0.5 contact hours (30 min)
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Geriatrics · 9 min · September 27, 2026
From the course: Fall Risk in Community-Dwelling Older Adults: The APTA Geriatrics Clinical Practice Guideline · 0.5 contact hours
This episode breaks down an APTA Geriatrics guideline on reducing fall risk in community-dwelling adults 65 and older, with a focus on multifactorial management, balance and multicomponent exercise, Tai Chi, and environmental modification. It also covers who the evidence applies to, how the recommendations were graded, and why some interventions are stronger choices for higher-risk patients.
Kirk-Sanchez N, McDonough C, Avin KG, Blackwood J, Hanke TA. Physical Therapy Management of Fall Risk in Community-Dwelling Older Adults: An Evidence-Based Clinical Practice Guideline From the American Physical Therapy Association – Geriatrics. J Geriatr Phys Ther. 2025;48(2):62-87. https://doi.org/10.1519/JPT.0000000000000454
What does the APTA Geriatrics clinical practice guideline recommend for managing fall risk in older adults who live in the community? Its authors identify multicomponent exercise as the most important intervention for falls and fall risk, and they state that such a program must include balance training that is progressive and challenging. The guideline, written by Kirk-Sanchez, McDonough, Avin, Blackwood and Hanke, was published in the Journal of Geriatric Physical Therapy in 2025. The development group also gave strong recommendations to Tai Chi and to participation in multifactorial management programs, and it advises against providing resistance training alone or education alone when the purpose is to reduce falls.
The authors cite 2020 surveillance data in which 27.6 percent of older adults in the United States reported at least one fall in the past year, amounting to more than 14 million falls, which were associated with almost 39,000 fall-related deaths. They also report that almost half of falls in older adults have been attributed to modifiable factors, such as environmental hazards or impairments in balance and walking, and they note that these factors fall within physical therapist practice.
According to the authors, earlier documents, including their own guidance statement and the 2022 World Falls Guideline, lacked the specificity needed to direct physical therapy management. For this guideline the group went to the systematic review literature, with particular attention to dosage and mode of delivery. It also examined whether a person's level of fall risk changes what works, and it added a decision algorithm to support clinical reasoning.
The recommendations address community-dwelling adults aged 65 and over who have no major health conditions preventing them from interacting in their environment without substantial support. The authors state that the guideline does not cover older adults who are institutionalized. The review excluded studies focused on hip fracture, osteoporosis, Parkinson disease and dementia, including moderate and severe cognitive impairment, although studies that included people with mild cognitive impairment were kept. For patients outside these criteria, the authors ask clinicians to use clinical judgment and to consult condition-specific evidence-based documents.
The group was made up of five physical therapists with clinical and methodological expertise, who searched the literature in 2015 and updated the search in 2018 and 2022. Only systematic reviews and meta-analyses published between 2005 and 2022 that reported falls as a number, rate or risk were eligible. Two members screened each article independently. Of 1,549 articles identified, 55 reviews were included. Each was rated with the AMSTAR 2 instrument; reviews rated acceptable or low were downgraded in level of evidence, and those rated unacceptable were excluded.
In grading each recommendation, the group weighed the evidence against benefits, harms, costs and patient preferences. Invited experts and public commenters reviewed the draft, and three older adult laypersons reviewed the final manuscript.
| Intervention | What the development group recommends |
|---|---|
| Multifactorial programs | Physical therapists and physical therapist assistants should participate in programs that combine screening, assessment, referral and interventions within scope |
| Multicomponent exercise | Must be provided or prescribed; must include balance training and may include other modes such as resistance training or Tai Chi |
| Balance training | Must be progressive and sufficiently challenging, and must include volitional step training, gait adaptability training or both |
| Tai Chi | Should be prescribed, particularly for older adults at lower fall risk |
| Environmental assessment | Should be provided, with recommended modifications, for older adults at high risk of falls |
The authors list the features that make balance training count: it should move the limbs and whole body in multiple directions, change the base of support, and reduce upper limb support as training goes on. Stepping should be self-directed or cued and performed forward, backward and to the side, and task and environmental conditions should be manipulated as the program progresses.
For dosage, the group recommends exercise performed for at least 150 minutes to 3 hours per week over 6 to 12 months. On Tai Chi, the authors note that the benefit appeared larger for people at lower fall risk. For people at higher risk, they state that multicomponent exercise should be the first choice over Tai Chi alone.
| Intervention | Recommendation | Strength |
|---|---|---|
| Resistance training alone | Should not be provided or prescribed when the purpose is reducing fall risk or fall rate | Moderate, level II evidence |
| Education alone | Should not be provided as the sole intervention to reduce falls | Strong, level I evidence |
| Reactive step (perturbation) training | May be included as a component of balance training | Weak, because the findings are mixed |
The word "alone" matters in both negative recommendations. The authors describe tailored progressive resistance exercise within a multicomponent plan as the standard of practice for people with identified strength impairments, and individualized patient education as presumed standard of care, but neither is sufficient on its own to reduce falls.
The group found several problems in the resistance training literature: samples were relatively small, no study separated participants by level of fall risk, risk of bias was consistently moderate to high, and resistance exercise was rarely separated from multicomponent protocols. For perturbation training, the analyses in community-dwelling older adults at increased risk were judged low in quality with a high risk of bias.
The group did not systematically review the evidence for fall risk screening or examination strategies, and it issues no specific screening recommendations. No recommendation was made on group versus individual delivery, because no direct comparisons were found in the same population.
The combined recommendation for a comprehensive approach, which pairs tailored education with individualized exercise and referral for factors outside physical therapy scope, rests on expert opinion, although the authors note that each component is recommended on strong evidence. They also state that the guideline is not intended to serve as a legal standard of care or an insurance benefit determination document.
The guideline is written for physical therapists and for physical therapist assistants working under the supervision of physical therapists. Within a multifactorial program, the authors describe the physical therapist's role as including some or all of screening, assessment, referral and intervention. Where no such program exists in the practice setting, they state that the physical therapist's role includes all four.
The authors write that the final decision must account for the patient's clinical presentation, values, preferences and resources, and that substantial departures from the guideline should be documented at the time the decision is made.
Kirk-Sanchez and colleagues identify multicomponent exercise that includes progressive, challenging balance training as the most important intervention for falls and fall risk in community-dwelling older adults.
The APTA Geriatrics development group strongly recommends Tai Chi for community-dwelling older adults, and the benefit appeared larger for people at lower fall risk. No included review reported serious adverse events from Tai Chi.
No. The development group recommends against providing resistance training alone when the purpose is to reduce fall risk or fall rate. The authors support progressive resistance exercise as part of a multicomponent plan for people with identified strength impairments.
Kirk-Sanchez N, McDonough C, Avin KG, Blackwood J, Hanke TA. Physical therapy management of fall risk in community-dwelling older adults: an evidence-based clinical practice guideline from the American Physical Therapy Association – Geriatrics. J Geriatr Phys Ther. 2025;48(2):62-87. doi:10.1519/JPT.0000000000000454
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