Automated detection of near falls: algorithm development and preliminary results
© Weiss et al; licensee BioMed Central Ltd. 2010
Received: 15 October 2009
Accepted: 5 March 2010
Published: 5 March 2010
Falls are a major source of morbidity and mortality among older adults. Unfortunately, self-report is, to a large degree, the gold-standard method for characterizing and quantifying fall frequency. A number of studies have demonstrated that near falls predict falls and that near falls may occur more frequently than falls. These studies suggest that near falls might be an appropriate fall risk measure. However, to date, such investigations have also relied on self-report. The purpose of the present study was to develop a method for automatic detection of near falls, potentially a sensitive, objectivemarker of fall risk and to demonstrate the ability to detect near falls using this approach.
15 healthy subjects wore a tri-axial accelerometer on the pelvis as they walked on a treadmill under different conditions. Near falls were induced by placing obstacles on the treadmill and were defined using observational analysis. Acceleration-derived parameters were examined as potential indicators of near falls, alone and in various combinations. 21 near falls were observed and compared to 668 "non-near falls" segments, consisting of normal and abnormal (but not near falls) gait. The best single method was based on the maximum peak-to-peak vertical acceleration derivative, with detection rates better than 85% sensitivity and specificity.
These findings suggest that tri-axial accelerometers may be used to successfully distinguish near falls from other gait patterns observed in the gait laboratory and may have the potential for improving the objective evaluation of fall risk, perhaps both in the lab and in at home-settings.
Falls are a significant cause of morbidity and mortality, especially among older adults and many patient populations . In June of 2009, research on falls among the elderly was listed as the 3rd item in the top priority group in the Institute of Medicine's report to Congress on national priorities for the United States . Much effort has been devoted to the development of methods for evaluating fall risk [3–6], but the most common means of quantifying falls remains self-report. Despite its widespread use, this method has three key limitations: 1) it is subjective in nature, relying on subjects' motivation and memory (which can be problematic in its own right), 2) it requires a long observation period (e.g., typically six months or more), and 3) sensitivity may be lacking (e.g., subjects are typically classified as fallers and non-fallers, but the absence of a more refined scale may limit sensitivity and the ability to evaluate intervention efficacy).
Different techniques have been developed to automatically identify falls and related measures with varying degrees of success using sensors embedded in the home environment or body-fixed sensors [7–9]. Body-worn fall-detection systems are intended for long-term, automated detection of activity, in general, and falls, more specifically [5, 10–16]. For example, methods based on accelerometry have been proposed as being suitable for the detection of falls in ambulatory subjects [5, 7, 14, 17–19]. These methods have been developed as part of alarm and similar warning systems in order to automatically identify an older adult who has experienced a fall and is in need of immediate assistance. This approach is appropriate for alarm and related applications and has, indeed, been used successfully for these purposes and for the assessment of activity. It is, nonetheless, important to keep in mind that a community-living older adult typically falls less than two times per year  and that falls, at least among the healthy elderly, are relatively rare events, albeit with very significant consequences. Thus, continuous monitoring of falls using body-fixed sensors would generally require very long periods of observation (e.g., half a year) to capture a fall incident, minimizing the practicality and feasibility of using this approach to quantify fall risk by measuring actual falls.
We hypothesized that methods based on body-fixed sensors could, however, be adapted to identify missteps or near falls, potentially enhancing the utility of an approach for assessing fall risk. Missteps and near falls are used here synonymously as a stumble or loss of balance that would result in a fall if sufficient recovery mechanisms were not activated . Automatic identification of near falls should, a priori, provide objective quantification of a sensitive marker of fall risk, perhaps over a shorter observation time periods. Indeed, a number of studies have found that near falls based on self-report are related to fall risk [21–27], that near falls are more frequent than falls [21–23, 25, 27, 28], and that near falls may occur before falls [23–25], enhancing the potential predictive value of near falls. These properties indicate that near falls are clinically relevant markers of falls worthy of further study. Objective techniques for quantifying these events are, however, lacking . The primary aim of the present study was to begin to develop and assess signal processing methods for detecting nearfalls using body-fixed sensors.
