Movement / note 03
Balance and falls prevention: what the evidence says
A large Cochrane review found exercise reduces falls in older people. Here is what that means, which exercises were involved, and where the evidence is weaker.
Falls are common enough that many older adults and the people around them quietly worry about them. This note looks at one practical question: does exercise actually reduce falls, and if so, which kinds? It draws on a major Cochrane review, plus guidance from the CDC, the National Institute on Aging and the NHS.
How common falls are
The CDC reports that more than one in four older adults report falling each year, and that about 3 million older adults are treated for a fall injury annually. The Cochrane review we use below puts it at least one in three among community-dwelling people over 65. The figures differ because they come from different sources and definitions, but both say falls are frequent.
The CDC's STEADI programme, which stands for Stopping Elderly Accidents, Deaths and Injuries, suggests three simple steps to reduce risk: talk to your doctor, keep moving and remove clutter. Exercise is one piece of a bigger picture, alongside home safety and medical review.
What the Cochrane review found
Cochrane reviews pool the results of many randomised trials. This one, published in 2019 and searching up to May 2018, included 108 trials with 23,407 participants in 25 countries. On average participants were 76 years old and 77% were women, and all lived in the community.
Across 81 trials comparing exercise of any type with a control, the reviewers found that exercise reduces the rate of falls by 23%. Put in numbers, if 850 falls happened among 1000 people over a year, exercise would mean about 195 fewer. It also cut the number of people who fell at least once by 15%, or about 72 fewer fallers out of an illustrative 480 per 1000. The reviewers rated the certainty of these findings as high.
Results varied by exercise type. Programmes of mostly balance and functional exercises (tasks like standing up and stepping) reduced the rate of falls by 24%, again with high certainty. Programmes combining several types, typically balance and functional work with resistance exercise, probably reduced falls by 34%, with moderate certainty. Tai Chi may also reduce falls. The reviewers were uncertain about programmes that were mainly resistance training, dance or walking.
Where the evidence is weaker
Most of the trials had unclear or high risk of bias, largely because people cannot be blinded to whether they are exercising. The effect on fractures (a possible 27% lower chance) and on falls needing medical attention rested on fewer studies and was rated low certainty. The effect on hospital admissions was unclear. Exercise made little important difference to health-related quality of life.
Side effects were reported to some degree in 27 trials. Apart from two serious events in one trial (a pelvic stress fracture and an inguinal hernia operation), they were mostly minor and of a muscle or joint nature. The authors also note that adverse events were closely monitored in only one trial, so safety data are limited.
What balance exercises look like
The NIA lists tai chi, yoga, standing on one foot, the heel-to-toe walk, walking backward or sideways, and practising standing up from a seated position. It suggests aiming for about three sessions of balance exercise a week. The CDC adds that strengthening the back, abdomen and leg muscles also helps balance. The CDC's weekly recommendation for adults 65 and older includes balance activities alongside aerobic and strengthening work. Read about the strengthening side in strength training for older adults.
The NHS describes a few gentle home options. In the one-leg stand, you face a wall with fingertips touching it, lift one leg, hold for 5 to 10 seconds and repeat 3 times on each side. In the heel-to-toe walk, you aim for at least 5 steps, with your fingers against a wall if needed. The NHS suggests doing these near a wall or stable chair, building up slowly, and trying at least twice a week.
Safety advice from the NIA is similar: go slowly, keep a sturdy chair, person or wall nearby, wear stable footwear or go barefoot for grip, and steady yourself if you feel unsteady. Walking is also part of staying mobile, covered in walking and how much is enough.
When to ask a clinician
The NIA advises seeking guidance from a doctor or physical therapist if you are unsure about a movement. The CDC encourages older adults to talk to a doctor about fall risk. The NHS describes its balance exercises as gentle, suitable even if you have not done much exercise for a while, and still suggests keeping a wall or stable chair close in case you lose your balance. The CDC's falls materials also cover medicines, eyesight, footwear and home hazards, which is why a clinician's wider view can be useful. This note is general background, not individual advice. More on the theme is on the movement shelf.
The short version
A large Cochrane review found, with high certainty, that exercise lowers the rate of falls in older people living at home, with the clearest benefit from balance and functional training. Evidence for fractures and hospital admissions is weaker. If you have fallen, feel unsteady or have health conditions, ask a clinician before starting a programme.