Cristina Herrera Ligero1, Ana Ruíz García 2, José David Garrido Jaén1 , Ignacio Bermejo Bosch1, Xavier Andrade Celdrán1, Rosa Porcar Seder1
(1) Instituto de Biomecánica (IBV) Universitat Politècnica de València (Edificio 9C) Camino de Vera s/n (46022) Valencia (Spain)
2 Algemesí Health Center, associated with the Health Department of La Ribera
In 2017, in line with its philosophy of promoting and transferring knowledge and technology, the Instituto de Biomecánica (IBV) developed FallSkip/IBV, a fall risk assessment application. This tool meets an explicit public healthcare demand, due to the high prevalence of falls among elderly people and the associated costs. FallSkip allows users to carry out, in just under two minutes, a complete assessment test and to obtain results on gait, balance, sitting and standing and reaction time, as well as an instantaneous final fall risk index. Its validity and reliability have been proved within diverse clinical contexts, including patients with Alzheimer’s or Parkinson's disease.
The objectivity of the results it provides, as well as its versatility and agility, make FallSkip a very useful tool in several types of care processes, where the quality of the care is primordial, not to mention efficiency and speed. Other current clinical uses include its use in programs for the prevention of falls in the elderly population in Primary Care, or in Physical Medicine and Rehabilitation Services, at both the care and research levels. Regarding the latter, the doctors involved highlight its simplicity, objectivity and its usefulness during the objectification of functional evolution and the design of specific treatments.
INTRODUCTION
IBV has more than 40 years of experience in research and innovation in healthcare technology and in the elderly. Within this framework, and in line with the philosophy of the center, in 2017, the IBV developed FallSkip/IBV, a biomechanical application for fall risk assessment (Ripoll et al., 2017). This development meets a specific public healthcare demand related to the high prevalence of falls among elderly people and the cost in terms of money and resources associated with the consequences that derive from them. In fact, falls are one of the major problems in the elderly population and one of the main geriatric symptoms and the second most common cause of accidental or non-intentional death in the world (WHO, 2016: Samantha Turner, Rupert Kisser, & Wim Rogmans, 2015).
Compared to other types of tools for fall risk assessment, such as the Physiological Profile Assessment (Lord, Menz, & Tiedemann, 2003) or the Berg (Wirz et al., 2010) and Tinetti (Raîche et al., 2000) clinical scales, which can be too long, costly, subjective or insensitive depending on the case, FallSkip is a flexible and objective instrument adapted to the needs of healthcare professionals.
FallSkip consists of a recording technique embedded in an Android device and a measuring protocol specifically designed for fall risk assessment. The protocol, based on a modified version of the Timed up and go test (Shumway-Cook et al., 2000), includes four consecutive phases: standing, starting to walk after hearing a sound, sitting and then getting up from a chair and, finally, walking again. The device is easily placed on the lumbar region of the subject being assessed (Figure 1) and measures the accelerations of their center of gravity, which in turn makes it possible to obtain biomechanical parameters related to balance, gait, the sit-to-stand activity and reaction time.
Figure 1. Placing FallSkip on the lumbar region.
These data are then combined with the main fall risk factors (age, gender and history of previous falls), thereby making it possible to obtain the final risk index (Figure 2). In this way, in under two minutes, FallSkip reliably and accurately assigns a person’s fall risk attributable to their functional state.
Figure 2. FallSkip results screen
FallSkip has demonstrated its reliability and validity in functional and fall risk assessment in various contexts, including patients with Alzheimer's disease (Serra-Añó et al., 2019) (López-Pascual et al., 2018) or Parkinson's disease (Serra-Añó et al., 2020). Also, the short duration of the test, together with its objectivity, make it an ideal system for use in any clinical context, where both aspects are important.
The objective of this article is to present the usefulness of FallSkip in the clinical field through real user experiences.
