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Non invasive blood flow assessment in diabetic foot ulcer using laser speckle
contrast imaging technique

Article · February 2014

DOI: 10.1117/12.2041874

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 Non invasive blood flow assessment in diabetic foot ulcer using laser
speckle contrast imaging technique
A. K. Jayanthy*a, N. Sujathab, M. Ramasubba Reddyb, V. B. Narayanamoorthyc
a
Department of Electronics and Instrumentation Engineering, Faculty of Engineering and
Technology, SRM University, Kattankulathur, Chennai, Tamilnadu, India; bBiomedical Engineering
Group, Department of Applied Mechanics, Indian Institute of Technology Madras, Chennai,
Tamilnadu, India; cDiabetic Foot Clinic, SMF Hospital, Chennai, Tamilnadu, India

ABSTRACT

Measuring microcirculatory tissue blood perfusion is of interest for both clinicians and researchers in a wide range of
applications and can provide essential information of the progress of treatment of certain diseases which causes either an
increased or decreased blood flow. Diabetic ulcer associated with alterations in tissue blood flow is the most common
cause of non-traumatic lower extremity amputations. A technique which can detect the onset of ulcer and provide
essential information on the progress of the treatment of ulcer would be of great help to the clinicians. A noninvasive,
noncontact and whole field laser speckle contrast imaging (LSCI) technique has been described in this paper which is
used to assess the changes in blood flow in diabetic ulcer affected areas of the foot. The blood flow assessment at the
wound site can provide critical information on the efficiency and progress of the treatment given to the diabetic ulcer
subjects. The technique may also potentially fulfill a significant need in diabetic foot ulcer screening and management.
Keywords: Blood flow, laser speckle, LSCI, diabetics, neuropathy, foot ulcer, amputation

1. INTRODUCTION
1
The International Diabetes Federation (IDF) has ranked India as the country with the second most diabetics affected
people worldwide. According to the statistics published by the IDF, it is estimated that the number of diabetic subjects in
India (in the age group of 20-79) accounts to 65.1 million1 in the year 2013. However, this is likely to rise to 109.0
million1 by 2035. The global prevalence estimates on the number of people with diabetes in the age group of 20-79 is
382 million1 in the year 2013 and it is likely to increase to 592 million1 by 2035. Diabetes is the fourth leading cause of
death in most developed countries2 and is also ranked among the leading causes of blindness, renal failure and lower
limb amputation.

Diabetes Mellitus is recognized as being a syndrome, a collection of heterogeneous disorders with the common elements
of hyperglycaemia (high blood sugar) and glucose intolerance as their hallmark, due to insulin deficiency or impaired
effectiveness of insulin action, or because of a combination of both.2 When blood glucose and blood pressure are not
controlled over time, diabetes can harm the blood vessels or nerves leading to diabetic neuropathy. Problems with
digestion, urination, impotence and many other functions can result, but the most commonly affected area due to
neuropathy is the legs and the feet.1 Nerve damage in these areas causes peripheral neuropathy and could manifest in
many ways including loss of sensation in the feet and toes. Loss of sensation is a particular risk because it can allow foot
injuries to escape notice and treatment, leading to diabetic ulcer and in certain cases may even lead to amputation.1
Diabetic foot ulcer is a major complication in patients with diabetic neuropathy and it is estimated that 15% of diabetics
develop a foot ulcer within their lifetime and that up to 70% of all non-traumatic amputations in the world occur in
diabetics.3 In another study, it was estimated that nonhealing foot ulcer preceded 85% of diabetic lower limb
amputations.4 Prevention of diabetic foot ulcer, which has been estimated to occur in 15% of diabetic patients at some
time over the course of their disease, has been proposed as a method to decrease the high incidence of lower limb
amputation.5 Therefore there is a potential need to screen diabetic neuropathic foot ulcers at an early stage.

