Wiedenmann et al.

European Review of
European Review of Aging and Physical Activity (2023) 20:1
https://doi.org/10.1186/s11556-023-00311-w Aging and Physical Activity

REVIEW ARTICLE Open Access

Exercise based reduction of falls

in communitydwelling older adults: a network
meta‑analysis
Tim Wiedenmann, Steffen Held, Ludwig Rappelt, Martin Grauduszus, Sofie Spickermann and Lars Donath*   

Abstract
Background Traditional meta-analyses with pairwise direct comparison revealed that a variety of exercise-based
training interventions can prevent falls in community-dwelling older adults. This network meta-analysis adds value by
comparing and ranking different exercise training strategies based on their effects on fall risk reductions determined
by analysis of direct and indirect comparisons.
Methods The studies included in this network meta-analysis were identified through a comprehensive search in five
biomedical databases (PubMed, SportDiscus, CINAHL, Web of Science and EMBASE). We included (randomized) con-
trolled trials (RCTs) that compared the occurance of fall events in older adults who received different interventional
treatments.
Results Seventy six comparisons from 66 RCTs with 47.420 (61% male / 39% female) participants aged 77 ± 4 (68
– 88) years were included in this network meta-analysis. The network model revealed low heterogeneity (­ I2 = 28.0,
95%CI 1.0 to 47.7%) and inconsistency (Q between designs = 15.1, p = 0.37). Postural control training was found
to be most effective in preventing falls (Postural Control Training: (home): Risk Ratio (RR) = 0.66, 95%-CI [0.49; 0.88],
P-score = 0.97;Postural Control Training: RR = 0.82, 95%-CI [0.75; 0.91], P-score = 0.82). Combined and multifactorial
interventions also display a robust but smaller effect (RR = 0.88–0.93, P-score = 0.65–0.47).
Conclusion Physical activity that includes balance training presents itself to be the most effective. Multifactorial
approaches are well investigated but could be slightly less effective than isolated postural control training.
Keywords Elderly, Training, Seniors, Balance, Strength, Fall prevention

Background expectancy in western societies and the increasing risk

Falls are a serious health concern and a major cause of of falls during the later years in life, resulting health care
morbidity and mortality in community-dwelling older costs caused by injurious falls will continue to increase
adults [1]. Approximately one in three older adults above until the end of the current century [4]. The prevention
the age of 65 fall at least once a year and half of them of falls is therefore not only of utmost importance for
are recurrent fallers [2, 3]. Considering the growing life maintaining independency of daily living, maintaining
wellbeing and quality of life in older adults [5] but also
*Correspondence: an urgent economic challenge for the healthcare system.
Lars Donath Available clinical practice guidelines for fall preven-
l.donath@dshs-koeln.de tion in the older population underpin the importance of
Department of Intervention Research in Exercise Training, Institute
of Exercise Training and Sport Informatics, Am Sportpark Müngersdorf 6, physical activity and exercise [6]. Observational, inter-
50933 Cologne, German Sport University Cologne, Cologne, Germany ventional and meta-analytical studies report beneficial
effects of physical activity in general and specific exercise

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Wiedenmann et al. European Review of Aging and Physical Activity (2023) 20:1 Page 2 of 10

