Occupational Therapy Interventions for Fall Prevention in Older Adults: A Systematic Review of Multimodal Strategies

Abstract

Background: Falls are a leading cause of morbidity and loss of independence among older adults, and occupational therapy (OT) offers a unique, multidimensional approach to fall prevention. This systematic review evaluates the effectiveness of OT-based interventions for improving balance, mobility, functional performance, and psychological outcomes related to fall risk in older adults. Methods: This review followed PRISMA (2020) guidelines. A comprehensive search of PubMed, Scopus, Dialnet, and OTseeker was conducted from March to May 2025. The inclusion criteria targeted studies involving non-pharmacological, OT-led interventions in adults aged ≥65. Seventeen studies were selected, including randomized controlled trials, pilot studies, and quasi-experimental designs. The data extraction and quality appraisal were performed independently by two reviewers. Results: The included interventions varied among exercise-based programs (e.g., Tai Chi, Pilates), virtual reality training, home safety modifications, cognitive–behavioral therapy, and wearable technologies. Most of the studies reported significant improvements in postural balance, fear of falling, and functional independence. Environmental adaptations and educational strategies also yielded positive outcomes. However, a real-world fall incidence reduction was inconsistently reported, and the methodological heterogeneity limited the meta-analytic synthesis. Conclusions: Occupational therapy contributes significantly to fall prevention through multimodal, person-centered strategies that integrate physical, cognitive, and environmental components. Future research should aim to standardize the outcome measures, include high-risk populations, and assess the long-term efficacy and cost-effectiveness of OT-led programs.

1. Introduction

Falls among older adults represent a major public health concern due to their high incidence; multifactorial etiology; and severe physical, psychological, and socioeconomic consequences. As global demographics shift toward an aging population, with the World Health Organization (WHO) projecting that by 2030 one in six individuals will be aged 60 or older, fall prevention has emerged as a critical priority in geriatric care [1]. These incidents not only threaten the independence and well-being of older individuals, but also exert significant pressure on healthcare systems and informal care networks [2,3].

Physiological aging inherently entails a progressive decline in neuromuscular, sensory, and cognitive systems, which collectively compromise postural control, muscle strength, balance, and mobility [4]. These impairments elevate the risk of falls and contribute to a loss of functional independence. Importantly, falls are not benign events: they are the second leading cause of accidental death worldwide and are frequently associated with hip fractures, traumatic brain injuries, hospitalizations, and long-term disability [5,6]. In Spain, and specifically in regions such as Extremadura, fall-related mortality continues to rise with an aging population, highlighting the urgent need for effective interventions.

The risk factors for falls are diverse and interrelated. They may be categorized into intrinsic factors (e.g., age-related physiological decline, chronic illnesses, and polypharmacy), extrinsic factors (e.g., environmental hazards, inadequate footwear, and poorly designed living spaces), and situational factors (e.g., risk-laden behaviors during daily tasks) [7]. Among these, the fear of falling (FoF) stands out as both a consequence and a predictor of future falls, often resulting in activity restriction, reduced mobility, and social isolation [8]. Notably, individuals may develop FoF even without prior falls, indicating the importance of addressing the psychosocial dimensions in prevention strategies.

Occupational therapy (OT) offers a unique and holistic approach to fall prevention by targeting the dynamic interaction between the person, their occupations (i.e., daily activities), and their environment. The primary goal of OT is to enhance functional independence, promote engagement in meaningful activities, and optimize quality of life. This is achieved through personalized interventions that may include functional training, cognitive–behavioral strategies, environmental modifications, assistive technology, and patient and caregiver education [1].

Although fall prevention programs are often implemented by multidisciplinary teams including physicians, physiotherapists, and nurses, occupational therapists are particularly well-positioned to assess and intervene at both the individual and contextual levels. They evaluate their clients’ home settings to identify potential hazards; provide tailored home modifications (e.g., grab bars, improved lighting); train clients in the safe performance of activities of daily living (ADLs); and deliver interventions that address physical (balance, strength), cognitive (attention, executive function), and emotional (confidence, fear) factors.

