The effect of reactive balance training on falls in daily life: an updated systematic review

Key points

1. 0125 randomised controlled trials were included; 14 reported falls data after the intervention
2. 02Participants who completed reactive balance training had a meaningfully lower risk of experiencing one or more falls compared to controls
3. 03Reactive balance training participants also experienced fewer falls overall compared to control groups
4. 04GRADE certainty of evidence was low to moderate, limited by lack of concealed allocation, lack of blinding, possible selective outcome reporting, and incomplete follow-up data
5. 05Adverse event prevalence was higher during reactive balance training than control interventions, though roughly half of all trials did not monitor adverse events

How it was conducted

Design

Updated systematic review and meta-analysis of randomised controlled trials; registered with PROSPERO (CRD); reported per PRISMA guidelines

Databases searched

Ovid MEDLINE, Embase Classic and Embase, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro); searched to November 2021

Included trials

25 randomised controlled trials of reactive balance training

Participants

Community-living older adults, people with Parkinson's disease, stroke, cerebral palsy, spinal cord injury, and long-term care residents

Intervention

Reactive balance training (RBT): participants intentionally experience repeated loss of balance via manual perturbations, moving platforms, treadmill perturbations, or slip and trip walkways, to practise balance reactions such as stepping or reach-to-grasp responses

Primary outcomes

Number of participants who fell after training (fall risk), number of falls after training (fall rate), and nature, frequency, and severity of adverse events

What they found

• RBT participants were less likely to fall than controls: overall risk ratio statistically significant (p=0.0-something; I-squared values reported but digits lost in source encoding); 10 of 14 studies with fall risk data reported fewer fallers in RBT groups
• RBT participants experienced fewer falls than controls: overall rate ratio statistically significant; 10 of 11 studies with fall rate data reported fewer falls in RBT groups
• When the analysis was restricted to studies with an active exercise control intervention only, the risk ratio and rate ratio were unchanged, suggesting the effect is not simply due to any exercise versus no exercise
• GRADE certainty of evidence was LOW for fall risk and fall rate across all studies; MODERATE for fall risk when only studies with an active control were analysed
• Adverse events prevalence was higher in RBT groups than control groups (p=0.0-something); 7 RBT participants reported fear or anxiety related to perturbations versus none in control groups
• 19 of 25 studies monitored adverse events; approximately half of all RBT trials did not monitor or report adverse events
• Risk of bias was high in 8 studies, some concerns in 1 study, and low in 5 studies among the 14 that reported falls data

Limitations

• Numbers lost to encoding: exact ratio values and confidence intervals are not recoverable from the source file; the direction and significance of effects are clearly reported but precise estimates are missing from this summary
• Approximately half of included RBT trials did not monitor adverse events, and even among those that did, selective or under-reporting is likely, meaning adverse event prevalence estimates are probably underestimates for both groups
• Control interventions were often less intense than RBT (some used usual care, stretching, or relaxation), which may have inflated the apparent effect size of RBT
• Funnel plot asymmetry was noted, but the cause could not be confirmed as publication bias versus true clinical heterogeneity or random chance; publication bias therefore cannot be ruled out

Why it matters

For patients

People at increased risk of falls, including older adults and those with neurological conditions, can expect a meaningful reduction in their likelihood of falling by participating in reactive balance training, though the training may involve more adverse events than conventional exercise.

For clinicians

Reactive balance training appears more effective than conventional balance exercise alone for reducing falls, but programmes should include clear intensity progression, adverse event monitoring, and trust-building with patients to address anxiety around perturbations.

For readers

This updated meta-analysis strengthens prior evidence that perturbation-based balance training reduces falls, but low-to-moderate GRADE certainty and widespread under-reporting of adverse events mean clinical uptake should be paired with robust safety monitoring.