training in particular for the prevention of falls [7–11]: Table 1 Search strategy
An impactful meta-analysis by Sherrington and col- Search level Search terms with Boolean operators
leagues, for example, found a reduction of falls by about
23% and in number of fallers by around 15% following Search #1 “falls” OR “faller*”
physical physical training [8]. Search #2 #1 AND (“aged” OR “senior*” OR “elder*” OR “old” OR “aging”
OR “ageing” OR “postmenopausal” OR “community-
The majority of the included exercise-based fall pre- dwelling”)
vention studies focus on balance exercises or resistance Search #3 #2 AND (“randomized” OR “placebo” OR “trial”)
training. While tendencies favouring balance exercises
for the prevention of falls can be observed [8], it is not
entirely clear whether balance exercise alone or in a com- inclusion criteria based on the PICOS approach [popu-
bination with multiple exercise forms is most effective lation (P), intervention (I), comparators (C), main out-
for reducing fall risk. A network meta-analysis enables come (O), and study design (S)] were applied: Full-text
the calculation and comparison of treatment estimates article published in English in a peer-reviewed journal;
from direct and indirect evidence by using a common Participants were community-dwelling, independently
comparator that multiple interventions compare against. living people involved in studies with a mean age of at
This allows for the estimation of comparative effects for least 65 years and an age larger than 60 years when sub-
a large variety of interventions, including some compari- tracting one standard deviation from the studies mean
sons that have never been made directly [12, 13]. Hence, age, without additional diseases (e.g., stroke, chronic
this network meta-analysis provides comprehensive stroke, Parkinson’s disease, multiple sclerosis, dementia,
effect rankings that can help to find the physical train- hip fractures or other fractures) or an acute or chronic
ing program that has the strongest effect on reducing the mental or physical illness (such as cancer, depression,
number of falls. mild cognitive impairment, diabetes mellitus or COPD)
Against this background, the aims of this network (P). All studies that included at least one exercise inter-
meta-analysis are: (i) to rank different physical activities vention group and one control or another exercise inter-
based on their effect on fall prevention in older adults vention group were eligible. To rule out crosstalk effects,
and (ii) to analyse which form of exercise is most suitable supplement and medication studies were excluded (I).
for fall prevention. The outcome of this network meta- Comparators were groups with no or light physical
analysis can help to find a training program that could exercise (C). Documentation of the incidence of falls,
prevent health care costs from rising and increases qual- to estimate the risk ratio (RR), for at least six months,
ity of life in the later years for older adults. regardless of whether they were documented within the
intervention period, as a follow-up after the intervention,
Methods or during the intervention and in a follow-up period. A
Search and screening procedures fall was defined as a subject’s unintentionally coming to
This network meta-analytical review was registered [14] rest on the ground or at some other lower level, not as a
and conducted in accordance with the Preferred Report- result of a major intrinsic event (e.g. stroke or syncope)
ing Items for Systematic Reviews and Meta-Analyses for or overwhelming hazard [16] (O). Furthermore, the stud-
Network Meta-Analyses (PRISMA-NMA) [15]. The liter- ies had to be two- or multiarmed randomized controlled
ature search and screening processes were independently trails (S). The exclusion criteria were: (1) No adequate
conducted by two researchers (SS and MG). Five health- control conditions, which made integration into the net-
related, biomedical and psychological data-bases (Pub- work impossible. (2) The use of an alternative supporting
Med/MEDLINE; SPORTDiscus EBSCO, the Cumulative structures or systems such as an exoskeleton.
Index to Nursing and Allied Health Literature (CINAHL
EBSCO); Web of Science and EMBASE) were screened Assessment of methodological quality of the studies
from inception of the respective journals until December The methodological quality (including risk of bias) of
3rd 2021. Relevant search terms (operators) were com- the included studies was independently rated by two
bined with Boolean conjunctions (OR/AND) and applied researchers (SS and MG) using the PEDro (Physiotherapy
on three search levels (Table 1). In addition, tracking of Evidence Database) scale [17]. The PEDro scale consists
cited articles and hand searching of relevant primary of 11 dichotomous (yes or no) items, in which the crite-
articles and reviews were also carried out. Duplicates ria 2–9 rate randomization and internal validity and the
were removed and the remaining studies underwent a criteria 10–11 rate the presence of statistical replicable
manual screening. The remaining studies were gradu- results. Criterion 1 relates to the external validity and is
ally screened using (1) the titles, (2) abstracts and (3) not being considered in the PEDro score sum. A PEDro
full-texts of the potentially eligible articles. The following score ≥ 6 from 0 to 10 [17] represents a high quality study.
Wiedenmann et al. European Review of Aging and Physical Activity (2023) 20:1 Page 3 of 10