Young adults (n = 10; ages: 22-28 yrs, 4 males) and older adults (n = 5; ages: 63-77 yrs, 3 males) participated in this study. Subjects in both groups were healthy and had no gait disturbances. Subjects were excluded if they had any disability likely to impair gait or balance, cognitive decline, or dementia (Mini Mental State Exam score<24). The research carried out on humans was in compliance with the Helsinki Declaration and the study protocol was approved by Human Studies Committee of the Tel Aviv Sourasky Medical Center. All subjects provided informed written consent.
The data was processed using Matlab (the MathWorks Inc). All gait intervals were divided into 5 second, non-overlapping segments. The normal gait segments were compared to the "near fall" segments. Acceleration-axis calibration was performed, as described previously , in order to correct for possible axis-tilt due to the orientation of the device on the subject or due to lower back tilt of the subject. The acceleration axes were calibratedto match the orthogonal axes. Afterwards, the anterior-posterior acceleration was low passed filtered (a 1 Hz cutoff frequency FIR filter was used). Step cycles were defined as the zero crossings of the filtered signal  and the intervals between each two successive steps determined the step cycle time series.
For each gait parameter, the best threshold for distinguishing between normal gait segments (i.e., epochs) and near falls was determined by plotting a range of possible thresholds using a Receiver Operating Characteristic curve, ROC, and choosing the threshold with the best specificity and sensitivity values, i.e., the ones closest to the (0,1) point. The algorithm performance was examined for each parameter separately and for two or three parameter combinations. For the multiple parameter combinations, we checked detection performance when all parameters were above a certain threshold, i.e., the "and" state, and when at least one parameter was above a certain threshold, i.e., the "or" state. Performance was expressed by means of sensitivity and specificity.
Sensitivity and specificity for detecting near falls using single parameters.
Near Fall mean
Near Fall mean
Sensitivity and specificity for detecting near falls using multiple parameters.
[Max-V, Maxp2p-V, Maxp2pdiff-V
Max-V, Maxdiff-V, Maxp2pdiff-V
Maxdiff-V, Maxp2p-V, Maxp2pdiff-V
The results of the present study demonstrate that a single accelerometer may be placed on the trunk of an individual to automatically distinguish near falls from other stepping patterns, with reasonable sensitivity and specificity. Interim analysis of a follow-up study among elderly fallers and non-fallers who walked over-ground also support the idea that these objectively identified near falls are more common among older adults with a history of falling, consistent with the results of self-report studies of near falls [21–28]. Taken together, these findings suggest that perhaps long-term recordings and measurement of near falls, as subjects carry out activities of daily living, is likely to be a clinically relevant, objective adjunct measure of fall risk, possibly improving sensitivity and reducing the observation time required.
This preliminary study has several limitations. Ongoing studies are designed to examine how the developed algorithms work in real-world conditions and to evaluate the predictive value of acceleration-derived measures of near falls in different control and patient populations (e.g., patients with neurodegenerative disease) and in aging (e.g., young vs. older adults). Normal balance responses may have been altered and restricted by the treadmill setup (e.g., the treadmill provides bars for support and promotes continuous walking). In this initial study, we focused on the identification of near falls, but made no attempt at differentiating between the loss of balance and the recovery. Theoretically, these are two distinct processes. In this work, we aimed to identify the "stumble" or near fall. It is, however, possible that some of the recovery phase may have been identified, although most of the derived parameters that had good success in identifying these events are, at least intuitively, more likely related to the loss of balance than to the recovery process. Further work is also needed to verify that the developed algorithms are successful at identifying near falls in normal and free walking environments. There are some subtle differences between over-ground walking and treadmill walking and, as a result, the accelerometer signal is not identical in both conditions. However, even on a treadmill, the signals from all three axes have a form that is similar to over-ground walking, supporting the idea that over-ground near falls can also be detected using the algorithms described.
Despite these and other limitations, the initial results reported here motivate continued work along these lines, provide a basis for future studies in both in the lab and at-home settings, and suggest that a tri-axial accelerometer can successfully identify near falls and may also have the potential for improving the objective evaluation of fall risk.