The recent literature highlights the effectiveness of various non-pharmacological interventions for reducing fall risk among older adults. These include structured exercise programs (e.g., Tai Chi, Pilates, and perturbation training); the use of virtual reality (VR) platforms for balance training; telehealth-based education; and the implementation of wearable technologies, such as smart belts or sensors [9,10,11]. It is important to note that certain modalities, such as Tai Chi, Pilates, and virtual reality platforms, are not occupational therapy interventions received in isolation. In the reviewed studies they were applied within OT-led programs, where occupational therapists integrated these approaches into holistic, person-centered strategies tailored to the individual’s occupational needs and environmental context. In this sense, despite the growing evidence base, studies specifically focusing on occupational therapy-led interventions remain limited and fragmented.

To address this gap, the present systematic review aims to synthesize the available evidence on occupational therapy interventions aimed at preventing falls in older adults. Specifically, it evaluates the effectiveness of interventions for improving balance, postural control, mobility, strength, fall-related self-efficacy, performance in ADLs, and overall well-being. The review also seeks to identify the key components of successful interventions, assess methodological quality, and highlight areas requiring further research.

By consolidating the evidence from recent clinical trials and observational studies, this review contributes to a better understanding of how occupational therapy can be effectively utilized within fall prevention frameworks. Given the multidimensional nature of falls and the increasing emphasis on aging in place, a clearer articulation of OT’s role in this domain is both timely and necessary.

In particular, resistance training—whether through structured exercise, aquatic methods, or functional occupational tasks—has emerged as a vital component of enhancing strength and reducing fall risk. This review also considers how resistance-based modalities are integrated within broader occupational therapy interventions.

2. Materials and Methods

The present systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines, using the 27-item checklist and adhering to methodological recommendations at each stage of the review process [12,13,14]. In this sense, we strictly adhered to the PRISMA 2020 guidelines, fully detailing all methodological procedures to ensure transparency and reproducibility.

2.1. Eligibility Criteria

Studies were selected based on the following inclusion criteria: (a) Target population: Adults aged ≥ 65 years. (b) Intervention: Non-pharmacological strategies focused on fall prevention through occupational therapy. (c) Outcomes: Assessments related to fall risk reduction, balance, mobility, postural control, muscle strength, fear of falling, and performance in activities of daily living. (d) Study design: Randomized controlled trials, comparative studies, observational studies, and case series. The inclusion of diverse study designs was intentional, as the current evidence base for occupational therapy-led fall prevention is limited and fragmented. Including observational and quasi-experimental studies allowed us to capture a broader range of real-world interventions while still distinguishing these from randomized controlled trials in the synthesis. (e) Time frame: Publications between 2015 and 2025. (f) Language: English or Spanish. The decision to restrict the search to English and Spanish was based on feasibility, as these are the languages spoken by the review team, ensuring accuracy in data interpretation. While this approach reduced the risk of translation errors, it may have excluded potentially relevant studies published in other languages.

On the other hand, the exclusion criteria included the following: (a) interventions based primarily on pharmacology, nutritional supplementation, physiotherapy, podiatry, or medicine; (b) studies involving populations under 65 years, or caregivers and healthcare professionals; (c) animal studies or protocol-only articles without published results; (d) systematic reviews or meta-analyses; and (e) articles lacking abstracts or keywords related to “falls,” “balance,” “posture,” or “occupational therapy.”

2.2. Information Sources and Search Strategy

A comprehensive search was performed across four databases: PubMed, Scopus, Dialnet, and OTseeker. Although the PEDro scale was used for quality assessment, the PEDro database itself was not included in the search. We selected PubMed, Scopus, Dialnet, and OTseeker because they provide broad coverage of occupational therapy and rehabilitation literature. The search period spanned from March to May 2025. The search strategy employed Medical Subject Headings (MeSHs) and Boolean operators: (a) MeSH terms: Accidental falls, occupational therapy, aged, postural balance, intervention, and treatment. (b) Boolean operators: “AND” to combine concepts and “OR” to include synonyms.