Data extraction NMA [19]. It is interpreted as the mean extent of cer-

Relevant data (required for calculating effect sizes) were tainty that one intervention is superior to any other and
extracted independently by two researchers (SS and MG) is analogous to the surface under the cumulative rank-
using a standardized extraction spreadsheet (Microsoft ing curve (SUCRA) [22] values of Bayesian NMA [19].
Excel) adapted from the Cochrane Collaboration [18]. To P-scores range from 0 to 100% with 0 and 1 being the the-
estimate the effect of exercise on the incidence of fallers, oretically worst and best treatment, respectively. Addi-
the number of fallers and non-fallers in each intervention tionally, a forest plot was created to further visualize the
group were extracted. If these values were not available, ranking and effects of the treatments. The decomposed
authors were contacted and asked to provide the data. Q-statistics (within and between designs) were used to
In addition to the outcomes, relevant information about interpret potential heterogeneity and inconsistency. Het-
the included studies (author, year of publication, number erogeneity was further quantified by ­I2 [23]. Funnel plots
of participants) and their interventional design (weeks, were created to check potential publication bias. All cal-
frequency, duration per session, type of intervention and culations and presentational figures were made using the
control condition) were also recorded. For the simplifica- R software (version 4.1.1; The R Foundation for Statisti-
tion of the network, similar treatments haven been sum- cal Computing) and the package ‘netmeta’ [20]. Values in
marized in (i) Active Control; (ii) Combined Postural the written text are presented as mean (SD) if not stated
Control Training;; (iii) Endurance Training; (iv) Inactive otherwise.
Control; (v) Multifactorial Training; (vi) Postural Control
Training; and (vii) Resistance Training. Thereby, ‘Postural
Control Training’ was defined as balance, coordination Results
and/or multitask training. ‘Combined Postural Control Study characteristics and quality
Training’ was chosen if resistance or endurance training Overview of screening and study selection are presented
were performed additionally to postural control training in Fig. 1. Details to all selected studies are given in Sup-
as it is the case in the popular OTAGO exercise program, plementary Table 1. Included trials (47.420 participants;
for example. ‘Multifactorial Training’ was categorized as 61 % male; 39 % female) enrolled on average 624 ± 1426
forms of training that included other non exercise related participants per study (range 21 to 6580) with an average
factors influencing the risk of falls (such as home haz- age of 77 ± 4 years (range from 68 to 88 years of age). The
ard management and visual, educational or behavioral average study quality was high as indicated by a PEDro
interventions) in addition to postural control training. score of 7.1 ± 1.0 (range 5 to 9). Apart from 5 three armed
For an additional differentiation within the three treat- designs [24–28], all remaining studies employed a two-
ment summaries (Postural Control Training, Combined armed design [29–88]. Data from 66 studies representing
Postural Control Training and Multifactorial Training) 76 pairwise comparisons were included. The most com-
the label “home” indicated whether the corresponding mon comparison was ‘Inactive Control’ vs. ‘Combined
intervention was conducted as home-based training. The Postural Control Training (home)’ (n = 19), followed by
‘active control’ treatment features interventions that are ‘Inactive Control’ vs. ‘Combined Postural Control Train-
not thought to influence the outcome of falls such as light ing’ (n = 10), and ‘Inactive Control’ vs. ‘Postural Training’
stretching and relaxation. (n = 9). All of the pairwise comparisons are depicted in
the network plot in Fig. 2. The network model revealed
low heterogeneity ­ (I2 = 28.0, 95%CI 1.0 to 47.7%) and
Statistical analysis
non-significant inconsistency (Q between designs = 15.1,
The RR were calculated for all interventional treatments
p = 0.37).
by dividing the incidence of the intervention group by the
incidence of the reference group. If values for the (RR)
were already given, these data were used. Additionally Risk of bias
mean error and 95% confidence interval (95%-CI) were The evaluation of the funnel plot revealed no consider-
evaluated. Subsequently, a network model was computed able asymmetries that would indicate a potential risk
[19, 20]. Therefore a frequentist approach was chosen. In of bias. (Fig. 3). Only four studies are located outside of
order to visualize the networks, a network graph was cre- the inverted funnel [33, 61, 78, 80]. Three of them inves-
ated. The estimations of treatment effects were calculated tigated ‘Combined Postural Control Training (home)’
based on a random effects model [21]. Thereby, the Inac- [33, 78, 80] and one investigated ‘Multifactorial Training
tive Control served as the reference treatment. A ranking (home)’ [61] all of them had an ‘Inactive Control’ Group
was created based on the P-score of the individual treat- as Comparator.
ments. The P-score represents the means of one sided
p-values under normality assumption in a frequentist
Wiedenmann et al. European Review of Aging and Physical Activity (2023) 20:1 Page 4 of 10

