Short answer: Exercise that challenges your balance is one of the best-tested ways to prevent falls in older people who live at home. In a review of 116 trials, programmes built on balance and functional exercises (standing and moving in ways that test your steadiness, such as rising from a chair, stepping and heel-to-toe walking) reduced the rate of falls by about a quarter, and tai chi and mixed programmes also helped. Programmes that combined that kind of exercise with more than three hours a week did best. Walking on its own, strength training on its own and stretching have not been shown to prevent falls. International guidelines recommend three or more sessions a week, made gradually harder over at least 12 weeks and then kept up. If you have had a fall that needed treatment, two or more falls in a year, a blackout, or a fall you could not get up from, ask a clinician for a falls assessment rather than starting on your own.
At least one in three people over 65 who live at home falls each year (Sherrington et al., 2019). Most balance advice responds to that with a list of exercises. What the lists rarely say is which kinds of exercise have been shown to prevent falls, how much of it the successful programmes involved, and which popular options have not been shown to work at all.
The evidence here is unusually strong for exercise research: dozens of randomised trials, pooled several times, with a clear pattern. This guide sets out that pattern and turns it into something you can start with, and it is explicit about the point where a home routine stops being enough.
What reduced falls in the trials
The most recent large pooling of the trials was done for the World Health Organization's physical activity guidelines. It covered 116 randomised trials with 25,160 participants aged 60 and over, living in the community. Overall, exercise reduced the rate of falls by 23%, with high-certainty evidence. The type of exercise made a clear difference (Sherrington et al., 2020):
| Type of programme | Trials | Rate of falls compared with no programme | Certainty of evidence |
|---|---|---|---|
| Balance and functional exercises | 39 | 24% lower (rate ratio 0.76, 95% CI 0.70 to 0.82) | High |
| Several types combined, most often balance and functional plus strength exercises | 15 | 28% lower (0.72, 0.56 to 0.93) | Moderate |
| Tai chi | 9 | 23% lower (0.77, 0.61 to 0.97) | Moderate |
| Strength (resistance) training alone | 5 | No clear effect (1.14, 0.67 to 1.97) | Very low |
| Dance | 1 | No clear effect (1.34, 0.98 to 1.83) | Very low |
| General physical activity, including walking | 2 | No clear effect (1.14, 0.66 to 1.97) | Very low |
"Balance and functional exercises" is the review's name for gait, balance, coordination and functional-task training. In practice that means exercises done standing up that make staying steady harder, and practising everyday movements such as getting up from a chair. The rows with no clear effect come from few, small trials, so they mean an effect has not been shown, not that it has been disproved. Stretching sits outside the table: the 2019 Cochrane review found no trials that compared flexibility exercise with a control group (Sherrington et al., 2019).
Walking deserves a plain word, because it is what many people do for their health. The designers of the Otago programme, described below, include a walking plan but state that walking "will not on its own result in a reduction in falls" (Otago Exercise Programme manual). Walking has other benefits worth having; our guide to the Japanese walking method covers what interval walking trials found. For falls, balance work is the part the trials point to.
How much, and how often
The review above also looked at dose. Programmes that included balance and functional exercises and added up to more than three hours a week cut the rate of falls by an estimated 42% (incidence rate ratio 0.58, 95% CI 0.45 to 0.76). Three or more hours a week of exercise without that balance content did not show a clear effect (0.83, 0.60 to 1.15), and the overall trend towards more benefit with more hours fell just short of statistical significance (p = 0.077) (Sherrington et al., 2020). An earlier version of the analysis reached a similar conclusion: the greatest effects came from programmes that challenged balance and involved more than three hours a week (Sherrington et al., 2017). The reading that fits both: the balance challenge is what matters most, and more time helps when it is spent on that.
The official recommendations are close to one another but not identical:
- World Falls Guidelines (2022), strong recommendation: programmes with "balance challenging and functional exercises (e.g. sit-to-stand, stepping)" offered "three times or more weekly", individualised, "progressed in intensity for at least 12 weeks and continued longer for greater effect" (Montero-Odasso et al., 2022).
- World Health Organization (2020): older adults should do "varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity, on 3 or more days a week" (WHO guidelines).
- US Physical Activity Guidelines (2018): older adults should do multicomponent activity "that includes balance training", and "studies of fall prevention programs generally include about three sessions a week" (Physical Activity Guidelines for Americans).
- NHS (England): activities that improve "strength, balance and flexibility on at least 2 days a week" (NHS).
So two days a week is the UK's minimum, while the trials that reduced falls, and the guidelines built on them, generally used three or more sessions.