To identify additional studies, backward citation searching was conducted on the reference lists of the included articles. Duplicates were identified and removed using the Rayyan platform. The search strategy for the different databases was as follows: for Pubmed, («Accidental falls» AND aged AND «Occupational Therapy» AND intervention OR treatment; for Scopus, (Accidental AND Falls AND Aged AND Occupational AND Therapy AND intervention OR treatment); and for Dialnet and OTseeker, (Accidental Falls AND intervention OR treatment).

2.3. Study Selection

From an initial pool of 517 articles, 95 duplicates were excluded, leaving 422 for title and abstract screening. Based on the predefined criteria, 321 articles were excluded. The full texts of 101 studies were assessed for eligibility, of which 17 articles met all the inclusion criteria and were included in the final synthesis. The entire selection process is illustrated in the PRISMA flow diagram (Figure 1).

2.4. Data Extraction

The data were extracted using a predesigned template including the following: (a) study authors and publication year; (b) study design; (c) sample size and participant characteristics; (d) type and duration of the intervention; (e) assessment tools used; (f) variables measured; and (g) main outcomes.

Two reviewers (A.C.P. and L.P.F) independently extracted the data and resolved discrepancies through discussion. To ensure the consistency and reliability of the data extraction and quality appraisal, the inter-rater agreement was calculated. The Cohen’s kappa coefficient between the two reviewers was 0.82, indicating substantial agreement. Any discrepancies were resolved through discussion, and when a consensus was not reached, a third senior reviewer was consulted. Although only two authors formally contributed to this systematic review, all stages of study selection, data extraction, and quality appraisal were performed independently by both reviewers to minimize bias.

2.5. Quality Assessment

The methodological quality of randomized controlled trials (RCTs) and pilot intervention studies was evaluated using the PEDro scale (Physiotherapy Evidence Database) [15]. Other study designs, such as quasi-experimental studies, comparative studies, and case series, were not assessed with the PEDro scale but were instead described narratively in terms of their design, sample, and limitations. This ensured that PEDro was applied strictly within its validated scope.

This scale consists of 11 items that assess internal validity and interpretability of clinical trials, although only 10 are scored (excluding the first item related to external validity). The PEDro scale has been validated as a reliable tool for appraising the methodological rigor of physical and rehabilitation-based interventions. Each included randomized controlled trial (RCT) was independently assessed by two reviewers using the PEDro criteria, which include aspects such as random allocation, concealed allocation, baseline comparability, blinding (of subjects, therapists, and assessors), adequate follow-up, intention-to-treat analysis, and between-group statistical comparisons. Disagreements in scoring were resolved through discussion or by a third reviewer when necessary. Studies scoring 6 or above (out of 10) were considered high quality, whereas scores below 6 were categorized as low-to-moderate quality, following commonly accepted thresholds in the literature. The detailed scores for each study are presented in the results in Section 3.6 and summarized in Table 2.

2.6. Data Synthesis

Given the heterogeneity in the interventions, populations, and outcome measures, a meta-analysis was not feasible. Instead, a narrative synthesis was performed, structured around the following categories: (a) type of intervention (e.g., exercise-based, technology-assisted, or cognitive–behavioral); (b) assessment domains (e.g., balance, strength, and fear of falling); (c) effectiveness and clinical relevance; and (d) common facilitators or barriers to implementation. Tables and figures were created to summarize the key study characteristics and outcomes.