We thank Eli Jacobi, Racheli Levitas, and the staff of the Laboratory for Gait and Neurodynamics for invaluable assistance. This work was supported in part by NIH (AG-14100), and by the EC (FP6 projects SENSACTION-AAL, INFSO-IST-045622 and FET, 018474-2, DAPHNet). Portions of this work were presented at the International Conference on Ambulatory Monitoring of Physical Activity and Movement, (ICAMPAM), Rotterdam, 2008.
- Thurman DJ, Stevens JA, Rao JK: Practice parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008, 70: 473-479. 10.1212/01.wnl.0000299085.18976.20.PubMedView ArticleGoogle Scholar
- Initial National Priorities for Comparative Effectiveness Research. List of Priorities. [http://www.iom.edu/Reports/2009/ComparativeEffectivenessResearchPriorities.aspx]
- AGS Guidelines: Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 2001, 49: 664-672. 10.1046/j.1532-5415.2001.49115.x.View ArticleGoogle Scholar
- Hausdorff JM: Gait dynamics, fractals and falls: Finding meaning in the stride-to-stride fluctuations of human walking. Hum Mov Sci. 2007, 26: 555-589. 10.1016/j.humov.2007.05.003.PubMed CentralPubMedView ArticleGoogle Scholar
- Narayanan MR, Lord SR, Budge MM, Celler BG, Lovell NH: Falls management: detection and prevention, using a waist-mounted triaxial accelerometer. Conf Proc IEEE Eng Med Biol Soc. 2007, 2007: 4037-4040.PubMedGoogle Scholar
- Whitney JC, Lord SR, Close JC: Streamlining assessment and intervention in a falls clinic using the Timed Up and Go Test and Physiological Profile Assessments. Age Ageing. 2005, 34: 567-571. 10.1093/ageing/afi178.PubMedView ArticleGoogle Scholar
- Bourke AK, O'Brien JV, Lyons GM: Evaluation of a threshold-based tri-axial accelerometer fall detection algorithm. Gait Posture. 2007, 26: 194-199. 10.1016/j.gaitpost.2006.09.012.PubMedView ArticleGoogle Scholar
- Hagler S, Austin D, Hayes T, Kaye J, Pavel M: Unobtrusive and Ubiquitous In-Home Monitoring: A Methodology for Continuous Assessment of Gait Velocity in Elders. IEEE Trans Biomed Eng. 2009,Google Scholar
- Weiss A, Herman T, Plotnik M, Brozgol M, Maidan I, Giladi N, Gurevich T, Hausdorff JM: Can an accelerometer enhance the utility of the Timed Up & Go Test when evaluating patients with Parkinson's disease?. Med Eng Phys. 2010, 32: 119-25. 10.1016/j.medengphy.2009.10.015.PubMedView ArticleGoogle Scholar
- Moe-Nilssen R: A new method for evaluating motor control in gait under real-life environmental conditions. Part 1: The instrument. Clin Biomech (Bristol, Avon). 1998, 13: 320-327. 10.1016/S0268-0033(98)00089-8.View ArticleGoogle Scholar
- Karantonis DM, Narayanan MR, Mathie M, Lovell NH, Celler BG: Implementation of a real-time human movement classifier using a triaxial accelerometer for ambulatory monitoring. IEEE Trans Inf Technol Biomed. 2006, 10: 156-167. 10.1109/TITB.2005.856864.PubMedView ArticleGoogle Scholar
- Mathie MJ, Coster AC, Lovell NH, Celler BG, Lord SR, Tiedemann A: A pilot study of long-term monitoring of human movements in the home using accelerometry. J Telemed Telecare. 2004, 10: 144-151. 10.1258/135763304323070788.PubMedView ArticleGoogle Scholar
- Mathie MJ, Celler BG, Lovell NH, Coster AC: Classification of basic daily movements using a triaxial accelerometer. Med Biol Eng Comput. 2004, 42: 679-687. 10.1007/BF02347551.PubMedView ArticleGoogle Scholar
- Narayanan MR, Scalzi ME, Redmond SJ, Lord SR, Celler BG, Lovell NH: A wearable triaxial accelerometry system for longitudinal assessment of falls risk. Conf Proc IEEE Eng Med Biol Soc. 2008, 2008: 2840-2843.PubMedGoogle Scholar