*jayanthy.velumani@gmail.com;

Biomedical Applications of Light Scattering VIII, edited by Adam Wax,

Vadim Backman, Proc. of SPIE Vol. 8952, 89521D · © 2014 SPIE
CCC code: 1605-7422/14/$18 · doi: 10.1117/12.2041874

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 Various screening techniques to identify people at high risk for diabetic foot ulceration have been proposed and are
currently in use.6 These include the evaluation of vibration perception threshold (VPT), plantar foot pressure
measurements, joint mobility and 5.07 Semmes-Weinstein monofilament (SWF) testing.6 Early identification of diabetic
foot ulcers has also been carried out using a micro light guide spectrophotometer to measure the microvascular oxygen
saturation (SaO2) in foot ulcers.7 The ability of the hyperspectral imaging technology which can quantify tissue oxy and
deoxyhemoglobin to predict diabetic foot ulcer healing has also been tested.8-9

The evaluation of foot ulcer includes assessment of neurological status, vascular status and evaluation of the wound
itself.10 Neurological status can be checked using the Semmes-Weinstein monofilament to check if the patient has
protective sensation or a tuning fork could also be used to check if the patient’s vibratory sensation is intact.10 Vascular
assessment includes checking pedal pulses, the dorsalis pedis on the dorsum of the foot, and the posterior tibial pulse
behind the medial malleolus, as well as capillary filling time to the digits.10 The ulcer wound evaluation includes
documentation of the wound’s location, size, shape, depth, base, and border.10 After all the above physical findings have
been noted, a differential diagnosis should also be established.10 The diabetic foot ulcer is particularly vulnerable to
development of a chronic ulcer because of a combination of poor nutritional blood flow, peripheral neuropathy and
impaired vascular responsiveness.11

A unique clinical imaging technique which can establish the onset of ulcer by measuring the decrease in blood flow can
be of great value to the clinicians. In this paper we are presenting the laser speckle contrast imaging (LSCI) technique as
a tool for assessing the changes in blood flow in diabetic foot ulcer (DFU) subjects. LSCI a noncontact, noninvasive and
whole field technique has been used in the past to characterize blood flow dynamics associated with the
microvasculature. The application of the LSCI technique in monitoring of capillary blood flow has been carried out by
simulating changes in capillary blood flow by rubbing the skin, occluding the blood flow by applying a rubber band
around the base of the finger or applying a blood pressure cuff on the upper arm and also studying the effect of
temperature changes by immersing one hand in cold water and the other in hot water.12-14 The retinal blood flow in
rabbits, rats and human eye has also been measured using the LSCI technique.15-17 The LSCI technique has also been
used to map cerebral blood flow in rats and very recently used in a pilot study to study cerebral blood flow in humans
during neurosurgery.18-22 A novel application of the LSCI technique has been used in the assessment of static scatterer
concentration in phantom body fluids and in assessment of depth in burn tissue phantoms.23-24 Characterization of
atherosclerotic plaques in human cadaveric aorta samples using the LSCI technique has also been carried out in the
past.25-26

The laser speckle contrast increases with decrease in velocity of the blood flow27 and diminished blood flow is observed
in diabetic ulcer affected tissue when compared to the surrounding normal tissue.11 These two factors can be made use to
identify the ulcer affected areas of the diabetic foot where the blood flow is decreased (and corresponding speckle
contrast is high) when compared to the surrounding normal tissue areas. The LSCI being an optical technique has the
added advantage of neither disturbing the blood flow nor harming the tissues. Therefore it is expected to be utilized
increasingly in the follow up of the treatment of the disease in the long run.

2. MATERIALS AND METHODS

The experiments were conducted at the diabetic foot clinic, Sundaram Medical Foundation (SMF) Hospital, Chennai. A
set of 5 subjects were used for this study. The average age was 44.2 with a standard deviation of 14.1. The target set
included one normal, one prediabetic and three diabetic subjects with foot ulcer. Even though marked differences were
found in the average foot blood flow pattern of normal and diabetic subjects, the comparison was made primarily for the
ulcer affected and non affected portions of the same subject to avoid any possible discrepancies related to the age factor.
All subjects who had ulcers secondary to neuropathy were included in the study and subjects who had signs of
inflammation, infection or active pus discharge were excluded from the study. The protocol was approved by the ethics
committee at IIT, Madras and all participants gave written informed consent. All the subjects washed and dried their foot
before conducting the experiment. The subjects were asked to lie down comfortably and images were taken for each foot
separately and analyzed.