3. Results

3.1. Study Selection

A total of 517 articles were initially retrieved from PubMed, Scopus, Dialnet, and OTseeker. After removing 95 duplicates using the Rayyan reference management platform, 422 studies were screened based on their titles and abstracts. Following strict application of inclusion and exclusion criteria, 101 articles were selected for full-text review. From these, 84 were excluded due to reasons such as a focus on pharmacological treatment, lack of occupational therapy intervention, or a population outside the target age group. Ultimately, 17 studies met all the eligibility criteria and were included in this systematic review: Allin LJ, et al. (2020) [10]; Jeter PE, et al. (2015) [16]; Liu B, et al. (2018) [17]; Li Y, et al. (2021) [18]; Patti A, et al. (2021) [19]; Nissim M, et al. (2020) [20]; Chan WL, et al. (2024) [21]; Tarbert RJ, et al. (2023) [22]; Adamit T, et al. (2023) [23]; Kamei T, et al. (2015) [24]; Liu M, et al. (2021) [25]; Cattaneo D, et al. (2019) [26]; Norgaard JE, et al. (2023) [27]; Wetherell JL, et al. (2018) [28]; Whitney J, et al. (2017) [29]; and Kwok BC, et al. (2016) [30].

3.2. Study Characteristics

Given the heterogeneity of methodologies, a narrative synthesis was adopted. To enhance clarity, the interventions were grouped into four categories: exercise based, technology assisted, cognitive–behavioral, and environmental. Within each category, randomized controlled trials were described first, followed by the other study designs.

The included studies encompassed a range of research designs, reflecting the multidisciplinary and complex nature of fall prevention in older adults. Most were randomized controlled trials (n = 11), while others included comparative or quasi-experimental studies (n = 3), pilot interventions (n = 2), and one case series (n = 1).

The participants were generally aged 65 or older, with several studies focusing on subgroups, such as individuals with prior falls, mild cognitive impairments, or post-stroke status. The mean age across the studies ranged from 63 to 86 years, and most of the samples included a higher proportion of women. The participants were either community dwelling or residents in assisted living facilities, and most retained sufficient functional capacity to engage in structured interventions.

The study durations ranged from short-term pilot programs of 4 weeks to longitudinal interventions lasting up to 6 months. The sample sizes were highly variable, ranging from as few as 21 participants in one pilot study [16] to 14,540 hospitalized older adults in a large-scale intervention [17].

The studies collectively assessed a broad range of variables relevant to fall prevention. Balance and postural control were central outcomes in nearly all the studies, as they are closely linked to fall risk. One study evaluated gait parameters, including speed, stride length, and step variability, under dual-task conditions [18].

Muscle strength, particularly in the lower extremities, was a frequent variable, given its role in functional mobility and fall recovery. The fear of falling, a recognized psychological barrier to mobility, was addressed in both the educational and exercise-based interventions.

Other important variables included reaction time, cognitive flexibility, executive function, pain, social participation, and perceived safety. The interventions aimed at improving home safety awareness, increasing adherence to mobility aids, and promoting engagement in daily activities were evaluated through both self-reported and objective measures.

Table 1. Characteristics and main results of the included studies on occupational therapy interventions for fall prevention in older adults.

