Restricted accessReview articleFirst published online 2025
The Effect of Perturbation-Based Balance Training on Fall Incidence,Mobility,Postural Control,and Fear of Falling of the Older Adults: A Systematic Review and Meta-Analysis
Perturbation-based training (PBT) is a balance training method that uses externally applied mechanical perturbations to trigger rapid reactions for regaining postural stability in a controlled environment. However, there is a lack of comprehensive reviews on PBT’s efficacy in older adults. Therefore, this study investigated the impact of PBT on older adults. Primary sources were gathered from SCOPUS, PubMed, CENTRAL, and Web of Science, covering data up to January 23, 2025. The analysis included 17 studies with 1,006 participants. Results indicated that PBT significantly reduced fall incidence (SMD: 4.82, 95% CI: 3.10–6.55, p = 0.001) and improved balance control (SMD: 0.47, p = 0.001), Timed Up and Go (SMD: 0.64, p = 0.02), fear of falling (SMD: 0.62, p = 0.004), reactive balance control (SMD: 0.72, p = 0.002), gait speed (SMD: 0.50, p = 0.01), and postural stability (SMD: 0.38, p = 0.001). The findings revealed that PBT improved mobility, postural control, and fear of falling while decreasing the fall incidence of older adults.
AartolahtiE.LönnroosE.HartikainenS.HäkkinenA. (2020). Long-term strength and balance training in prevention of decline in muscle strength and mobility in older adults. Aging Clinical and Experimental Research, 32(1), 59–66. https://doi.org/10.1007/s40520-019-01155-0
2.
AllinL. J.BrolinsonP. G.BeachB. M.KimS.NussbaumM. A.RobertoK. A.MadiganM. L. (2020). Perturbation-based balance training targeting both slip-and trip-induced falls among older adults: A randomized controlled trial. BMC Geriatrics, 20, 1–13. https://doi.org/10.1186/s12877-020-01605-9
3.
AlQahtaniM. (2024). Impact of Wii Fit Training (WFT) and Reactive Balance Training (RBT) for in elder age population: A comparative analysis. Journal of Pharmacy & Bioallied Sciences, 16(Suppl 1), S452–S455. https://doi.org/10.4103/jpbs.jpbs_712_23
4.
AppeaduM. K.BordoniB. (2023). Falls and fall prevention in the elderly. In StatPearls [Internet]. StatPearls Publishing.
5.
ArghavaniH.ZolaktafV.LenjannejadianS. (2020). Comparing the effects of anticipatory postural adjustments focused training and balance training on postural preparation, balance confidence and quality of life in elderly with history of a fall. Aging Clinical and Experimental Research, 32(9), 1757–1765. https://doi.org/10.1007/s40520-019-01358-5
6.
BierylaK. A.MadiganM. L. (2011). Proof of concept for perturbation-based balance training in older adults at a high risk for falls. Archives of Physical Medicine and Rehabilitation, 92(5), 841–843. https://doi.org/10.1016/j.apmr.2010.12.004
7.
BrüllL.HezelN.ArampatzisA.SchwenkM. (2023). Comparing the effects of two perturbation-based balance training paradigms in fall-prone older adults: A randomized controlled trial. Gerontology, 69(7), 910–922. https://doi.org/10.1159/000530167
8.
BunnF.DickinsonA.SimpsonC.NarayananV.HumphreyD.GriffithsC.MartinW.VictorC. (2014). Preventing falls among older people with mental health problems: A systematic review. BMC Nursing, 13, 1–15. https://doi.org/10.1186/1472-6955-13-4
9.
ChenW.-C.LiY.-T.TungT.-H.ChenC.TsaiC.-Y. (2021). The relationship between falling and fear of falling among community-dwelling elderly. Medicine, 100(26), Article e26492. https://doi.org/10.1097/MD.0000000000026492
10.
ChienJ.-E.HsuW.-L. (2018). Effects of dynamic perturbation-based training on balance control of community-dwelling older adults. Scientific Reports, 8(1), Article 17231. https://doi.org/10.1038/s41598-018-35644-5
11.
CoelhoD. B.de OliveiraC. E. N.GuimarãesM. V. C.de SouzaC. R.Dos SantosM. L.de Lima-PardiniA. C. (2022). A systematic review on the effectiveness of perturbation-based balance training in postural control and gait in Parkinson’s disease. Physiotherapy, 116, 58–71. https://doi.org/10.1016/j.physio.2022.02.005
12.
DesaiP.KaurT.DsouzaP.ShahM. R. (2018). Effectiveness of perturbation based balance training in an older individuals: A randomized clinical trial. International Journal of Health Sciences and Research, 8(7), 122–134.
13.