FALLSKIP: USER EXPERIENCES IN THE CLINICAL FIELD
Use in Primary Care
In the Primary Care field, it is necessary to manage the high pressure on care efficiently without losing sight of the quality of the medical activity. In this sense, the Health Department of La Ribera launched a project three years ago to identify risk factors and establish strategies to prevent falls among the geriatric population. To do so, in addition to defining the patient’s social healthcare profile, physicians needed an objective tool that could help them to functionally assess the person, establish their fall risk and, at the same time, sustain the necessary efficiency in this field (García et al., 2018). In this context, FallSkip allowed them to carry out such a task and they found in their sample that more than half of the assessed patients had a moderate, high or very high risk, laying the foundations for the definition of the most appropriate management approaches in each case.
It was also possible to compare the results provided by FallSkip with other types of tools, such as the SPPB (Short Physical Performance Battery) and the icon-FES (Falls Self-Efficacy Scale) questionnaire, which are used respectively to assess the functionality of the lower limbs and confidence when performing everyday life activities, obtaining promising results (Folch et al., 2019).
It should be noted that this project was the result of a collaboration agreement between the IBV and ALZIRA (the University Hospital of La Ribera) managed by Ribera Salud II UTE Ley 18/82, which was created precisely to meet the needs expressed by healthcare professionals. This collaboration therefore granted Primary Care physicians access to the use of new technologies, with the aim of improving the management, detection and handling of the risk of falls among the elderly. The physicians involved said that the FallSkip tool was well received, and they highlighted its speed, usability and the fact that it is so easy to use, and how obtaining valuable clinical results in such a short time allowed them to improve efficiency in the care provided to elderly people (Folch et al., 2019).
Use in the field of Rehabilitation
Physical Medicine and Rehabilitation is another field in which this technology has aroused most interest, probably because functional assessment is one of its main and indeed essential tools. As a result, fall risk assessment using FallSkip has found a niche both in the healthcare area per se, and in the research branch of the specialty.
In the first case, in the healthcare field, we can find examples such as that of the La Plana University Hospital, in Castellón, where patients with fractures of a possible osteoporotic origin were assessed both by bone densitometry and by FallSkip. In this way, by obtaining information on both bone condition and the risk of falling, it is possible to establish a series of specific therapeutic approaches depending on the results of both assessments, thereby improving efficiency and the success of this care circuit. Another example is the Physical Medicine and Rehabilitation Service of the Arnau de Vilanova Hospital in Valencia. This unit uses FallSkip as an initial screening tool for patients with some type of instability or dizziness, only referring for an assessment with posturography those patients who present a specific pattern. This has helped in the management of this type of processes, and to improve the processing of consultations based on objective data.
Medical research is the preliminary step for the implementation or standardization of specific treatments or actions, and it is therefore necessary if we are to improve the management of care processes. Given its importance, it is essential to have valid, reliable and objective tools for measuring results. At the La Fe University and Polytechnic Hospital, FallSkip has been included in the methodology used to assess motor function in stroke patients, part of a study of the effects on gait of a rehabilitation system that employs a direct neuronal interface (Vázquez et al.). At the General University Hospital Consortium in Valencia, for its part, FallSkip has been included in the screening process for possible instability due to chemotherapy neurotoxicity in patients with breast cancer. In addition, these results are being compared with static posturography and with quality-of-life questionnaires.
Assessment of post-Covid-19 aftereffects
Finally, given our current public healthcare situation, we cannot ignore the consequences of the SARS-CoV-2(COVID-19) coronavirus pandemic. To date, since the first cases were detected in our country, more than 4.9 million people have suffered from this disease in Spain. Many of them, although they have recovered, are experiencing or have experienced long-term respiratory, cognitive, neurologic or musculoskeletal consequences, among others (Iannaccone et al., 2020). Regarding the latter, it is frequently found that such individuals’ overall motor performance has deteriorated and that they have a motor impairment that can secondarily lead to an increased risk of falls. All around the world, multidisciplinary teams have assessed and monitored these aftereffects, using functional assessment tools such as the Timed up and Go (Butler et al., 2021), the Sit-to-Stand test or Short Performance Physical Battery (Vasconcello-Castillo et al., 2020). As an alternative to these, FallSkip is presented as a tool that is able to functionally assess different gestures or activities (gait, balance, sitting and standing) and to rapidly provide a fall risk index. Thus, several hospitals have incorporated this system into their functional assessment protocols for patients with post-Covid-19 aftereffects.