What makes an exercise "challenging" for balance
The World Falls Guidelines describe what effective programmes contained: exercises built around daily tasks, such as sit-to-stand, squats, reaching while standing, standing with a narrower base of support, and stepping and walking in different directions, at different speeds, in different places and while doing a second task at the same time. Weights can be added to some of them. The exercises "should be challenging… but safe… and achievable", and should be reviewed and progressed regularly (Montero-Odasso et al., 2022).
In practice, an exercise gets harder when you need less support from your hands, stand with your feet closer together (side by side, then one in front of the other, then on one leg), move while you balance, or add a second task, such as counting backwards. The Otago programme progresses its balance exercises in exactly that direction, "from holding on to a stable structure to performing the exercise independent of support" (Otago Exercise Programme manual). An exercise you can do easily while chatting has probably stopped challenging you.
A programme with trials behind it: Otago
If you search for balance exercises, you will meet the name Otago. It is a home programme developed at the University of Otago in New Zealand: leg-strengthening and balance-retraining exercises, prescribed individually by a trained instructor over five home visits and made harder at each one, with ankle cuff weights starting at 1 kg. The exercises take about 30 minutes, three times a week with rest days between, and participants are also asked to walk for up to 30 minutes at least twice a week if it is safe (Otago Exercise Programme manual).
In the first trial, women aged 80 and over were randomised to the programme (116) or to usual care with the same number of social visits (117); over a year the exercise group had 88 falls and the control group 152 (Campbell et al., 1997). Pooling the individual data from four trials, with 1,016 people aged 65 to 97, the programme reduced both falls and fall-related injuries by 35% (incidence rate ratio 0.65 for each) (Robertson et al., 2002). A later meta-analysis of seven trials (1,503 participants, mean age 81.6) found a similar reduction in the rate of falls (incidence rate ratio 0.68, 95% CI 0.56 to 0.79). It also found that of the 747 people still in the studies at 12 months, 274 (36.7%) were still exercising three or more times a week (Thomas et al., 2010).
Two things follow. What was tested was a supervised programme: a physiotherapist or trained nurse assessed each person, chose the exercises and progressed them. Doing the exercises from a printout alone is not what the trials measured, and I cannot confirm that it works as well. And keeping it up is the hard part. The World Falls Guidelines note that the benefits "are lost on cessation" and that people who stop because of illness or caring duties should be encouraged to return (Montero-Odasso et al., 2022); our guide to what predicts sticking with exercise covers why the return after a gap matters so much.
A place to start at home
The NHS publishes a short set of balance exercises for home use and suggests doing them near a wall or a stable chair "just in case you lose your balance" (NHS, balance exercises):
| Exercise | How (NHS description, shortened) |
|---|---|
| Sideways walking | Feet together, knees slightly bent; step sideways slowly, then bring the other foot to join it. About 10 steps each way |
| Simple grapevine | Walk sideways by crossing one foot over the other, then bring the other foot to join it; 5 cross-steps each side, fingertips on a wall if needed |
| Heel-to-toe walk | Place one heel directly in front of the other foot's toes, looking ahead; at least 5 steps, moving away from the wall as you improve |
| One-leg stand | Face the wall with fingertips touching it; lift one leg, keeping your hips level; hold 5 to 10 seconds, 3 times each side |
| Step-up | On a step with a rail or near a wall, step up and down slowly and under control; up to 5 with each leg |
How to turn that into something closer to what the trials did:
- Set up for safety first. Use a kitchen counter or the back of a heavy chair that will not slide, wear shoes that grip, and keep the floor around you clear.
- Add the functional part. The effective programmes practised everyday movements too. Standing up from a chair slowly and under control, relying on your hands less as it gets easier, is the simplest; the World Falls Guidelines name sit-to-stand first.
- Aim for three sessions a week. Twice a week is the NHS minimum; three or more is what the guidelines built on the trials recommend.
- Make it harder as it gets easier. Move from two hands on the counter to one, then to fingertips, then to hands hovering just above it; bring your feet closer together; hold a little longer. Keep the challenge real but safe.
- Keep going past 12 weeks. That is the minimum period in the World Falls Guidelines, and the benefit fades when the exercise stops.
Tai chi is a reasonable alternative or addition, particularly in a group class with an instructor. It had moderate-certainty evidence in the review above, and the World Falls Guidelines give it a strong recommendation.