DevasahayamA. J.FarwellK.LimB.MortonA.FlemingN.JagroopD.AryanR.SaumurT. M.MansfieldA. (2023). The effect of reactive balance training on falls in daily life: An updated systematic review and meta-analysis. Physical Therapy, 103(1), pzac154. https://doi.org/10.1093/ptj/pzac154
14.
DunskyA. (2019). The effect of balance and coordination exercises on quality of life in older adults: A mini-review. Frontiers in Aging Neuroscience, 11, Article 318. https://doi.org/10.3389/fnagi.2019.00318
15.
DuvalS.TweedieR. (2000). Trim and fill: A simple funnel‐plot–based method of testing and adjusting for publication bias in meta‐analysis. Biometrics, 56(2), 455–463. https://doi.org/10.1111/j.0006-341x.2000.00455.x
16.
FlorenceC. S.BergenG.AtherlyA.BurnsE.StevensJ.DrakeC. (2018). Medical costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics Society, 66(4), 693–698. https://doi.org/10.1111/jgs.15304
17.
FranceschiC.GaragnaniP.MorsianiC.ConteM.SantoroA.GrignolioA.MontiD.CapriM.SalvioliS. (2018). The continuum of aging and age-related diseases: Common mechanisms but different rates. Frontiers in Medicine, 5, Article 61. https://doi.org/10.3389/fmed.2018.00061
18.
GerardsM.MarcellisR.SendenR.PoezeM.de BieR.MeijerK.LenssenA. (2023). The effect of perturbation-based balance training on balance control and fear of falling in older adults: A single-blind randomised controlled trial. BMC Geriatrics, 23(1), Article 305. https://doi.org/10.1186/s12877-023-03988-x
19.
GerardsM. H.MarcellisR. G.PoezeM.LenssenA. F.MeijerK.de BieR. A. (2021). Perturbation-based balance training to improve balance control and reduce falls in older adults–study protocol for a randomized controlled trial. BMC Geriatrics, 21, 1–12. https://doi.org/10.1186/s12877-020-01944-7
20.
GerardsM. H.McCrumC.MansfieldA.MeijerK. (2017). Perturbation‐based balance training for falls reduction among older adults: Current evidence and implications for clinical practice. Geriatrics & Gerontology International, 17(12), 2294–2303. https://doi.org/10.1111/ggi.13082
21.
HaagsmaJ. A.OlijB. F.MajdanM.Van BeeckE. F.VosT.CastleC. D.DingelsZ. V.FoxJ. T.HamiltonE. B.LiuZ.RobertsN. L. S.SylteD. O.AremuO.BärnighausenT. W.BorzìA. M.BriggsA. M.CarreroJ. J.CooperC.El-KhatibZ.PolinderS. (2020). Falls in older aged adults in 22 European countries: Incidence, mortality and burden of disease from 1990 to 2017. Injury Prevention: Journal of the International Society for Child and Adolescent Injury Prevention, 26(Suppl 2), i67–i74. https://doi.org/10.1136/injuryprev-2019-043347
22.
HafströmA.MalmströmE.-M.TerdènJ.FranssonP.-A.MagnussonM. (2016). Improved balance confidence and stability for elderly after 6 weeks of a multimodal self-administered balance-enhancing exercise program: A randomized single arm crossover study. Gerontology and Geriatric Medicine, 2, Article 2333721416644149.
23.
HamedA.BohmS.MersmannF.ArampatzisA. (2018). Exercises of dynamic stability under unstable conditions increase muscle strength and balance ability in the elderly. Scandinavian Journal of Medicine & Science in Sports, 28(3), 961–971. https://doi.org/10.1111/sms.13019
24.
HughesD. C.WallaceM. A.BaarK. (2015). Effects of aging, exercise, and disease on force transfer in skeletal muscle. American Journal of Physiology. Endocrinology and Metabolism, 309(1), E1–E10. https://doi.org/10.1152/ajpendo.00095.2015
25.
HulzingaF.de RondV.VandendoorentB.GilatM.GinisP.D’CruzN.SchlenstedtC.NieuwboerA. (2021). Repeated gait perturbation training in Parkinson’s disease and healthy older adults: A systematic review and meta-analysis. Frontiers in Human Neuroscience, 15, Article 732648. https://doi.org/10.3389/fnhum.2021.732648
26.
HunterS. K.PereiraH. M.KeenanK. G. (2016). The aging neuromuscular system and motor performance. Journal of Applied Physiology, 121(4), 982–995. https://doi.org/10.1152/japplphysiol.00475.2016
27.
JohnsonJ.RodriguezM. A.Al SnihS. (2020). Life-space mobility in the elderly: Current perspectives. Clinical Interventions in Aging, 15, 1665–1674. https://doi.org/10.2147/CIA.S196944
28.
