Perturbation-Based Balance Training Reduces Falls and Fall Injuries in Older People: Insights on Mechanisms and Optimal Training Parameters from a Systematic Review and Meta-Analysis

Falls are common among older adults and significantly impact their quality of life. Perturbation-based balance training (PBT) is a task-specific intervention designed to improve reactive balance. This systematic review evaluated the efficacy of PBT in reducing falls, injurious falls, and fall risk factors in older adults. PubMed, CINAHL, EMBASE, and Cochrane databases were searched from inception to June 2024. Randomised controlled trials (RCTs) assessing the effects of PBT on falls or fall risk factors, including reactive balance via laboratory-induced perturbations, were included. Two reviewers independently screened studies and extracted data. Meta-analyses were conducted using a random-effects model, and certainty of evidence was assessed using the GRADE approach. Twenty-five RCTs involving 2,659 participants were included. PBT significantly reduced fall rates by 23% (rate ratio [RR]⍰0.77, 95% CI 0.60–0.99; I ² =57%, low certainty) and injurious falls by 24% (RR⍰0.76, 95% CI 0.58–0.98; I ² =0%) compared to controls. PBT improved reactive balance (e.g., lab-induced falls) but had limited effects on other fall risk factors (e.g., gait). In the dosage subgroup analysis, only PBT programs for at least 6 hours reduced falls by 33%. PBT reduces falls and related injuries, likely through enhanced reactive balance rather than physical improvements. While many PBT programs are low doses (∼2 hours), higher doses (6+ hours) likely offer greater fall protection. Further high-quality trials using accessible PBT methods are needed to support scalable implementation.