Nº	Authors (Year)	Study Design	Population and Characteristics	Intervention	Assessment Instruments	Main Results
1	Allin LJ, et al. (2020) [10]	RCT	34 participants, 61–75 years	Perturbation training vs. Otago	FES, balance tests	↓ slip falls (p = 0.027), ↑ reactive balance
2	Zahedian-Nasab N, et al. (2021) [11]	RCT	60 participants, mean age 70.8, no severe disabilities	6 weeks VR balance exercises (Xbox)	FES, BBS, TUG	Improved balance (p = 0.001) and TUG (−2.3 s)
3	Jeter PE, et al. (2015) [16]	Pilot RCT	21 legally blind, no vestibular disorders	8 weeks Ashtanga Yoga	Wii Balance Board	↑ balance stability, ↑ flexibility and strength
4	Liu B, et al. (2018) [17]	Quasi-experimental	14,540 hospitalized patients, mean age 79.9	Early mobilization program	Visual audits	↑ mobilization, ↓ hospital stay by 6.1 days
5	Li Y, et al. (2021) [18]	Comparative	25 Tai Chi practitioners vs. controls, ≥65 years	Tai Chi stair descent tasks	Motion analysis	Better postural control, reduced trunk/head tilt
6	Patti A, et al. (2021) [19]	RCT	41 healthy older adults, mean age 63	13 weeks Pilates vs. physical activity	Handgrip, BBS, Romberg	Both groups improved; Pilates enhanced balance
7	Nissim M, et al. (2020) [20]	Pilot RCT	42 older adults, mean age 74.4	12 weeks aquatic vs. land Ai-Chi	Tinetti, memory/cognitive tests	Improved balance, fall risk, and working memory
8	Chan WL, et al. (2024) [21]	Pilot RCT	42 participants, mean age 68.2	8 weeks exergames (Ring Fit Adventure)	Mini-BES, FTSS, TUG, Icon-FES, CTT	Significant improvements in balance and mobility
9	Tarbert RJ, et al. (2023) [22]	Case series	20 residents with fall risk, mean age 86.8	Smart belts with airbags	Environmental and functional assessments	60% reduction in severe fall injuries
10	Adamit T, et al. (2023) [23]	RCT	66 stroke survivors, mean age 64.6	10 OT-led cognitive–behavioral sessions (FaCoT)	MoCA, NGSE, GDS, RNLI, FIM	Improved performance, emotional state, daily participation
11	Kamei T, et al. (2015) [24]	RCT	130 community dwelling, mean age 75	Home risk modification program	Falls diary, awareness questionnaire	Reduced home falls, ↑ preventive behaviors
12	Liu M, et al. (2021) [25]	RCT	300 participants, mean age 75, community dwelling	6 OT home visits + adaptations	HBMA, Tinetti	Improved home safety and fall control
13	Cattaneo D, et al. (2019) [26]	RCT	90 with Parkinson’s/MS/Stroke, mean age 63	Educational + exercise program	BBS, TUG, 10MWT, ABC, CIQ	↑ confidence, no reduction in falls
14	Norgaard JE, et al. (2023) [27]	RCT	140 participants, mean age 72, history of falls	4 perturbation treadmill sessions	Frailty and performance scales, FES	Reduced falls by 22%, but not statistically significant
15	Wetherell JL, et al. (2018) [28]	Pilot RCT	42 community dwelling, mean age 77.9	ABLE: Exercise + exposure + safety	FES, ACS	↓ fear of falling, ↓ activity avoidance, no fall reduction
16	Whitney J, et al. (2017) [29]	Pilot RCT	191 residents, mean age 83.5	Multifactorial risk assessment program	Balance, depression, cognitive and ADL scales	Safe intervention, but no improvement in falls or balance
17	Kwok BC, et al. (2016) [30]	RCT	80 frail adults, mean age 70	12 weeks Wii balance board training	FES, TUG, 6MWT	↓ fear of falling, mixed results for strength, no fall reduction

RCT = randomized controlled trial; FES = fall effectiveness scale; BBS = Berg Balance Scale; TUG = Timed Up and Go test; FOF = fear of falling; ADLs = activities of daily life; HBMA = Home Mobility Assessment; OT = occupational therapist, FTSS = Five Time Sit-to-Stand; CTT = Color Trails Test; MoCA = Montreal Cognitive Assessment; NGSE = New General Self-Efficacy Scale; GDS = Geriatric Depression Scale; DEX = Dec Executive Questionnaire; RNLI = Return to Normal Life Index; FIM = Functional Independence Measure; ABC = Activity Balance Confidence Scale; CIQ = Community Integration Questionnaire; PBT = perturbation-based balance training; MMSE = Mini Mental State Examination; ACS = Activity Card Sort; MFRA = Multifactorial Falls Risk Assessment; NCW = Narrow Corridor Walk; 6MW = 6 Minute Walk; VR = virtual reality.

shows the studies with occupational therapy interventions related to fall prevention in older adults. This table summarizes the essential characteristics and outcomes of the included studies. A full version of this table, with extended details on the methodology, instruments, and secondary outcomes, is provided as Supplementary Table S1.