KurzI.GimmonY.ShapiroA.DebiR.SnirY.MelzerI. (2016). Unexpected perturbations training improves balance control and voluntary stepping times in older adults-a double blind randomized control trial. BMC Geriatrics, 16, 1–11. https://doi.org/10.1186/s12877-016-0223-4
29.
LabancaL.IovineR.BragonzoniL.BaroneG.FarellaG.BenedettiM. G. (2020). Instrumented platforms for balance and proprioceptive assessment in patients with total knee replacement: A systematic review and meta-analysis. Gait & Posture, 81, 230–240. https://doi.org/10.1016/j.gaitpost.2020.07.080
30.
LandisJ. R.KochG. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33(1), 159–174.
31.
LesinskiM.HortobágyiT.MuehlbauerT.GollhoferA.GranacherU. (2015). Effects of balance training on balance performance in healthy older adults: A systematic review and meta-analysis. Sports Medicine, 45(12), 1721–1738. https://doi.org/10.1007/s40279-015-0375-y
32.
LuL.MaoL.FengY.AinsworthB. E.LiuY.ChenN. (2021). Effects of different exercise training modes on muscle strength and physical performance in older people with sarcopenia: A systematic review and meta-analysis. BMC Geriatrics, 21(1), Article 708. https://doi.org/10.1186/s12877-021-02642-8
33.
LurieJ. D.ZagariaA. B.PidgeonD. M.FormanJ. L.SprattK. F. (2013). Pilot comparative effectiveness study of surface perturbation treadmill training to prevent falls in older adults. BMC Geriatrics, 13, 1–8. https://doi.org/10.1186/1471-2318-13-49
34.
MacKayS.EbertP.HarbidgeC.HoganD. B. (2021). Fear of falling in older adults: A scoping review of recent literature. Canadian Geriatrics Journal: CGJ, 24(4), 379–394. https://doi.org/10.5770/cgj.24.521
35.
MaherC. G.SherringtonC.HerbertR. D.MoseleyA. M.ElkinsM. (2003). Reliability of the PEDro scale for rating quality of randomized controlled trials. Physical Therapy, 83(8), 713–721.
36.
MansfieldA.PetersA. L.LiuB. A.MakiB. E. (2007). A perturbation-based balance training program for older adults: Study protocol for a randomised controlled trial. BMC Geriatrics, 7, 1–14. https://doi.org/10.1186/1471-2318-7-12
37.
MansfieldA.PetersA. L.LiuB. A.MakiB. E. (2010). Effect of a perturbation-based balance training program on compensatory stepping and grasping reactions in older adults: A randomized controlled trial. Physical Therapy, 90(4), 476–491. https://doi.org/10.2522/ptj.20090070
38.
MansfieldA.WongJ. S.BryceJ.KnorrS.PattersonK. K. (2015). Does perturbation-based balance training prevent falls? Systematic review and meta-analysis of preliminary randomized controlled trials. Physical Therapy, 95(5), 700–709. https://doi.org/10.2522/ptj.20140090
39.
McCrumC.BhattT. S.GerardsM. H.KaramanidisK.RogersM. W.LordS. R.OkuboY. (2022). Perturbation-based balance training: Principles, mechanisms and implementation in clinical practice. Frontiers in Sports and Active Living, 4, Article 1015394. https://doi.org/10.3389/fspor.2022.1015394
40.
McCrumC.GerardsM. H.KaramanidisK.ZijlstraW.MeijerK. (2017). A systematic review of gait perturbation paradigms for improving reactive stepping responses and falls risk among healthy older adults. European Review of Aging and Physical Activity: Official Journal of the European Group for Research Into Elderly and Physical Activity, 14, 1–11. https://doi.org/10.1186/s11556-017-0173-7
41.
MelzerI.OddssonL. I. (2013). Improving balance control and self-reported lower extremity function in community-dwelling older adults: A randomized control trial. Clinical Rehabilitation, 27(3), 195–206. https://doi.org/10.1177/0269215512450295
42.
MontgomeryP. G.PyneD. B.MinahanC. L. (2010). The physical and physiological demands of basketball training and competition. International Journal of Sports Physiology and Performance, 5(1), 75–86. https://doi.org/10.1123/ijspp.5.1.75
43.
NørgaardJ. E.AndersenS.RygJ.StevensonA. J. T.AndreasenJ.OliveiraA. S.DanielsenM. B.JorgensenM. G. (2023). Effect of treadmill perturbation-based balance training on fall rates in community-dwelling older adults: A randomized clinical trial. JAMA Network Open, 6(4), Article e238422. https://doi.org/10.1001/jamanetworkopen.2023.8422
44.
OkuboY.SchoeneD.LordS. R. (2017). Step training improves reaction time, gait and balance and reduces falls in older people: A systematic review and meta-analysis. British Journal of Sports Medicine, 51(7), 586–593. https://doi.org/10.1136/bjsports-2015-095452
45.