- de Bruin ED, Hartmann A, Uebelhart D, Murer K, Zijlstra W: Wearable systems for monitoring mobility-related activities in older people: a systematic review. Clin Rehabil. 2008, 22: 878-895. 10.1177/0269215508090675.PubMedView ArticleGoogle Scholar
- Zijlstra W: Assessment of spatio-temporal parameters during unconstrained walking. Eur J Appl Physiol. 2004, 92: 39-44. 10.1007/s00421-004-1041-5.PubMedView ArticleGoogle Scholar
- Lindemann U, Hock A, Stuber M, Keck W, Becker C: Evaluation of a fall detector based on accelerometers: a pilot study. Med Biol Eng Comput. 2005, 43: 548-551. 10.1007/BF02351026.PubMedView ArticleGoogle Scholar
- Kangas M, Konttila A, Lindgren P, Winblad I, Jamsa T: Comparison of low-complexity fall detection algorithms for body attached accelerometers. Gait Posture. 2008, 28: 285-291. 10.1016/j.gaitpost.2008.01.003.PubMedView ArticleGoogle Scholar
- Lee Y, Kim J, Son M, Lee M: Implementation of accelerometer sensor module and fall detection monitoring system based on wireless sensor network. Conf Proc IEEE Eng Med Biol Soc. 2007, 2007: 2315-2318.PubMedGoogle Scholar
- Leveille SG, Jones RN, Kiely DK, Hausdorff JM, Shmerling RH, Guralnik JM, Kiel DP, Lipsitz LA, Bean JF: Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA. 2009, 302: 2214-2221. 10.1001/jama.2009.1738.PubMed CentralPubMedView ArticleGoogle Scholar
- Wiles CM, Busse ME, Sampson CM, Rogers MT, Fenton-May J, van Deursen R: Falls and stumbles in myotonic dystrophy. J Neurol Neurosurg Psychiatry. 2006, 77: 393-396. 10.1136/jnnp.2005.066258.PubMed CentralPubMedView ArticleGoogle Scholar
- Stack E, Ashburn A: Fall events described by people with Parkinson's disease: implications for clinical interviewing and the research agenda. Physiother Res Int. 1999, 4: 190-200. 10.1002/pri.165.PubMedView ArticleGoogle Scholar
- Srygley JM, Herman T, Giladi N, Hausdorff JM: Self-report of missteps in older adults: a valid proxy of fall risk?. Arch Phys Med Rehabil. 2009, 90: 786-792. 10.1016/j.apmr.2008.11.007.PubMed CentralPubMedView ArticleGoogle Scholar
- Ashburn A, Hyndman D, Pickering R, Yardley L, Harris S: Predicting people with stroke at risk of falls. Age Ageing. 2008, 37: 270-276. 10.1093/ageing/afn066.PubMedView ArticleGoogle Scholar
- Teno J, Kiel DP, Mor V: Multiple stumbles: a risk factor for falls in community-dwelling elderly. A prospective study. J Am Geriatr Soc. 1990, 38: 1321-1325.PubMedView ArticleGoogle Scholar
- Nilsagard Y, Lundholm C, Denison E, Gunnarsson LG: Predicting accidental falls in people with multiple sclerosis -- a longitudinal study. Clin Rehabil. 2009, 23: 259-269. 10.1177/0269215508095087.PubMedView ArticleGoogle Scholar
- Arnold CM, Faulkner RA: The history of falls and the association of the timed up and go test to falls and near-falls in older adults with hip osteoarthritis. BMC Geriatr. 2007, 7: 17-10.1186/1471-2318-7-17.PubMed CentralPubMedView ArticleGoogle Scholar
- Ryan JW, Dinkel JL, Petrucci K: Near falls incidence. A study of older adults in the community. J Gerontol Nurs. 1993, 19: 23-28.PubMedView ArticleGoogle Scholar
- Mansfield A, Lyons GM: The use of accelerometry to detect heel contact events for use as a sensor in FES assisted walking. Med Eng Phys. 2003, 25: 879-885. 10.1016/S1350-4533(03)00116-4.PubMedView ArticleGoogle Scholar
- Moe-Nilssen R, Helbostad JL: Estimation of gait cycle characteristics by trunk accelerometry. J Biomech. 2004, 37: 121-126. 10.1016/S0021-9290(03)00233-1.PubMedView ArticleGoogle Scholar