Table 1

Summary of findings. Rate of falls outcome (falls per person-years) for types of exercise

Type of exerciseFollow-up rangeIllustrative comparative risks* (95% CI)Relative effect (95% CI)No. of participants (studies)Certainty of the evidence (GRADE)Comments
Assumed riskCorresponding risk
Exercise† (all types) versus control‡ (eg, usual activities)3 to 30 monthsControlExercise (all types)Rate ratio 0.77 (0.71 to 0.83)¶12 981 (59 RCTs)High**Overall, there is a reduction of 23% (95% CI 17% to 29%) in the number of falls. Guide to the data: If 1000 people were followed over 1 year, the number of falls in the overall population would be 655 (95% CI 604 to 706) compared with 850 in the group receiving usual care or attention control. In the unselected population, the corresponding data are 466 (95%CI 430 to 503) compared with 605 in the group receiving usual care or attention control. In the selected higher-risk population, the corresponding data are 924 (95%CI 852 to 996) compared with 1200 in the control group
All studies population
850 per 1000§655 per 1000 (604 to 706)
Not selected for high risk population
605 per 1000§466 per 1000 (430 to 503)
Selected for high risk population
1200 per 1000§924 per 1000 (852 to 996)
Balance, and functional exercises†† versus control‡ (eg, usual activities)3 to 30 monthsControlExercise (gait, balance, and functional (task) training)Rate ratio 0.76 (0.70 to 0.81)7920 (39 RCTs)HighOverall, there is a reduction of 24% (95% CI 19% to 30%) in the number of falls. Guide to the data based on the all-studies estimate:If 1000 people were followed over 1 year, the number of falls would be 646 (95% CI 595 to 689) compared with 850 in the group receiving usual care or attention control
All studies population
850 per 1000‡‡646 per 1000 (595 to 689)
Specific exercise population
930 per 1000‡‡707 per 1000 (651 to 754)
Resistance exercises§§ versus control‡ (eg, usual activities)4 to 12 monthsControlExercise (resistance training)Rate ratio 1.14 (0.67 to 1.97)327 (5 RCTs)Very lowThe evidence is of very low certainty, hence we are uncertain of the findings of an increase of 14% (95% CI 33% reduction to 97% increase) in the number of falls. Guide to the data based on the all-studies estimate: If 1000 people were followed over 1 year, the number of falls would be 969 (95% CI 570 to 1675) compared with 850 in the group receiving usual care or attention control
All studies population
850 per 1000¶¶969 per 1000 (570 to 1675)
Specific exercise population
630 per 1000¶¶719 per 1000 (423 to 1242)
3D (Tai Chi) exercise*** versus control‡ (eg, usual activities)6 to 17 monthsControlExercise (3D (Tai Chi))Rate ratio 0.81 (0.67 to 0.99)2655 (7 RCTs)LowOverall, there may be a reduction of 19% (95% CI 1% to 33%) in the number of falls. Guide to the data based on the all-studies estimate:If 1000 people were followed over 1 year, the number of falls may be 689 (95% CI 570 to 842) compared with 850 in the group receiving usual care or attention control
All studies population
850 per 1000†††689 per 1000 (570 to 842)
Specific exercise population
1020 per 1000†††827 per 1000 (684 to 1010)
3D (dance) exercise‡‡‡ versus control‡ (eg, usual activities)12 monthsControlExercise (3D (dance))Rate ratio 1.34 (0.98 to 1.83)522 (1 RCT)Very lowThe evidence is of very low certainty, hence we are uncertain of the findings of an increase of 34% (95% CI 2% reduction to 83% increase) in the number of falls. Guide to the data based on the all-studies estimate: If 1000 people were followed over 1 year, the number of falls may be 1139 (95% CI 833 to 1556) compared with 850 in the group receiving usual care or attention control
All studies population
850 per 1000§§§1139 per 1000 (833 to 1556)
Specific exercise population
800 per 1000§§§1072 per 1000 (784 to 1464)
General physical activity (including walking) training¶¶¶ versus control‡ (eg, usual activities)12 to 24 monthsControlExercise (general physical activity (including walking))Rate ratio 1.14 (0.66 to 1.97)441 (2 RCTs)Very lowThe evidence is of very low certainty, hence we are uncertain of the findings of an increase of 14% (95% CI 34% reduction to 97% increase) in the number of falls. Guide to the data based on the all-studies estimate: If 1000 people were followed over 1 year, the number of falls may be 969 (95% CI 561 to 1675) compared with 850 in the group receiving usual care or attention control
All studies population
850 per 1000****969 per 1000 (561 to 1675)
Specific exercise population
670 per 1000****764 per 1000 (443 to 1320)
Multiple categories of exercise (often including, as primary interventions: gait, balance, and functional (task) training plus resistance training†††† versus control‡ (eg, usual activities)2 to 25 monthsControlExercise (multiple types (including, as primary interventions: gait, balance, and functional (task) training plus resistance training))Rate ratio 0.66 (0.50 to 0.88)§§§§1374 (11 RCTs)ModerateOverall, there is probably a reduction of 34% (95% CI 12% to 50%) in the number of falls. Guide to the data based on the all-studies estimate If 1000 people were followed over 1 year: the number of falls would probably be 561 (95% CI 425 to 748) compared with 850 in the group receiving usual care or attention control
All studies population
850 per 1000‡‡‡‡561 per 1000 (425 to 748)
Specific exercise population
1180 per 1000‡‡‡‡779 per 1000 (590 to 1039)
  • GRADE Working Group grades of evidence. High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited.The true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

  • *-

  • †Exercise is a physical activity that is planned, structured and repetitive and aims to improve or maintain physical fitness. There is a wide range of possible types of exercise, and exercise programmes often include one or more types of exercise. We categorised exercise based on the Prevention of Falls Network Europe (ProFaNE) taxonomy that classifies exercise type as: (i) gait, balance, and functional [task] training; (ii) strength/ resistance (including power); (iii) flexibility; (iv) three-dimensional (3D) exercise (eg, Tai Chi, Qigong, dance); (v) general physical activity; (vi) endurance; and (vii) other kind of exercises. The taxonomy allows for more than one type of exercise to be delivered within a programme.