3.3. Intervention Categories

3.3.1. Exercise-Based Interventions

The intervention modalities varied widely, highlighting the versatility of occupational therapy for addressing fall risk from multiple angles. Several studies focused on physical exercise programs, such as Tai Chi [18], Pilates [19], or aquatic Ai-Chi [20], with sessions delivered two to three times per week. These exercises emphasized balance, postural control, and core strength.

The aquatic and land-based physical interventions (e.g., Ai-Chi, Tai Chi, and Pilates) ranged from 12 to 13 weeks, and showed improvements in balance and strength [19,20]. The Tai Chi practitioners showed enhanced postural strategies and reduced center of mass deviation when descending stairs [18].

Most of the exercise-based studies showed improvements in balance, gait, and lower-limb strength, although the impact on actual fall rates was inconsistent.

3.3.2. Technology-Assisted Interventions

Other interventions adopted technology-enhanced approaches, including virtual reality (VR) using Xbox Kinect [11], or exergames like Nintendo Ring Fit Adventure [21], which were designed to enhance motivation while improving dynamic balance and lower-limb strength.

The interventions varied in intensity and structure, but shared the common goal of enhancing safety, confidence, and physical function. The VR and exergame-based interventions typically involved twice-weekly sessions lasting 60 min for 6–8 weeks. The exercises included squats, lateral steps, and coordination challenges delivered in a gamified environment [21].

The innovative studies also explored the use of wearable devices, such as smart belts equipped with airbag systems that inflate upon fall detection, minimizing impact and alerting caregivers [22].

Overall, the interventions reviewed demonstrated promising results. Most of the studies reported statistically significant improvements in at least one of the targeted outcomes. For instance, Zahedian-Nasab N, et al. (2021) [11] found that balance scores and TUG performance improved significantly following VR training, while Liu et al. (2021) [25] reported improved mobility and fall efficacy following occupational therapy-led home modifications. Use of smart belts reduced the incidence of severe fall injuries and improved caregiver response times [22].

The technology-assisted programs increased adherence and engagement, with positive effects on balance, mobility, and fear of falling, although the fall reduction was not always significant.

3.3.3. Cognitive–Behavioral and Educational Interventions

Cognitive–behavioral and educational approaches led by occupational therapists were used to improve fall-related self-efficacy, especially among stroke survivors [23].

Cognitive–behavioral sessions, like the ones in the FaCoT program [23], were implemented through 10 individual weekly sessions with occupational therapists, focusing on self-awareness, behavioral planning, and emotional regulation.

The educational and cognitive–behavioral interventions improved participants’ confidence and emotional resilience, although these changes were not always associated with reduced fall rates [26]. Perturbation-based treadmill training was effective at improving laboratory performance, but its transferability to everyday fall reduction remains inconclusive [27].

These interventions improved fall-related self-efficacy, emotional resilience, and participation, but the evidence on fall reduction remains mixed.

3.3.4. Environmental and Multicomponent Interventions

The environmental interventions included home safety assessments and adaptations implemented by occupational therapists [17,24], often combined with caregiver training and health education.

The environmental interventions involved occupational therapists conducting 6–10 home visits over several months, identifying and modifying hazards and educating both patients and caregivers [17].

These interventions demonstrated improvements in safety awareness and fall prevention behaviors, particularly when combined with caregiver training, although the reductions in actual fall rates were modest.

