Worry about an older person falling is a concern that never goes away in any family with an older relative. A single fall can go from a hip fracture and hospital admission to the person never daring to walk alone again, and quality of life drops sharply. The most natural reaction from family members is therefore to keep repeating, "Walk slowly", "Be careful", "Hold on tight".
The evidence shows, however, that simply telling older people to be careful is not an effective way to prevent falls. Balance, like strength, can be retrained, and the single most effective fall prevention intervention with the strongest evidence is exercise that challenges balance. This article goes through the causes of falls, which exercise really reduces falls, the effective exercise "dose", specific fall prevention programmes with evidence, the vicious circle of fear of falling, and how exercise (physiotherapy, changing the "person") and home modification (occupational therapy, changing the "environment") divide the work. It also states the limits of exercise plainly: it lowers the fall "rate", and it does not guarantee zero falls.
The different factors behind falls, and what exercise does
Falls are rarely caused by a single factor. They result from several risk factors adding together: weaker muscles, poorer balance and gait, failing eyesight, medication side effects, and tripping hazards in the home. The World Falls Guidelines 2022 (Montero-Odasso et al. 2022) recommend a multifactorial risk assessment for older people at high risk (covering mobility, vision, cognition, medication review including medicines that raise fall risk, postural hypotension and the environment), and position strength plus balance or multimodal exercise as the core modifiable intervention.
The point is that among all these factors, exercise that challenges balance is the single most effective factor and the one that changes things most. Exercise is a necessary condition and not a sufficient one, however. Medication, eyesight, postural hypotension and the home environment are equally important and must be assessed and dealt with together. It should not be thought that doing only exercise solves every problem.
Difficulty and amount required of fall prevention exercise
Fall prevention does not mean that any activity works. Sherrington et al. (2017, Br J Sports Med) pooled data from 88 trials, 99 comparisons and 19,478 older people, and found that exercise reduced the fall rate by about 21% overall (RaR 0.79, 95% CI 0.73–0.85). The real key is in the detail. Programmes that both "challenge balance" and total "more than 3 hours a week" reduced falls by about 39% (IRR 0.61, 95% CI 0.53–0.72), and these two variables alone explained 76% of the differences between trials. In other words, whether a programme works depends largely on how much it challenges balance and whether the training hours are enough.
The amount of exercise required for fall prevention: effective fall prevention exercise must challenge balance to some degree, be done for more than 3 hours a week, and be kept up. If the amount is not enough, or the movements that train balance are missing, the fall prevention effect is greatly reduced. This also explains why "a few more walks" is usually not enough to prevent falls.
Fall prevention effect of different types of exercise
Sherrington et al. (2019, Cochrane) pooled data from 108 randomised controlled trials with 23,407 older people and ranked the types of exercise by certainty of evidence. Balance and functional exercise was the most effective (RaR 0.76, high certainty). Multimodal exercise had an RaR of 0.66 (moderate certainty), and tai chi had an RaR of 0.81 (low certainty). The effect of resistance (strength) training alone on the fall rate was "uncertain". The best practice recommendations of Sherrington 2011 say more directly that walking alone is not enough, and older people at high risk should not be prescribed a brisk walking programme.
- Balance and functional exercise: RaR 0.76, high certainty, most effective (Sherrington 2019)
- Multimodal exercise (usually combining balance, function and resistance): RaR 0.66, moderate certainty
- Aims directly at the core mechanism of falls, control of the centre of gravity and reaction
- Needs a high balance challenge plus enough dose to work (see the previous section)
- Resistance training alone has an "uncertain" effect on the fall rate (Sherrington 2019). Strength is an ingredient, and balance is the active ingredient in preventing falls
- Walking alone is good for the heart and lungs but not enough to reduce falls (Sherrington 2011)
- Older people at high risk should not be prescribed a brisk walking programme, which may even be harmful (Sherrington 2011)
Fall prevention exercise programmes supported by clinical research
Besides the main principles, the following two fall prevention programmes with evidence behind them, which can be carried out in practice, are worth knowing.
Otago exercise programme (mainly home-based training)
- Lower limb strength plus balance training (can be done at home). The pooled analysis by Thomas et al. 2010 showed a fall rate IRR of 0.68.
- Mortality at 12 months also fell (RR 0.45, 0.25–0.80).
- An honest limitation: serious or injurious falls did not fall significantly (RR 1.05, 0.91–1.22).
- Another practical limitation: adherence at 12 months was only about 37%, so keeping going is the hard part of getting results.
Tai chi / Tai Ji Quan (Moving for Better Balance)
- Li et al. 2018 (JAMA Intern Med), a randomised controlled trial of 670 older people at high risk.
- Tai chi vs stretching: IRR 0.42, a 58% reduction in falls.
- Tai chi vs general multimodal exercise: IRR 0.69, a 31% reduction, better than general multimodal exercise.
- Culturally familiar and low-impact, but the certainty of the Cochrane pooled evidence is lower (RaR 0.81), and it needs to be practised correctly with guidance.
