title: Do extreme values of daily-life gait characteristics provide more information about fall risk than median values?
abstract: BACKGROUND
  Gait characteristics estimated from daily-life trunk accelerations reflect gait quality and are associated with fall incidence in older adults. While associations are based on median values of these gait characteristics, their extreme values may reflect either high-risk situations or steady-state gait and may thus be more informative in relation to fall risk.
  
  
  OBJECTIVE
  The objective of this study was to improve fall-risk prediction models by examining whether the use of extreme values strengthens the associations with falls.
  
  
  METHODS
  Trunk acceleration data (Dynaport MoveMonitor) were collected from 202 older adults over a full week. From all walking episodes, we estimated the median and, as reliable estimates of the extremes, the 10th and 90th percentiles of gait characteristics, all over 10-second epochs. In addition, the amount of daily activities was derived from the acceleration data, and participants completed fall-risk questionnaires. Participants were classified as fallers based on one or more falls during 6 months of follow-up. Univariate analyses were performed to investigate whether associations with falls were stronger for the extremes than for the medians. Subsequently, three fall-risk models were compared: (1) using questionnaire data only, (2) adding the amount of activities and medians of gait characteristics, and (3) using extreme values instead of medians in the case of stronger univariate associations of the extremes.
  
  
  RESULTS
  Stronger associations were found for the extreme characteristics reflecting high regularity, low frequency variability, and low local instability in anterior-posterior direction, for high symmetry in all directions and for low entropy in anterior-posterior and vertical directions. The questionnaire-only model improved significantly by adding activities and gait characteristics' medians. Replacing medians by extremes with stronger associations did improve the fall prediction model, but not significantly.
  
  
  CONCLUSIONS
  Associations were stronger for extreme values, indicating "high gait quality" situations (ie, 10th and 90th percentiles in case of positive and negative associations, respectively) and not for "low gait quality" situations. This suggests that gait characteristics during optimal performance gait provide more information about the risk of falling than high-risk situations. However, their added value over medians in prediction is limited.
authors.affiliation: MOVE Research Institute Amsterdam, Faculty of Human Movement Sciences, VU University Amsterdam, Amsterdam, Netherlands.
authors.forename: Sietse M
authors.identifier: http://orcid.org/0000-0002-9400-6125
authors.initials: SM
authors.lastname: Rispens
authors.forename: Kimberley S
authors.identifier: http://orcid.org/0000-0003-0902-8440
authors.initials: KS
authors.lastname: van Schooten
authors.forename: Mirjam
authors.identifier: http://orcid.org/0000-0001-8416-2602
authors.initials: M
authors.lastname: Pijnappels
authors.forename: Andreas
authors.identifier: http://orcid.org/0000-0001-9107-3552
authors.initials: A
authors.lastname: Daffertshofer
authors.forename: Peter J
authors.identifier: http://orcid.org/0000-0002-0917-8548
authors.initials: PJ
authors.lastname: Beek
authors.forename: Jaap H
authors.identifier: http://orcid.org/0000-0002-7719-5585
authors.initials: JH
authors.lastname: van Dieën
keywords: accelerometry; accidental falls; activities of daily living; aged; gait; logistic models; risk assessment; walking