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 A random intensity distribution pattern called as a speckle pattern is formed when coherent light is either reflected from
a rough surface or propagates through a medium with random refractive index fluctuations.28 Goodman has developed a
detailed theory and explained the first order and second order statistics of speckle patterns.29 The extremely complex
speckle pattern is best described quantitatively by the methods of probability and statistics. In the early days of lasers,
speckle was regarded purely as a nuisance as it severely affected the resolution in experiments where laser light was
used, for example in holography and much effort was directed towards reducing speckle in images formed in laser
light.27 However, it was not long before researchers started to study speckle for its own sake and to develop practical
applications of the phenomenon.27 Speckles produced by biological subjects was termed as biospeckle.12

Ulcer
affected area
in the foot

Diabetic foot with ulcer

Figure 1. Schematic of the experimental arrangement.

The schematic of the experimental arrangement is shown in Figure (1). A He Ne laser (λ= 632.8 nm) was used to
illuminate the feet of diabetic foot ulcer subjects. The source to target distance was 20cm and a divergent beam was used.
The bio-speckle pattern in the foot was imaged with an 8-bit monochrome CCD camera (Model XC/ST-50CE, Sony,
Japan). Images acquired were transferred from the camera to a PC equipped with a frame grabber card (Data
Translation, Germany). These images were processed offline by using the developed algorithm. Briefly, the recorded raw
speckle image was converted to a false colour contrast image, by applying a 5x5 sliding window. At each window
position, the mean gray-level intensity (I) and standard deviation (σ) were determined.

The speckle contrast (K) is defined as the ratio of the standard deviation to the mean intensity30 and is expressed in
equation (1). The speckle contrast (K) of the center pixel in the window was computed using equation (1).

σ
K= (1)
〈I 〉

When an object moves, the speckle pattern it produces also changes. For small movements of a solid object, the speckles
move with the object and remain correlated whereas for larger movements, they decorrelate and the speckle pattern
changes completely.30 The speckle pattern can also decorrelate even if the individual scatterers are able to move without
the need for a global movement as they can for example in the case of a fluid and is termed as ‘time varying speckle
pattern’.30 In such cases the time varying speckle pattern's intensity fluctuations contain information about the velocity
distribution of the scatterers and/or the velocity of the entire object. Time-varying speckle is frequently observed when
biological samples are observed under laser-light illumination.

In case of blood the moving scatterers namely the blood cells produce the time varying speckle. The higher the velocity
of blood, the faster are the fluctuations and the more blurring occurs in a given integration time.31 Any variation in the
velocity of the blood thus causes a corresponding increase or decrease in the contrast value of the speckle pattern.

The relation between the speckle contrast and the temporal statistics of the fluctuating speckle has been considered and
the spatial variance of the intensity (σs2 (T)) of the time integrated speckle image is estimated to be equal to the time

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 average of the autocovariance of the intensity fluctuation29 and is given by equation (2) where T is the integration time
and Ct is the autocovariance of the intensity fluctuations in the intensity of a single speckle.

T
1
σ s (T ) = ∫ Ct (τ )dτ
2
( 2)
T 0

As the capillary network which is situated in the dermal layer of the skin is very convoluted in nature, this means that
there is no overall single direction for the blood flow and as such we take the line of sight velocity distribution to be
Lorentzian in nature.13 Thus assuming a flow velocity distribution with a Lorentzian profile, and using equation (2) it
was showed that in an ideal system with no multiple scattering and perfect speckle formation, the speckle contrast (K),
integrated over a time T is given by equation (3) where T is the exposure time of the CCD camera and τc is the time taken

K= τ c / 2T (1 − exp( −2T / τ c ) (3)

for the autocorrelation function of the intensity to fall to a value 1/e of the original, and is referred to as correlation time
of the intensity fluctuations.32 Using equation (1) the speckle contrast K can be calculated from the image and can be
substituted in equation (3) to evaluate τc. Relative flow images can be obtained by calculating 1/τc at each image pixel. A
higher pixel value (intensity value) is analogous to faster blood flow.26

The precise relationship between the velocity of the moving scatterers and the correlation time of intensity fluctuations is
still unknown. In a very first attempt to relate the factors, Briers approximated the relation which is expressed as follows
in equation (4).33

λ
v= μm / sec (4)
2πτ c

When He Ne laser light (λ=633nm) is used the equation (4) reduces to equation (5). Many assumptions and
approximations have been made in derivation of the equations.12

0.1
v= μm / sec (5)
τc

Bonner and Nossal34 have developed an elaborate model taking into account the size of the scattering particles (red blood
cells) which leads to a more appropriate equation (6) for the velocity of the scatterers. The correlation time τc calculated
from equation (3) can be substituted in equation (6) to evaluate the velocity of the moving scatterers.

