Running head: The Reactive Leg Drop: A Novel Sensory-Motor Assessment 1

The Reactive Leg Drop: A Simple and Novel Sensory-Motor Assessment to Predict Fall

Risk in Older Individuals

The leading cause of fatal and nonfatal unintentional injuries among people aged 65 and

older are falls1. Roughly a third of adults fall every year and the likelihood of falling increases

with aging.1 In the USA, over $23 billion is spent annually on fatal and non-fatal fall costs for

the elderly.2 Previous research shows that decreased muscle function is directly related to a loss

of muscle mass leading to a decline in strength and power which may contribute to the likelihood

of accidental falls and decreased in the elderly’s quality of life.3

There are many tests that examine older adults’ functional ability. One of these

assessments is the Sit-to-Stand test which has the participant stand up from a chair, without

pushing off, five times as quick as they can.4 Another functional test is the Timed ‘Up & Go’ test

where the subject gets up from an arm chair, walks 3 meters, turns, walks back to the chair, and

then sits back down while being observed.4 Most of these field tests focus on the motor skills that

are involved in falls, but very few assess the integration of both sensory and motor systems,

which is required to avoid a fall.

Therefore, there is a need for a field test that can assess motor and sensory function to

better predict fall risk and help identify high-risk individuals. The purpose of this study is to

examine a novel sensory-motor assessment, the reactive leg drop, and evaluate its utility for

predicting fall risk.

Background Literature

Lusardi et al5 explained that a fall was “an event in which an older adult unintentionally

came to rest on the ground or other lower supporting surface, unrelated to a medical incident or

to an overwhelming external physical force” (4). Some factors of fall risks are visual
The Reactive Leg Drop: A Simple and Novel Sensory-Motor Assessment 2

impairment,6 reduced efficacy of postural responses,5 female sex,6 diminished sensory acuity,5

cognitive decline,6 impaired musculoskeletal,5 neuromuscular,5 and/or cardiopulmonary

systems,5 environmental factors,5.6 depression and low balance efficacy,5 history of falls,6

polypharmacy,5,6 balance and gait disorders,6 deconditioning associated with inactivity,5 and

pain.6 Mazur et al6 used “general history (including fall history and balance disorders) and by

performing a physical examination (postural balance and gait assessment), geriatric functional

assessment, blood work, electrocardiogram, abdominal ultrasound, and chest Z-ray” to evaluate

patients (1255). Mazur et al6 also argued that fall prevention in the hospital or in a heath care

facility setting requires multifactorial risk assessments and interventions tailored to each

patient’s specific needs. While there are many studies out there, there is no truly effective fall

prevention program that has been presented; therefore, there is a need for better studies to predict

fall risks for geriatric patients.6 Buatois et al4 found that “Posturography evaluation under

conflicting sensory conditions by the SOT”, when compared to static and dynamic

posturographic tests and to clinical balance tests, is a better tool to help assess who is at risk of

falling repeatedly in older subjects that are active, independent, and non-institutionalized (351).

Position sense is an important role in moving safely and if the position sense is disturbed

it can affect daily activities and lead to injuries.7 Previous studies done on position sense focused

on the upper limbs; however, our lower limbs contribute to difficulty in moving and performing

daily activities as well.7 Paschalis et al7 stated that “Muscle reaction time is defined as the time

from a stimulus to the beginning of a muscle response, and has been used frequently in the

evaluation of motor performance” (497). Linford et al8 had a 6-week neuromuscular training

program where subjects did therapeutic exercises along with their normal daily activities. In the

study, Linford et al8 found that their program “significantly reduced reaction time while
The Reactive Leg Drop: A Simple and Novel Sensory-Motor Assessment 3

marginally increasing the electromechanical delay of the peroneus longus muscle in healthy

subjects.”

Rationale and Purpose

Motor function is not the only issue to consider when assessing fall risk across the age

span. Sensory function is an important component of falling; therefore, a new test that examines

both sensory and motor function simultaneously is necessary. The purpose of this study is to

determine how effective the reactive leg drop is at detecting the deficits in sensory and motor

function across the age span.

Methodology

Subjects

Fourteen young females (mean ± SD: 20.9 ± 1.3 yrs) and ten older females (mean ± SD:

75.9 ± 3.9 yrs) volunteered for this study. Participants could not have musculoskeletal

dysfunctions or circulatory/edema pathologies involving hip, knee, or ankle joints to be eligible.

Participants also needed to be independently living, able to come to the lab for testing, and

complete an informed consent form with a heath history questionnaire and a physical activity

readiness questionnaire. This study was approved for human participant research by the

University institutional review board.

Data Collection Procedures

Before beginning the study, the participants were directed to avoid any lower body

exercise 24 hours prior to testing. Participants were first familiarized with each assessment

before the testing session. Participants then completed a balance assessment to evaluate their

sway index. Following the balance assessment, the participants performed a series of reactive leg

drops under multiple sensory conditions.

