technology for diabetes patients, which enable the ability to monitor (using a feedback system with a CGM – constant glucose monitoring) and administer the insulin that he needs so as not to fall ill. It’s a long leap from the insulin pen, a huge improvement for many in its own right, which Tom once used every day, several times a day, for 20 years. Now Tom wears his pump all the time, it has become an extension of his bodily functions, and drastically improved his own healthcare. ‘It’s very odd, getting used to having a cable attached to you, but now it’s completely not a thing I think about any more. Type 1 diabetics have to make around 120 decisions a day, on top of everything else, so this pump allows the amount of decisions to reduce.’ However, getting one in the first place was the difficult part.
‘We’ve had insulin pumps since the late 90’s but when I was younger it was just rich kids in America that could have these pumps, as because of the healthcare insurance system out there, only those who could afford it could have them.’ As Tom continues, the NHS is wildly different, and it was only the most at risk patients who were first put on insulin pumps, but over the years the system changed and it became slightly more accessible. Eventually, after a lot of conversations, and research, and asking, Tom was eventually put on a trial by his diabetes nurse, ‘the heartbeat of diabetes care.’
Here’s the unedited audio of Tom Higham and I speaking about the issues, concerns and aspirations of technology that aims to make life for those with Type 1 diabetes easier.
So much of it is finding the right healthcare team, and the right authority for your specific care that will help you get access to these options, as well as having the ability to trust that the person helping you will actually listen. So often, as Tom explains, those with chronic, life-time illness become a scholar of their own condition: ‘You very quickly become, as you grow up, more expert than all of your healthcare team because most of your health care team, except maybe the consultant, haven’t been working on diabetes for twenty five years, whereas I have.’
But so often any significant technological advancement can be seen as a quick fix, or a cure, can be a potentially problematic conversation, particularly with parents of those with type 1 diabetes. As Tom Higham explains, it’s about a lot more than the device itself. Technology such as the partially closed loop system like the one that Tom uses can significantly change the quality of life for a child that until previously, would have to be monitored by a parent every two hours, even while sleeping. However, it won’t solve everything. New technology and research is unfortunately seen as the next answer, or even a potential cure by parents trying to make sense of their child’s illness, when what Tom says is really helpful is perspective, balance and customised care; ‘I made massive mistakes as a kid with diabetes, and look, I’m alright.’
But of course, there are developments in diabetes technology that are something to get excited about. For Tom, the really exciting thing in the near future is a fully closed loop technology, which differs to his current system in that you essentially remove the human from the process; ‘It removes the ability to have to dose, with the premise being that the system could automatically give me more or less insulin specifically when I need it, therefore removing human error and the problems around very young kids not necessarily making the right decisions at the right moments.’
However it will take time, about twenty years by Tom’s estimates, to get closed loop technology fully out into the world. Science takes, and needs, this time, is where medical technology rubs up against the speed, and expectations, of innovation. Medicine, and health care, needs time to make sure that nothing goes wrong, and that the solution, or process, that they are investing in is safe. With innovation, it’s often a process of iteration, another iteration, and then a rapid push to market that doesn’t always consider the long term effects of doing so, especially, as Tom mentions, when it comes to people’s health.
As Alex Casson also says, time is a big factor in putting any new technology into the hands of patients; ‘One of the frustrating things about being an academic is how unresponsive we are. In many ways, we’re at the cutting edge of a lot of things, but research moves slowly, it can take months for a grant to be funded, and even longer to do the work and then clinical trials.’
Just recently, with the latest Apple press conference, Tim Cook mentioned this slowness during the latest iWatch release, which removed the health monitoring features altogether, citing that the FDA’s process would ‘hold us back from innovating too much, the cycles are too long.’
So what are the next advances in clinical technology? For Alex and his team, battery power is another issue to address. During my conversation with Tom, he tells me about an instance his battery was running low, which involved hurriedly asking the German organiser of the event he was at where the nearest shop was to pick up a spare AA battery.
Alex’s team have looked at where power can be harvested, and fed back, into devices meaning a longer batter life, or a potentially circular energy cycle (much like the kinetic watch) that therefore cuts down on the need to charge. It’s all about finding the optimal place for a person to wear the device to get this kind of energy generation; ‘In creating wearables with energy harvesting in mind, you have this trade off between how much energy you can collect for making your electronics (the average wearable uses anything between 100 and 1000 microwatts) and how much energy is used in processing, versus how big the wearable is and how much motion interference you get in the collected signal. Often motion corrupts everything, so you want to try and minimize it for good sensing, but maximize it for good energy harvesting.’ As Alex mentions, there are so many ways to harvest data, from the arcs that your legs move in, to your upper body, where most of the most important biosignals are. So there’s a lot to consider. Alex’s team are looking at low power, real time signal processing embedded within dedicated hardware to get the best possible performance from a wearable device.
I couldn’t leave Alex’s office without asking what he’s excited about as a scientist, and what he’d like to see in the future of his field. Alex’s ambitions are rightfully grounded in useful, clear feedback, which in most ways is the golden goose in clinical technology. We have to be able to make sense of the data in ways we can understand and respond to because, as he mentions, ‘Is a website the limits of our ability?’. A lot of this, as we are starting to see, is not just a technological issue, but a behavioural one. How do we grow to accommodate these interventions as an individual so that it is not only understandable, but not an overwhelming prospect, particularly for those that are struggling to deal with a disease such as diabetes.
As well as their conformals research, Alex’s team are currently working on wearables that be inserted into shoes to help detect the early signs of foot ulceration in diabetes patients, but has other hope for this area. ’I’d love to do more work with wearables in shoes. You know those bumps on the pavement by crossings? They cause a large amount of accidents in old people who slip and fall on them, so I’d love to create a wearable that virtually recreates those textures using haptic feedback.’
At the end of both my conversations with Alex and Tom, we talk about how people actually live with clinical technology, particularly when it becomes one of the most integral parts of their life. Before I leave Alex’s office, he writes on the wall behind me, on his wish-list of projects, a funding possibility for investigating how people will view, and live with conformal technology. When it comes to technology, and our fears and aspirations in making our lives better, we are human, all too human.