3.5
v= μm / sec (6)
τc

Associated errors with the quantitative determination of blood flow have been analyzed by several groups and the
equation (3) has been subsequently modified.35-37 The value of τc can be estimated by using the corrected equation35-37
and a quantitative analysis can be carried out to estimate actual changes in the blood flow values. In this paper we are
dealing with a qualitative approach to measure the changes in average speckle contrast value with variations in blood
flow due to the diabetic foot ulceration.

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 3. RESULTS AND DISCUSSION
The LSCI technique having the added advantage of a full field technique is being used in this work to assess changes in
capillary blood flow in the ulcer affected areas of the diabetic foot. Areas of high flow blur the speckle image to a
greater extent reducing its contrast compared to low flow areas.

The study was conducted on normal, pre-diabetic and diabetic foot ulcer subjects. Three subjects with diabetic foot ulcer
have been used for the study. All the diabetic ulcer subjects were neuropathic. Each foot was divided into two regions
namely the fore foot and hind foot region to enable analysis of the image intensities in the two regions of the same foot.
The comparison of contrast values between subjects is not feasible because of large variations in capillary blood flow
within the subjects and hence the comparison is carried out within the same subject and separately in each foot. The
comparison of contrast values has been carried out in the normal area, ulcer affected area and immediate area
surrounding the ulcer affected area in the same foot of each subject.

A selected area in the target foot (fore foot or hind foot) is illuminated using a He Ne laser source and the raw speckle
image is obtained using the experimental setup shown in Figure (1). The contrast value of the raw speckle pattern is
calculated using equation (1) and then converted into a false color contrast map. The false colour contrast map of the fore
foot left leg of a normal subject is shown in Figure 2(a) and that of a diabetic subject without ulcer is shown in Figure
2(b). Figure 2(c) shows the false colour contrast map of the fore foot left leg of a diabetic subject with a visible ulcer and
Figure 2(d) shows the image of the fore foot right leg of a subject with a fully open wound in the area.

o
MMie
H

(4)

8 HM 11 LI L3 1 1.1
bi bi 141 !.- !7! 14/ M

o o o o o o 8
§ § I 21
, H 71 A II II

IIMMEMIE

11

14

Figure 2. False colour contrast image of the fore foot of the (a) normal subject (b) diabetic subject without ulcer (c) diabetic subject
with a visible ulcer (d) diabetic ulcer subject with fully open wound.
§ § H
fi

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 A uniform fixed area of 150x150 pixels was chosen in the ulcer affected area, its immediate vicinity and in a region far
off from the ulcer (hindfoot region) and the average speckle contrast values were calculated for this area and are
tabulated in Table 1. All the subjects under examination were having foot ulcer in the forefoot area and hence hindfoot
area was considered as a control area for each foot. The values highlighted within brackets represent the speckle contrast
values in the ulcer affected areas of the foot.

Table 1 – Speckle contrast values in different areas of the foot

Sample Patient status
no:
Gender Age Foot imaged Fore foot area Hind foot area
1 Normal Male 31 LF 0.0309 0.0308
2 Normal Male 31 RF 0.0362 0.0353
3 Prediabetic Female 34 LF 0.0380 0.0307
4 Prediabetic Female 34 RF 0.0359 0.0383
5 Diabetic Female 45 LF 0.0479 0.0419

6 Diabetic ulcer Female 45 RF 0.0540(0.0681) 0.0320

7 Diabetic ulcer Male 67 LF 0.0492(0.0701) 0.0679
8 Diabetic ulcer Male 67 RF 0.0534(0.1349) 0.0457
9 Diabetic Female 44 LF 0.0425 0.0433
10 Diabetic ulcer Female 44 RF 0.0372(0.0171) 0.0435
(fully open
wound)