  • ‡A control intervention is one that is not thought to reduce falls, such as general health education, social visits, very gentle exercise, or ’sham’ exercise not expected to impact on falls.

  • §The all-studies population risk was based on the number of events and the number of participants in the control group for this outcome over the 59 RCTs. We calculated the risk in the control group using the median falls per person-year for the subgroups of trials for which (a) an increased risk of falls was not an inclusion criterion (29 RCTs, 6123 participants), or (b) increased risk of falls was an inclusion criterion (30 RCTs, 6858 participants).

  • ¶Subgroup analysis found no difference based on whether risk of falls was an inclusion criterion or not (test for subgroup differences: χ2=0.90, df=1, p=0.34, I2=0%).

  • **There was no downgrading, including for risk of bias, as results were essentially unchanged with removal of the trials with a high risk of bias on one or more items.

  • ††Using Prevention of Falls Network Europe (ProFaNE) taxonomy, gait, balance, and functional [task] training is: gait training = specific correction of walking technique, and changes of pace, level and direction; balance training = transferring bodyweight from one part of the body to another or challenging specific aspects of the balance systems; functional training = functional activities, based on the concept of task specificity. Training is assessment-based, tailored and progressed. Exercise programs included in this analysis contained a single primary exercise category (gait, balance, and functional [task] training); these exercise programs may also include secondary categories of exercise.

  • ‡‡The all-studies population risk was based on the number of events and the number of participants in the control group for this outcome over the 59 all-exercise types RCTs. The specific exercise population risk was based on the number of events and the number of participants in the control group for this outcome over the 39 RCTs.

  • §§Using Prevention of Falls Network Europe (ProFaNE) taxonomy, resistance training is any type of weight training (contraction of muscles against resistance to induce a training effect in the muscular system). Resistance is applied by body weight or external resistance. Training is assessment-based, tailored and progressed. Exercise programmes included in this analysis had resistance training as the single primary exercise category; these exercise programmes may also include secondary categories of exercise.

  • ¶¶The all-studies population risk was based on the number of events and the number of participants in the control group for this outcome over the 59 all-exercise types RCTs. The specific exercise population risk was based on the number of events and the number of participants in the control group for this outcome over the 5 RCTs.

  • ***Using Prevention of Falls Network Europe (ProFaNE) taxonomy, 3D (Tai Chi) training uses upright posture, specific weight transferences and movements of the head and gaze, during constant movement in a fluid, repetitive, controlled manner through three spatial planes. Exercise programmes included in this analysis had 3D (Tai Chi) training as the single primary exercise category; these exercise programmes may also include secondary categories of exercise.

  • †††The all-studies population risk was based on the number of events and the number of participants in the control group for this outcome over the 59 all-exercise types RCTs. The specific exercise population risk was based on the number of events and the number of participants in the control group for this outcome over the seven RCTs.

  • ‡‡‡Using Prevention of Falls Network Europe (ProFaNE) taxonomy, 3D (dance) training uses dynamic movement qualities, patterns and speeds whilst engaged in constant movement in a fluid, repetitive, controlled manner through three spatial planes. Exercise programmes included in this analysis had 3D (dance) training as the single primary exercise category; these exercise programmes may also include secondary categories of exercise.

  • §§§The all-studies population risk was based on the number of events and the number of participants in the control group for this outcome over the 59 all-exercise types RCTs. The specific exercise population risk was based on the number of events and the number of participants in the control group for this outcome in the sole RCT.

  • ¶¶¶Using Prevention of Falls Network Europe (ProFaNE) taxonomy, physical activity is any movement of the body, produced by skeletal muscle, that causes energy expenditure to be substantially increased. Recommendations regarding intensity, frequency and duration are required in order to increase performance. Exercise programmes included in this analysis had general physical activity (including walking) training as the single primary exercise category; these exercise programmes may also include secondary categories of exercise.

  • ****The all-studies population risk was based on the number of events and the number of participants in the control group for this outcome over the 59 all-exercise types RCTs. The specific exercise population risk was based on the number of events and the number of participants in the control group for this outcome in the two RCTs.

  • ††††Exercise programmes included in this analysis had more than one primary exercise category. We categorised exercise based on the Prevention of Falls Network Europe (ProFaNE) taxonomy that classifies exercise type as: (i) gait, balance, and functional (task) training; (ii) strength/ resistance (including power); (iii) flexibility; (iv) three-dimensional (3D) exercise (eg, Tai Chi, Qigong, dance); (v) general physical activity; (vi) endurance; and (vii) other kind of exercises. The programmes of ten included, as the primary intervention, gait, balance, and functional (task) training plus resistance training. The exercise programmes may also include secondary categories of exercise.

  • ‡‡‡‡The all-studies population risk was based on the number of events and the number of participants in the control group for this outcome over the 59 all-exercise types RCTs. The specific exercise population risk was based on the number of events and the number of participants in the control group for this outcome over the 11 RCTs.

  • §§§§Sensitivity analyses revealed little difference in the results when only trials that include the most common two components (balance and functional exercises plus resistance exercises) were pooled (RaR 0.69, 95% CI 0.48 to 0.97; 1084 participants; 8 studies; I²=72%).