Some examples would be the Rehabilitation Services of the La Fe University and Polytechnic Hospital, the General University Hospital Consortium in Valencia, or the Arnau de Vilanova Hospital, where the use of FallSkip has been added to the battery of tests or scales used in the follow-up consultations of these patients. Usually conducted one month after the patient has been discharged, and then again 5 or 6 months later, these assessments allow professionals to objectify the evolution of the patient and to help design specific rehabilitation objectives, also improving the safety of the treatment.
Figure 3. A snapshot taken during a FallSkip assessment of a patient with post-Covid-19 aftereffects.
Image courtesy of the Physical Medicine and Rehabilitation Service of the La Fe University and Polytechnic Hospital.
The study of patients with Covid-19 aftereffects is still ongoing and many questions regarding the long-term effects of this disease have yet to be answered. However, some of the findings have already been published in a number of forums. In the case of the Valencia General Hospital, the results of the assessment one month after discharge from the Intensive Care Unit indicate that the most frequent aftereffects include dyspnea, arthromyalgia, anxiety/depression, impaired balance with increased risk of falls, and loss of grip strength in both hands. (Ezzeddine, A. et al.,2021). The preliminary results of the study carried out at the La Fe Hospital in Valencia show a significant functional recovery between 4 and 6 months after discharge, highlighting the improvement in the parameters related to lower limb strength and its correlation with the score in the “Sit to Stand” section of FallSkip, as well as in the balance section and in the final fall risk rate (D’Ors, C. et al., 2021).
CONCLUSIONS
• The FallSkip/IBV system for fall risk assessment is a valid, reliable and flexible tool, adapted to the main needs of healthcare professionals.
• It is particularly useful in the evolutionary functional control of the patient, as well as in the design and selection of the most appropriate therapeutic options for each case.
• Thanks to its ability to rapidly obtain objective information, the integration of FallSkip/IBV within care processes makes it possible to improve the quality of the care provided and to increase the efficiency of the healthcare services.
ACKNOWLEDGEMENTS
First of all, we would like to express our most sincere thanks to all the clinical entities and healthcare professionals who have shared their experiences with FallSkip/IBV with us, and to those who have also allowed us to explicitly mention them in this article. We would particularly wish to highlight the involvement of the healthcare professionals in the Primary Care unit of the Health Area of La Ribera, as well as the physicians in the Physical Medicine and Rehabilitation areas of the following hospitals: La Plana in Castellón, the La Fe University and Polytechnic Hospital, the General University Hospital Consortium in Valencia, and the Arnau de Vilanova Hospital.
We would also like to thank the IVACE (the Valencian Institute of Business Competitiveness) for the support they have given to the IBV’s activities in this field, as can be seen by the funding we have received within the framework of the Project (IMAMCJ/2021/1), in Nominative Line S8021000 distributed in favor of the technology centers of the Autonomous Community of Valencia, approved by the Budget Law of the Generalitat (Government of Valencia) for 2021.
Project co-funded by IVACE
REFERENCES
D’Ors Vilardebó, C., González-King Garibotti, C., Alonso Barquero, J., Elvira López, L., Vázquez Arce, I., Viosca Herrero, E. La Fe University and Polytechnic Hospital (7 and 8 May 2021). Functional assessment in a post-Covid consultation: experience after a year of pandemic. 30th Congress of the Valencian Society of Physical Medicine and Rehabilitation. Valencia. Spain.
Ezzeddine Angulo, A., Sogues Colom, AL., Elia Martínez, JM., Castillo, E., Máñez Añon, I., Íñigo Huarte, V., CHGUV. (7 and 8 May 2021). Functional assessment 1 month and 6 months after being discharged from hospital after infection by Sars-Cov-2, with admission to the Intensive Care Unit. 30th Congress of the Valencian Society of Physical Medicine and Rehabilitation. Valencia. Spain.