The Reactive Leg Drop: A Simple and Novel Sensory-Motor Assessment 4

Balance Assessment

The first part of the testing session was the balance assessment where each participant

completed the modified clinical test of sensory integration of balance (m-CTSIB) test using a

Biodex Balance System SD (Biodex Medical Systems, Inc., Shirley, NY, USA). The m-CTSIB

assessed each participant’s sway index using the postural sway from the participant’s center

point on the platform.9 Postural stability is an individual’s ability to maintain an upright

position.9 This balance assessment was adapted from Thiele et al.9 This assessment had four

conditions: eyes-open on a firm surface (EOFS), eyes closed on a firm surface (ECFS), eyes-

open on a soft surface (EOSS), and eyes closed on a soft surface (ECSS). Each condition lasted

30 seconds and the participants were instructed to stand on the platform with their feet shoulder-

width apart, their body centered on the platform, and standing upright.9 They were also directed

to take their shoes off and rest their hands on their hips while looking straight ahead and standing

as still as they could.9 Each condition was progressively more difficult to challenge their sensory

systems.10 The sway index was automatically calculated and provided at the end of each

participant’s assessment by the manufacturer’s (Biodex Balance System SD) software.

Reactive Leg Drop

The next part of the testing session was the reactive leg drop. Each participant sat in a

dynamometer with their right leg extended to their maximal range of motion (ROM) and held up

by an elastic band held by the researcher. The participants were asked to relax their quadriceps

and then the investigator would let go of the elastic band, allowing the participant’s right leg to

free-fall. The participant was asked to extend their leg back to a full extension as fast as they

could once they felt their leg falling. There were four different conditions for the reactive leg

drop: eyes-open looking at the limb (EO), eyes-closed (EC), eyes-closed while performing a
The Reactive Leg Drop: A Simple and Novel Sensory-Motor Assessment 5

diverting activity; the jenndrassik maneuver (EC_JEN), and eyes-open with the vision of the

lower lib blocked (EO_BLK). The change in the participant’s knee joint angle from the starting

position to the lowest position is our dependent variable.

Data Analysis

Each leg drop was recorded on a wireless tablet (iPad, Apple, CA, USA) and a video

analysis software (kinovea, version 0.8.25) was used to measure the knee joint angle of each

participant. The knee joint angle was measured in two positions: the passively extended position

and the position in which the participant stopped their limb from falling before they proceeded to

extend it back to the starting position. The lateral joint line served as the axis of limb rotation, the

greater trochanter served as the stationary anatomical landmark, and the lateral malleolus served

as a moving anatomical landmark. The kinovea video analysis software has been shown to be a

reliable measurement tool of movement.11

Statistical Analysis

Between group differences (young vs. older) were examined with paired smaple t-tests

for each dependent variable. A Pearson correlation was used to examine the relationship between

reactive leg drop knee angle and the proprioceptive condition from the balance assessment

(ECFS). An alpha level of p < 0.05 was used for all statistical comparisons.

Results

There was no significant difference between sway index for younger and older women

for the EOFS and ECFS balance assessments (Figure 1). Older women had a significantly greater

knee joint angle in the EC_JEN leg drop condition (Figure 2). The correlation between knee joint

angle and ECFS was only significant in older women with R2=0.82143 (Figure 3).
The Reactive Leg Drop: A Simple and Novel Sensory-Motor Assessment 6

Sway Index
1
0.9
0.8
Young EOFS
0.7
Old EOFS
0.6
Young ECFS
0.5
Old ECFS
0.4
0.3
0.2
0.1
0

Figure 1

Knee Joint Angle

48
47
46
45 Young
Old
44
43
42
41
40

Figure 2
The Reactive Leg Drop: A Simple and Novel Sensory-Motor Assessment 7

R² = 0 90

80
Knee Joint Angle during Leg Drop

70

60

50

40 Older
Trendline (Older)
30 Young
20

10

0
0.2 0.4 0.6 0.8 1 1.2 1.4 1.6
SWAY INDEX - Eyes Closed, Firm Surface

Figure 3

Discussion

There were no significant differences between younger and older female in the balance

assessments, this could have been because the older group may have been too healthy. There was

a significant difference in the knee angle which means that the older women let their leg drop

further before kicking it back up than the younger women. This also meant that the younger

women reacted faster and produced a motor compensation before the older women. The leg drop

condition that relied the most on proprioception (EC_JEN) showed a strong, significant

relationship with the balance condition that relied the most on proprioception (ECFS).

Conclusion

The knee joint angle of a reactive leg drop was sensitive to differences with age, showing

a significant difference between the young and the old. Knee angle also had a strong, significant

relationship with sway index in the older women, indicating that the reactive leg drop depends

heavily on proprioceptive function and may be a good predictor of fall risk.

Implications
The Reactive Leg Drop: A Simple and Novel Sensory-Motor Assessment 8

Most functional ability assessments currently focus on evaluating motor function in older

adults and not sensory function. A new assessment utilizing sensory and motor function

simultaneously is crucial to assess sensory-motor integration. This study provides a novel

sensory-motor assessment to examine fall risk in the older population.

The Reactive Leg Drop: A Simple and Novel Sensory-Motor Assessment 9

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