It is observed from Table (1) that in the case of normal and prediabetic subjects (samples 1 to 4) the speckle contrast
values are consistent in all the four areas (fore foot and hind foot area of both feet) of the feet within each subject. For
example in sample no. 1 the average speckle contrast value in the fore foot area of the left leg is 0.0309 and that in the
hind foot area of the same foot is 0.0308 which are almost the same. Also in case of sample no. 5 (diabetic foot without
ulcer) the corresponding contrast values are 0.0479 and 0.0419. This shows that there is uniformity in the blood flow
throughout the foot with no abnormalities in capillary blood flow in case of absence of foot ulcers. As mentioned earlier
the contrast comparison is made for each foot separately.

In the case of diabetic foot ulcer subjects (samples 5 to 10) there is a significant change in the contrast values between
the ulcer affected tissue area and the immediate surrounding tissue area. In the case of subjects affected with ulcer
(samples 6, 7, 8 and 10), in the ulcer affected tissue area there is an increase in contrast value (represented by bold
numerals) when compared to the surrounding normal tissue which clearly shows that there is a decrease in capillary
blood flow in the ulcer affected area. For example in sample no. 7 the ulcer affected area shows a contrast value of
0.0701 (fore foot area of left foot) which is higher when compared to a contrast value of 0.0492 (fore foot area of left
foot) in the surrounding normal tissue area. This correlates well with the theory that capillary blood flow decreases in
ulcer affected areas of the diabetic foot.11

When comparing the speckle contrast values in the immediate vicinity of ulcer affected area to values in the far off
normal tissue area there is increase in former value (in most of the cases). For example in sample no. 6 the corresponding
values are 0.0540 and 0.0320 which shows that the ulcer area has also got its own effect on the immediate surrounding
normal tissue areas.

The areas not affected by the ulcer and which are far away from the ulcer affected area have decreased contrast values in
both foot. We have observed a change in this trend only in the case of sample no. 7, where a greater contrast value of
0.0679 was observed in the hindfoot region although there was no visible ulcer, indicating reduced blood flow. This
change was noted and indicated to the clinician so that the patient could be put on observation for possible development
of ulcer in the near future. This also gives an insight into the application of LSCI technique in screening of diabetic
patients for the possibility of ulcer development.

Sample no. 10 corresponds to an ulcer (fully open wound) and hence a large decrease in contrast value is observed which
correlates with a high capillary blood flow. The low contrast value observed in the affected area of the fore foot right leg

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 of the subject is attributed to the full exposure of the tissue. The changes in average speckle contrast values with different
areas of the foot for the 10 samples are graphically represented in Fig. 3.

0.1320
Average speckle contrast

Forefoot
0.1100
Hindfoot
0.0880 Forefoot Ulcer
0.0660
0.0440
0.0220
0.0000
1 2 3 4 5 6 7 8 9 10
Sample number

Figure 3. Average speckle contrast variations in normal (hindfoot), ulcer (forefoot) and vicinity of ulcer (forefoot) areas of different
samples.

4. CONCLUSIONS
The pilot study conducted here is intended to provide preliminary data on the use of the LSCI technique in assessing
blood flow variations in DFU subjects. LSCI is used here as a purely non-invasive and non-contact technique as it
neither disturbs the blood flow nor causes damage to the tissues. It was observed that ulcer affected areas were having
lower blood flow compared to other areas of the same foot and the extent of this variation changes with position. Due to
the reduced blood flow, the ulcer affected area hardens and eventually breaks open to a fully open wound, where the
capillaries are exposed with subsequent increase in blood flow.

Analysis of blood flow variations in different parts of the normal / ulcer affected foot based on contrast deviations puts
forward the possible application of LSCI technique in monitoring of diabetic foot ulcers in subjects who have a long
history of uncontrolled blood sugar and blood pressure. It can possibly be extended for screening the onset of ulcer in
diabetic patients at an early stage by identifying areas having less blood flow in the foot. The technique could also be
used in the management of foot ulcers by monitoring the capillary blood flow on a regular basis during the treatment of
the disease.

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