Folch, B., Donato, C., Ruivo, M., Ruiz, A., Tapia, A., Palop, V., Pitarch Corresa, S., Pedrero, J. F., Garrido Jaen, J. D., & Andrade Celdrán, J. (2019). Healthcare innovation in the management of the risk of falling in elderly people in Primary Care. Revista De Biomecánica (Online), (66).
Iannaccone, S., Castellazzi, P., Tettamanti, A., Houdayer, E., Brugliera, L., de Blasio, F., Cimino, P., Ripa, M., Meloni, C., Alemanno, F., & Scarpellini, P. (2020). Role of Rehabilitation Department for Adult Individuals with COVID-19: The Experience of the San Raffaele Hospital of Milan. Archives of Physical Medicine and Rehabilitation, 101(9), 1656-1661. 10.1016/j.apmr.2020.05.015
López-Pascual, J., Hurtado Abellán, J., Inglés, M., Espí-López, G., & Serra-Añó, P. (2018). P 151 – Reliability of variables measured with an Android device during a modified timed up and go test in patients with Alzheimer’s disease. Gait & Posture, 65, 484-485. 10.1016/j.gaitpost.2018.07.072
Lord, S. R., Menz, H. B., & Tiedemann, A. (2003). A Physiological Profile Approach to Falls Risk Assessment and Prevention. Physical Therapy, 83(3), 237–252
Raîche, M., Hébert, R., Prince, F., & Corriveau, H. (2000). Screening older adults at risk of falling with the Tinetti balance scale. The Lancet, 356(9234), 1001-1002
Ripoll, E. M., Sánchez, J. F. P., Jaén, J. D. G., Pascual, J. L., Bosch, I. B., Corresa, S. P., Alonso, M. I. S., Moreno, C. C., Vilela, J. M., & Celdrán, J. A. (2017). FallSkip: Fall risk assessment in older adults. Revista De Biomecánica, (64), 55-60
Ruiz García, A., Martínez Lopez, E., Ruiz García, M., Juan, S. C., Clemente García, M., Donato Ripoll, C., Femenía, P. O., Pérez Nicolás, E., García Sáez, J., & Torrecilla Hernandez, M. (2018). -PROFILE AND RISK OF FALLS IN PATIENTS IN A HEALTHCARE CENTER. FALLSKIP STUDY. Semergen. 2018; 44 (Espec Congr 17): 1148
Samantha Turner, Rupert Kisser, & Wim Rogmans. (2015). Falls among older adults in the EU-28: Key facts from the available statistics.
Serra-Añó, P., Pedrero, J. F., Hurtado-Abellán, J., Inglés, M., Espí-López, G., & Lopez Pascual, J. (2019). Mobility assessment in people with Alzheimer disease using smartphone sensors. Journal of Neuroengineering and Rehabilitation, 16(1), 1-9
Serra-Añó, P., Pedrero-Sánchez, J. F., Inglés, M., Aguilar-Rodríguez, M., Vargas-Villanueva, I., & López-Pascual, J. (2020). Assessment of Functional Activities in Individuals with Parkinson’s Disease Using a Simple and Reliable Smartphone-Based Procedure. International Journal of Environmental Research and Public Health, 17(11), 4123.
Shumway-Cook, A., Brauer, S., & Woollacott, M. (2000). Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Physical Therapy, 80(9), 896-903.
Vasconcello-Castillo, L., Torres-Castro, R., Solís-Navarro, L., Rivera-Lillo, G., & Puppo, H. Functional and Respiratory Assessment in Post COVID-19 patients: What are the best tests? Kinesiology 39(2): 109-115
Vázquez-Díez, Juan (1); Martínez-Expósito, Aitor (2); Montalva-Iborra, Alberto (1); Viosca-Herrero, Enrique (1); Pons, José L. (2). The use of a brain computer interface (BCI) in gait rehabilitation of stroke patients. (1) La Fe Healthcare Research Institute (Valencia, Spain) (2) Neural Rehabilitation Group of the Spanish National Research Council (Madrid, Spain)
Wirz, M., Müller, R., & Bastiaenen, C. (2010). Falls in persons with spinal cord injury: validity and reliability of the Berg Balance Scale. Neurorehabilitation and Neural Repair, 24(1), 70-77.
