A fall can be a frightening experience. Even a single fall can affect confidence and make someone more cautious about moving around. Unfortunately, this can sometimes create a vicious cycle:

A fall → Fear of falling → Less activity → Reduced strength and balance → Gait and postural changes → Increased risk of another fall

But falls are not simply an inevitable part of getting older, and feeling more unsteady doesn’t mean that nothing can be done.

What is balance and what keeps us upright?

Balance is a complex skill involving the brain, eyes, inner ear, muscles, joints and nervous system. Physiotherapy can assess how these different systems are contributing to someone’s balance and provide targeted treatment and exercise to help people move more safely and confidently.

We often think of balance as simply staying upright and not falling over, but in reality it is much more complicated.

Your body is constantly making tiny adjustments to maintain your centre of gravity within your base of support. This happens automatically as you stand, walk, turn, reach, step over obstacles and change direction.

Your brain receives information from several different systems:

Vision

Our eyes provide information about our surroundings and where we are in relation to the environment.

The vestibular system

The vestibular system, located within the inner ear, provides information about head movement and orientation in space.

Proprioception

Proprioception is our body’s ability to sense where our joints and limbs are positioned without the need to look at them. Sensory nerve endings within muscles, tendons and joints provide the brain with information about body positioning and movement.

The brain and nervous system

The brain integrates all of this information and produces an appropriate movement response. This happens incredibly quickly and, most of the time, without us consciously thinking about it.

When any part of this system is affected, balance can become more challenging and falls more likely.

Why does balance become impaired?

There is rarely one single cause of poor balance.

Balance can be affected by changes in strength, sensation, vision, reaction speed, coordination, cognition, vestibular function and mobility.

Medical conditions such as Parkinson’s disease, stroke, multiple sclerosis, dementia and peripheral neuropathy can affect balance. Arthritis and pain can also change the way someone moves, while medications, dizziness, low blood pressure and environmental hazards may increase a person’s risk of falling.

Reduced physical activity can be another important factor. When we stop challenging our balance and strength, the body becomes less accustomed to responding to unexpected movements or changes in our environment. This is why physiotherapy is such an important part of falls prevention.

Why do people fall?

A fall usually occurs when the demands placed on our balance system exceed our ability to respond. As we age, or when neurological or physical conditions affect movement, these responses can become slower or less effective.

A small trip that someone might previously have recovered from can therefore result in a fall. This is one reason why falls prevention isn’t simply about making the environment safer. We also need to consider how effectively the person’s body can respond when something unexpected happens.

How can physiotherapy help with falls and balance?

Physiotherapy can play a key role in assessing and managing falls risk.

Current NICE guidance recommends assessing gait and balance in people who have fallen and providing a falls-prevention exercise programme where gait or balance impairment is identified.

A physiotherapy examination will typically include:

  • Strength
  • Balance
  • Gait pattern
  • Walking speed
  • Turning and changing direction
  • Transfers
  • Reaction to loss of balance
  • Joint mobility
  • Coordination
  • Blood pressure
  • Sensation
  • Use of walking aids
  • Cognition
  • Confidence and fear of falling
  • How someone manages everyday activities

This helps identify why someone may be falling, rather than simply treating the fall itself.

Strength training

Strength is an essential component of good balance. Strong leg and trunk muscles help us control our body when standing, walking, climbing stairs and responding to a trip or change in surface. Physiotherapy may therefore include progressive strengthening exercises targeting areas such as:

  • The quadriceps
  • Gluteal muscles
  • Calf muscles
  • Hip muscles
  • Core and trunk muscles

Exercises can be progressed according to the individual’s ability. The goal isn’t simply to make someone stronger in a gym environment. It is to make them strong enough for everyday life.

Balance training

Balance improves through practice. However, effective balance training isn’t necessarily about standing still while holding onto a chair. As someone becomes safer and more confident, physiotherapy can introduce increasingly challenging situations that require the body to make appropriate balance adjustments. This might include:

  • Narrowing the base of support
  • Changing direction
  • Reaching outside the base of support
  • Stepping in different directions
  • Walking over obstacles
  • Changing speed
  • Turning
  • Walking on different surfaces
  • Moving while performing another task

The challenge should be carefully selected so that it is appropriate and safe for the individual. Research and international falls guidance support appropriately challenging balance and leg-strengthening exercise as important components of falls prevention.

Reactive balance: what happens when you lose your balance?

One area that is often particularly useful is reactive balance training. Reactive balance is our ability to recover when something unexpectedly disturbs our balance. For example:

You trip → Your brain detects the loss of balance → Your body generates a rapid stepping response → You regain your stability

Physiotherapy can incorporate exercises that safely practise these types of responses. This might involve controlled stepping in different directions or responding to carefully introduced challenges. The aim is to help the nervous system practise how to react when balance is unexpectedly disturbed. This type of training should always be appropriately assessed and supervised, particularly for someone with a significant falls risk.

Improving walking and mobility

Walking is not simply a series of steps. Every step involves transferring your weight, maintaining your centre of gravity and preparing the body for the next movement. Physiotherapy can work on:

  • Step length
  • Walking speed
  • Foot clearance
  • Weight transfer
  • Turning
  • Starting and stopping
  • Walking over obstacles
  • Changes in direction

For people with neurological conditions such as Parkinson’s disease, specific gait strategies and external cues may also be particularly helpful.

Dual tasking: can you walk and think at the same time?

Something as simple as walking while talking to someone can become surprisingly challenging when balance is impaired. Walking while carrying shopping, looking for something, talking, using a phone or navigating a busy environment requires the brain to divide its attention between different tasks. This is known as dual tasking. Physiotherapy may therefore incorporate dual-task exercises where appropriate. For example, someone might practice walking while:

  • Counting
  • Carrying an object
  • Turning their head
  • Talking
  • Responding to instructions
  • Navigating around obstacles

This helps make rehabilitation more relevant to the situations people encounter in everyday life.

Confidence and fear of falling

Falls aren’t only a physical problem. After a fall, it is very common for someone to become worried about falling again. They may start avoiding:

  • Going outside
  • Stairs
  • Uneven ground
  • Hills or inclines
  • Shopping
  • Social activities
  • Walking without someone else present

Unfortunately, avoiding movement can lead to further weakness and reduced confidence, potentially increasing falls risk. Physiotherapy can help break this cycle by gradually exposing someone to movements and situations they have become fearful of, in a controlled and supportive environment. As physical ability improves, confidence can improve too.

Close-up of a man holding an elderly woman's hands

What about walking aids?

A walking stick, frame or other mobility aid can be extremely helpful for some people. However, choosing the correct aid and using it properly is important. A physiotherapist can assess whether an aid is appropriate and ensure that it is adjusted correctly. They can also teach someone how to use it safely in different situations, such as stairs, kerbs and uneven surfaces. A walking aid should ideally support independence rather than unnecessarily restrict it.

Looking beyond exercise

Falls are often multifactorial, meaning that several factors may contribute to someone’s risk. Physiotherapy can identify physical contributors but falls prevention may also involve looking at other areas and signposting or referring on to another appropriate healthcare professional if required. These might include:

  • Vision
  • Footwear
  • Medication
  • Dizziness
  • Blood pressure
  • Nutrition and hydration
  • Home hazards
  • Bone health
  • Neurological or cardiovascular conditions

For people with recurrent or more serious falls, a comprehensive falls assessment is indicated. NICE recommends this for certain higher-risk groups, including people who are living with frailty, have had two or more falls in the previous year, or were unable to get themselves up after a fall.