How to do balance training in practice
"Challenging balance" is not an abstract slogan. It is a process that can progress step by step and get harder in stages. The core principle is to keep pushing the body towards the edge of "nearly losing balance but still safe", so that the brain and muscles learn to correct posture. The practical direction of progression is as follows (the therapist must grade it according to individual ability, and it must be done in a safe environment).
- 1Narrow the baseWhen standing, start with the feet apart, then bring them together, then semi-tandem, and finally one foot in front of the other, gradually narrowing the support area of the feet.
- 2Move the centre of gravityPractise shifting weight forward, back, left and right, and reaching for things, to train control of the centre of gravity.
- 3Reduce supportAt first hold on with both hands, then with one hand, then touch lightly with the fingertips, and only at the end let go, reducing the help from the hands step by step.
- 4Add a dual taskWhile standing or walking, count or chat with someone at the same time, imitating how the body keeps balance when attention is divided in daily life.
The difficulty of the exercise needs to be judged by a professional. When to make it harder and when to go back a level must be decided by the physiotherapist according to the older person's ability and fall risk at the time. The whole practice must also be done in a safe environment with a firm handrail or support and someone watching. Making it harder alone makes falling more likely.
The vicious circle brought by fear of falling
The cost of one fall is often more than the physical injury. A fall (or even a near-fall) is enough to trigger fear of falling, and the older person starts to do less. Less activity makes strength and balance decline faster, and the person becomes more likely to fall. This forms the vicious circle of "fear of falling, then less activity, then weaker body, then falling more easily". The value of exercise is that it lowers the fall rate and breaks this circle at the same time.
How strong the related evidence is: a study by Kumar et al. in 2016 (Cochrane) showed that exercise can reduce older people's fear of falling (SMD 0.37, 95% CI 0.18–0.56). However, this is low-quality evidence, and the effect appeared mainly in the short term just after training. The long-term effect was smaller and did not reach statistical significance. Reducing fear of falling through exercise is therefore a reasonable direction, but it should not be treated as a proven long-term effect.
How physiotherapy and occupational therapy divide the work on fall prevention
A complete fall prevention plan depends on two pillars: changing the "person" on one side and changing the "environment" on the other. The two complement each other, and neither can be left out.
- Training balance, lower limb strength and gait, raising the body's own ability to prevent falls
- Prescribing exercise programmes with evidence (such as Otago and tai chi / Moving for Better Balance)
- Grading by ability, challenging balance progressively, and supervising correct posture and safety
- Home modification: handrails, non-slip surfaces, lighting and removing tripping hazards
- Assessing risk in the older person's actual home and daily routes
- See the occupational therapy article on home modification for fall prevention (this article does not rewrite the content on handrails, non-slip surfaces or home modification)
Put simply, physiotherapy makes the older person "steady on their feet and walking well", and occupational therapy makes the home "free of traps". For older people at high risk, both are needed to make a complete fall prevention plan.
Starting safely
Fall prevention exercise does not mean finding a few balance movements and telling an older person to follow them. To start training safely and effectively, the following principles are suggested.
- First have a physiotherapist assess fall risk and function, then design the exercise individually, and not one set of movements for everyone.
- Progress from low challenge to high challenge, making it harder only once each level is steady.
- Do everything in a safe environment, with something firm to hold and someone watching.
- Deal with medication, eyesight, postural hypotension and other factors together, referring to a doctor or eye specialist when needed (refer out).
- Combine with home modification (occupational therapy) to improve environmental risk, so that both legs of the plan move together.
- Older people at high risk should not start a brisk walking programme on their own (Sherrington 2011).
Do not push into difficult movements. Trying difficult balance movements alone without a professional assessment, or practising alone with no one watching, raises the risk of falling and injury. If severe dizziness, chest pain or marked breathlessness occurs during practice, stop at once and seek medical help.
The evidence on fall prevention exercise and its limits
The limits mentioned in this article are listed one by one below, so that families and older people can set reasonable expectations.
- Exercise reduces the fall "rate" and does not eliminate falls. The best figure is a relative reduction (about 21–39%), not zero falls.
- Dose and balance challenge are both needed: the 39% benefit requires over 3 hours a week and a high challenge to balance (Sherrington 2017).
- Walking alone is not enough, and brisk walking may be harmful for people at high risk (Sherrington 2011).
- Strength alone is weaker than balance: resistance training alone has an uncertain effect on the fall rate (Sherrington 2019).
- The reduction in injurious falls is less certain: Otago showed no significant fall in serious injury falls (RR 1.05), and adherence was only about 37% (Thomas 2010).
- The benefit for fear of falling is low certainty and short term (Kumar 2016), and the certainty of the pooled evidence for tai chi is also lower (RaR 0.81).
- Falls have many causes: medication, eyesight, postural hypotension and the environment must be dealt with together, and exercise is necessary but not sufficient.
All these limits rest on the same premise: that older people actually do enough exercise and keep it up for long enough. Yet the older people who most need balance training are often the ones who find it hardest to go out. Because of fear of falling and needing a family member to go with them, even travel and stairs are a big hurdle, and attendance at a centre stops after a few sessions. This is not a problem of evidence on effectiveness but one of access to services. The point of home physiotherapy is that the start and continuation of training no longer depend on whether the older person can get out that day.