Fig. 1 Flow chart of the different phases of study screening and selection. A: no RCT; B: wrong age; C: study without community dwelling people;
D: population with high risk of falling (stroke, Parkinson’s disease, multiple sclerosis, dementia, hip fracture, severe visual impairment, mild cognitive
impairment, fractures); E: Study in which Exercise is not measured in a controlled way; F: no incidence of fallers; G: study without exercise; H: Study
with medications or supplements; I: duplicates; J: Chronic or acute illnesses, e.g. depression, diabetes mellitus, COPD, cancer, mental & physical
disabilities; K: Measurement of rate of fallers under 6 months reported; L: wrong language; M: no full text; N: Study results reported by another
study; O: only abstract, poster etc.; P: Intervention groups in network not comparable; Q: not responded after 3 reminders for data request

Treatment‑ranking and ‘Endurance Training’ with similar P-scores ranging

The ranking of the different treatments is depicted in from 0.65 to 0.44 and RR from 0.88 to 0.95. ‘Multifacto-
Fig. 4. The RR that the P-score rankings are based upon rial Training (home) is third to last with a P-score of 0.36
and their 95%-CI are depicted in Fig. 5. ‘Postural Con- and a RR of 0.97. ‘Inactive Contol’ and ‘Active Control’
trol Training (home)’, and the regular ‘Postural Control rank the lowest among the treatments with respective
Training’ rank the highest with respective P-scores of P-scores of 0.23 and 0.10.
0.97 and 0.82. The two highest ranked exercise modes
display low RR from 0.60 to 0.82 for ‘Postural Control Discussion
Training (home)’ and regular ‘Postural Control Train- This network meta-analysis was conducted to extend
ing’ respectively. The third to eighth ranked interventions meta-analytical knowledge by analysing the direct and
are ‘Multifactorial Training’, ‘Combined Postural Con- indirect comparison of different forms of physical train-
trol Training (home)‘, ‘Resistance Training’, ‘Combined ing and its effects on the relative fall risk in older adults.
Postural Control Training’, ‘Resistance Training (home)’ Compared to a traditional meta-analytical approach with
Wiedenmann et al. European Review of Aging and Physical Activity (2023) 20:1 Page 5 of 10

Fig. 2 Network plot with all of the direct comparisons represented by the linking lines. The number of comparisons is represented by the number
on the lines. The thickness of the lines increases with the number of comparisons

Fig. 3 Funnel plot

Fig. 4 P-score ranking

Wiedenmann et al. European Review of Aging and Physical Activity (2023) 20:1 Page 6 of 10

Fig. 5 Forest plot. RR: risk ratio; 95%-CI: 95% confidence interval

pairwise direct comparison, our network meta-analysis Campbell et al. (2007) found that single factorial inter-
provides additional evidence by ranking the effects of ventions had similar but slightly favourable effects com-
numerous different training interventions that were not pared to multifactorial interventions [89] when it comes
comparable in previous analyses. Our key finding was to the prevention of falls. However, it might be reason-
that balance and strength focused exercise modes are the able to assume that multifactorial interventions result in
most beneficial for the prevention of fall events. broader adaptations than single factorial approaches. As a
Among all included exercise modes, the balance type result, larger effects could potentially be stimulated when
exercise modes revealed the lowest relative risk for a fall the interventions are performed with an adequate inten-
event and was therefore placed highest in the P-score sity, frequency and duration. Thus, although the effects of
ranking outranking the resistance training and resist- the combined interventions are inferior to the best sin-
ance training combined approaches. These findings are gle factorial interventions, the high precision of the data
aligned with previous findings and reflect the majority combined with the large amount of included evidence (51
of available clinical guidelines but go beyond them [6, 8]. direct comparisons) leads to the assumption that some
In the most recent and impactful meta-analysis, Sher- combined and multifactorial interventions might be a
rington and colleagues concluded that physical train- valuable alternative suited for a large variety of popula-
ing, if challenging enough, leads to a reduction of falls tions with different demands. The value of multifactorial
of approximately 23% [8]. They further emphasized that interventions might even be higher when the interven-
training involving balance exercises is most beneficial for tions are designed with different domains that are spe-
the prevention of falls. This is well in line with the treat- cific to the needs of the individual patient. A very recent
ment ranking of the postural control training in our net- statement with new guidelines discussed by experts from
work meta-analysis and the 18 - 34% reduction in fall risk different fields who were led by Montero-Odasso and
implied by the computed risk ratio of our analysis. Addi- colleagues emphasizes the efficacy of multidomain inter-
tionally, our current network meta-analysis displays that ventions and the assessment of individual needs [90]. It is
these reductions in fall risk are also present when pos- possible that with a new and more personalized approach
tural control training is performed at home and largely to a multifactorial training the effects of the intervention
unsupervised. would be larger. In contrast, ‘Resistance Training’, Resist-
‘Multifactorial Training’, ‘Combined Postural Training ance Training (home), ‘Endurance Training’, and ‘Mul-
(home)’ and ‘Combined Postural Training’ are associated tifactorial Training (home)’, “and do not have a robust
with a slight reduction of fall risk and a high precision of positive effect on the relative risk of falls. While these
data, indicated by narrow confidence limits. These find- interventions display a risk ratio that is also slightly lower
ings suggest that an interventional approach with multi- than the control, they are accompanied by verylarge con-
ple different exercise modes or other non-exercise related fidence limits. There is a noticeable difference in the risk
factors are inferior in magnitude but robust in effect reduction between ‘Multifactorial Training’ which places
occurance of fall risk reductions compared with the most third in the treatment ranking and its home base coun-
beneficial postural control training interventions when terpart ‘Multifactorial Training (home)’ which has no
they are performed isolated. This is at least partially in clear positive effect on the reduction of fall risk. A simi-
line with a meta-regression and meta-analysis from 2007. lar difference but considerably smaller in magnitude is
Wiedenmann et al. European Review of Aging and Physical Activity (2023) 20:1 Page 7 of 10