Who should get checked first
The World Falls Guidelines treat some people as being at high risk of falling, and recommend a full falls risk assessment by a clinician rather than exercise alone. That applies to anyone who has had a fall with an injury that needed medical treatment, two or more falls in the past 12 months, a fall after which they lay on the floor unable to get up for at least an hour, known frailty, or a suspected blackout (Montero-Odasso et al., 2022). The same guidelines suggest three simple questions to start the conversation: have you fallen in the past year, do you feel unsteady when standing or walking, and do you worry about falling. If the answer to any of them is yes, a check of your walking and balance is worthwhile.
The NHS advises seeing a GP if you are worried about your balance or mobility or have had a fall, and calling 999 if someone has fallen and may have injured their head, back, neck or hip, or cannot get up (NHS, falls). Its falls services can also check eyesight, bone health, medicines and the home, because falls can have several causes.
While exercising, the Otago manual advises stopping and contacting a doctor if dizziness, chest pain or shortness of breath occurs, or muscle pain does not go away, and working within a pain-free range if you have arthritis or another painful condition (Otago Exercise Programme manual). The trials summarised here were in people living at home. The 2017 analysis found no evidence of a fall-prevention effect from exercise in residential care, in stroke survivors or in people recently discharged from hospital (Sherrington et al., 2017); in those situations, a programme designed by a physiotherapist is the safer route.
The one-leg test
You may have seen claims that standing on one leg predicts how long you will live. The study behind them followed 1,702 people aged 51 to 75. One in five (20.4%) could not complete a 10-second one-legged stand, and over a median of seven years their risk of death was higher even after adjusting for age, sex, body mass index and other conditions (hazard ratio 1.84, 95% CI 1.23 to 2.78) (Araujo et al., 2022). It is an association from an observational study, and the authors themselves list uncontrolled factors such as recent falls and physical activity. It suggests the test tells you something; it does not show that practising the test changes your lifespan. If you try it, stand next to a counter.
Mistakes worth avoiding
- Counting on walking alone to prevent falls. It has other benefits, but it has not been shown to prevent falls on its own.
- Holding on too tightly for too long. An exercise that no longer challenges your balance is no longer doing the part the trials relied on.
- Stopping after a few weeks. The guidelines ask for at least 12 weeks and then continuation, and the benefit fades when you stop.
- Treating stretching as fall prevention. It has its uses, covered in our stretching routine for beginners, but no trial has compared it with doing nothing for falls.
- Exercising around warning signs. Dizziness, blackouts or repeated falls need a medical check, not a harder routine.
The bottom line
The exercise that prevents falls is exercise that makes balance harder: standing and moving with less support, a narrower base and more complex tasks, plus everyday movements such as rising from a chair. In the trials, those programmes reduced falls by about a quarter, and by more when they added up to over three hours a week; tai chi also helped. Aim for three sessions a week, make them progressively harder, and keep going well beyond 12 weeks. Walking, strength training on its own and stretching have their place, but none has been shown to prevent falls by itself. If you have already had an injurious fall, repeated falls or a blackout, start with a falls assessment.
Frequently Asked Questions (FAQ)
How often should seniors do balance exercises? The World Falls Guidelines recommend three or more sessions a week, and the US guidelines note that fall-prevention studies generally used about three. The NHS minimum is two days a week for strength, balance and flexibility activities. In the pooled trials, programmes with balance exercises that added up to more than three hours a week had the largest effect.
Is walking enough to prevent falls? Not on its own, as far as the trials show. Programmes of general physical activity, including walking, had no clear effect on falls, and the designers of the Otago programme state that walking alone will not reduce falls. Walking is still worth doing for its other benefits.
Who should see a doctor before starting balance exercises? The World Falls Guidelines recommend a full falls assessment for anyone who has had a fall needing medical treatment, two or more falls in a year, a fall after which they could not get up for an hour, frailty, or a suspected blackout. The NHS also advises seeing a GP if you are worried about your balance or have had a fall. Dizziness or chest pain during exercise is a reason to stop and seek advice.
How long does it take for balance exercises to work? I cannot confirm a timeline for any individual. The World Falls Guidelines recommend progressing a programme for at least 12 weeks and continuing it, because the benefit is lost when exercise stops. The Otago trials measured falls over about a year.
Is tai chi as good as balance exercises? In the pooled trials, tai chi reduced the rate of falls by 23% with moderate-certainty evidence, against 24% with high-certainty evidence for balance and functional exercises. The World Falls Guidelines recommend both. Choose the one you are more likely to keep doing.
Medical disclaimer: This article is for informational purposes only. Always consult a qualified healthcare provider before making changes to your health routine.
Sources
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- Sherrington C, Fairhall N, Kwok W, et al. Evidence on physical activity and falls prevention for people aged 65+ years: systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. International Journal of Behavioral Nutrition and Physical Activity, 2020;17(1):144 — PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC7689963/
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