OkuboY.SturnieksD. L.BrodieM. A.DuranL.LordS. R. (2019). Effect of reactive balance training involving repeated slips and trips on balance recovery among older adults: A blinded randomized controlled trial. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 74(9), 1489–1496. https://doi.org/10.1093/gerona/glz021
46.
OliveiraA. A. d.NossaP. N. M. d. S.Mota PintoA. (2019). Assessing functional capacity and factors determining functional decline in the elderly: A cross-sectional study. Acta Medica Portuguesa, 32(10), 654–660. https://doi.org/10.20344/amp.11974
47.
PaquetteM. R.LiY.HoekstraJ.BravoJ. (2015). An 8-week reactive balance training program in older healthy adults: A preliminary investigation. Journal of Sport and Health Science, 4(3), 263–269. https://doi.org/10.1016/j.jshs.2014.06.004
48.
PetrovicA.WirthR.KlimekC.LuegG.DaubertD.GiehlC.TrampischU. S. (2024). Impact of reactive balance training on a perturbation treadmill on physical performance in geriatric patients: Results of a single-center, assessor blinded randomized controlled trial. Journal of Clinical Medicine, 13(19), Article 5790. https://doi.org/10.3390/jcm13195790
49.
RiegerM. M.PapegaaijS.SteenbrinkF.Van DieënJ. H.PijnappelsM. (2020). Perturbation-based gait training to improve daily life gait stability in older adults at risk of falling: Protocol for the REACT randomized controlled trial. BMC Geriatrics, 20, 1–12. https://doi.org/10.1186/s12877-020-01566-z
50.
RiegerM. M.PapegaaijS.SteenbrinkF.van DieënJ. H.PijnappelsM. (2024). Effects of perturbation-based treadmill training on balance performance, daily life gait, and falls in older adults: REACT randomized controlled trial. Physical Therapy, 104(1), pzad136. https://doi.org/10.1093/ptj/pzad136
51.
RikliR. E.JonesC. J. (2013). Development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years. The Gerontologist, 53(2), 255–267. https://doi.org/10.1093/geront/gns071
52.
RodriguesF.DomingosC.MonteiroD.MorouçoP. (2022). A review on aging, sarcopenia, falls, and resistance training in community-dwelling older adults. International Journal of Environmental Research and Public Health, 19(2), Article 874. https://doi.org/10.3390/ijerph19020874
53.
RossiL. P.BrandalizeM.PereiraR.GomesA. R. S. (2014). The effects of a perturbation-based balance training on neuromuscular recruitment and functional mobility in community-dwelling older women: A randomized controlled trial. Topics in Geriatric Rehabilitation, 30(4), 256–263. https://doi.org/10.1097/tgr.0000000000000035
54.
RossiL. P.PereiraR.BrandalizeM.GomesA. R. S. (2013). The effects of a perturbation-based balance training on the reactive neuromuscular control in community-dwelling older women: A randomized controlled trial. Human Movement, 14(3), 238–246. https://doi.org/10.2478/humo-2013-0029
55.
SadeghiM. (2023). The effect of eight weeks of reactive neuromuscular training on balance, strength and quality of life of elderly women. Exercise Physiology and Performance, 1(1), Article 1.
56.
SchoenebergB.McNealB.ReisnerJ.FriesenA.ReedT.GoodwinJ. F. (2024). The efficacy of perturbation-based balance training among older adults: A systematic review. Physical & Occupational Therapy In Geriatrics, 42(4), 1–17. https://doi.org/10.1080/02703181.2024.2319241
57.
TavaresG. M. S.PachecoB. P.GottliebM. G. V.MüllerD. V. K.SantosG. M. (2020). Interaction between cognitive status, fear of falling, and balance in elderly persons. Clinics, 75, Article e1612. https://doi.org/10.6061/clinics/2020/e1612
58.
Tornero-QuiñonesI.Sáez-PadillaJ.Espina DíazA.Abad RoblesM. T.Sierra RoblesÁ. (2020). Functional ability, frailty and risk of falls in the elderly: Relations with autonomy in daily living. International Journal of Environmental Research and Public Health, 17(3), Article 1006. https://doi.org/10.3390/ijerph17031006
59.
XuQ.OuX.Li J. (2022). The risk of falls among the aging population: A systematic review and meta-analysis. Frontiers in Public Health, 10, Article 902599. https://doi.org/10.3389/fpubh.2022.902599
60.
ZechA.HübscherM.VogtL.BanzerW.HänselF.PfeiferK. (2010). Balance training for neuromuscular control and performance enhancement: A systematic review. Journal of Athletic Training, 45(4), 392–403. https://doi.org/10.4085/1062-6050-45.4.392