observed for ‘Resistance Training’ and ‘Resistance Train- influence becomes less strong (up to about 12% reduc-
ing (home)’. These observations are in line with other tion of fall risk) but still rather clear due to narrow confi-
meta-analyses which found that home based exercise dence limits. With the exception of balance training type
interventions do not have a clear benefit for the preven- exercise and the combined postural training approach,
tion of falls [91] and are less effective than supervised training performed at home was not as effective as train-
programs [92]. A possible explanation for these shared ing that was completely supervised. Future studies should
findings might be that the compliance, adherence and investigate the role of training intensity and effort as well
the effort exerted in training are not sufficient when an as the effects of multimodal exercise training over longer
intervention is performed largely or completely unsuper- study periods up to ≥ 1 year.
vised at home. The two interventions that fall out of line
are the postural control training and the combined pos- Supplementary Information
tural control training which combines strength or endur- The online version contains supplementary material available at https://​doi.​
ance training with the former. For these two approaches org/​10.​1186/​s11556-​023-​00311-w.
the unsupervised home training displays a larger effect
Additional file 1. Supplementary table with all the studies and their
than the supervised intervention or the same effect for information.
postural control training and the combined intervention
respectively. However, there are only two studies [38, 88]
Acknowledgements
directly comparing ‘Postural Control Training (home)’ Not applicable.
with other interventions included in this analysis and
Authors’ contributions
therefore the findings should be interpreted with caution.
SH and LD conceptualized the Study. MG and SS selected the studies and
It is reasonable to assume that with increasing evidence extracted the data. TW, SH and LR performed the network meta-analysis. TW
the effect of ‘Postural Control Training (home)’ would prepared the original draft. TW, SH, LR and LD reviewed and edited the draft.
All authors read and approved the final manuscript.
regress in the direction of its fully supervised counterpart
that ist not practiced at home. Funding
Open Access funding enabled and organized by Projekt DEAL. This research
was not funded.
Strengths & Limitations
Some limitations need to be addressed. One limitation Availability of data and materials
was the heterogeneity in duration of the studies and fol- The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
low up periods. Future research should investigate how
the length of an intervention period influences the effects
Declarations
of the different training modes. Another limitation was
the amount of evidence that is available for the analysis. Ethics approval and consent to participate
For some of the investigated interventions data preci- Not applicable.

sion is very low. This is likely due to the sparsity of stud- Consent for publication
ies and overall evidence that was included in the analysis Not applicable.
for certain interventions. When data precision is as low
Competing interests
as it is for the resistance and endurance training inter- The authors declare that they have no competing interests.
ventions one has to be cautious when interpreting the
results. Emerging studies should, however, help to solve
Received: 26 August 2022 Accepted: 16 January 2023
this issue. Other than the sparsity of data for some of
the interventions, the quality of the included evidence is
good. This is indicated by the overall high PEDro scores
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