3.4. Assessment Instruments

The assessment methods were diverse and tailored to the specific objectives of each intervention. Balance and gait were commonly measured using the Berg Balance Scale (BBS), Timed Up and Go (TUG), and Mini-BESTest. Muscle strength and functional mobility were evaluated using tests such as the Five Times Sit-to-Stand (FTSS) and one-leg stance.

Fear of falling and self-efficacy were assessed using scales like the Falls Efficacy Scale International (FES-I) and Icon-FES. The cognitive and emotional parameters were addressed using instruments such as the Montreal Cognitive Assessment (MoCA) and the Geriatric Depression Scale (GDS).

For measuring functional independence, scales such as the Barthel Index, Lawton & Brody Scale, and Functional Independence Measure (FIM) were employed. Environmental awareness and fall risk perception were evaluated through a specific questionnaire developed for older adults in one study [24].

3.5. Summary of Results

Overall, the included interventions demonstrated positive effects on balance, mobility, and self-confidence, though reductions in actual fall rates were less consistent. Exercise- and technology-based approaches were most effective at improving physical performance, whereas cognitive–behavioral and environmental strategies enhanced fall-related self-efficacy and safety. The diversity of interventions supports the role of occupational therapy as a flexible and integrative discipline in fall prevention.

Among the included studies, several incorporated resistance-based components (e.g., lower-limb strengthening, Pilates, and aquatic resistance) as part of the intervention, highlighting its relevance within occupational therapy for fall prevention. In this sense, while the studies varied in scope and methodology, the evidence supports the role of occupational therapy as an effective component in multifaceted fall prevention strategies for older adults.

Table 1 summarizes the essential characteristics and outcomes of the included studies. A full version of this table, with extended details on the methodologies, instruments, and secondary outcomes, is provided as Supplementary Table S1.

3.6. Methodological Quality

To assess the methodological quality of the studies included in this systematic review, the PEDro (Physiotherapy Evidence Database) scale was used, as discussed in Section 3.2. Only the RCTs and pilot trials were scored using the PEDro scale, whereas the non-RCT designs (quasi-experimental studies, observational studies, and case series) were excluded from this scoring system and are discussed narratively. As a result, three articles in the review could not be assessed using this scale.

The PEDro scale includes 11 items assessing methodological quality: (1) eligibility criteria, (2) random allocation, (3) concealed allocation, (4) baseline comparability, (5) blinding of participants, (6) blinding of therapists, (7) blinding of assessors, (8) adequate follow-up, (9) intention-to-treat analysis, (10) between-group statistical comparisons, and (11) point measures and variability. Each item (except the first, which is not scored) is rated 0 or 1, for a maximum score of 10.

The average score for the articles was 5.28 points. Five articles were classified as ‘good’, i.e., scoring between 6 and 8 points. However, eight articles were rated as ‘fair’, with a score of 4 to 5 points. And only one article obtained 2 points, being defined as ‘poor’, with a score between 0 and 4.

The scores are presented in

Table 2. Description of PEDro Scale.

	1	2	3	4	5	6	7	8	9	10	11	Score
Allin, LJ, et al. [10]	Yes	Yes	No	Yes	No	No	No	Yes	No	Yes	Yes	5/10
Zahedian-Nasab N. et al. [11]	Yes	Yes	No	No	No	No	Yes	Yes	No	Yes	Yes	5/10
Jeter P E, et al. [16]	Yes	Yes	No	Yes	No	No	Yes	No	No	No	Yes	4/10
Liu B, et al. [17]
Li Y, et al. [18]
Patti A, et al. [19]	Yes	Yes	No	No	No	No	Yes	Yes	No	Yes	Yes	5/10
Nissim, M, et al. [20]	No	Yes	No	Yes	No	No	Yes	Yes	No	Yes	Yes	6/10
Chan, W. L. S., et al. [21]	Yes	Yes	No	No	No	No	No	No	No	Yes	No	2/10
Tarbert RJ, et al. [22]
Adamit T, et al. [23]	Yes	Yes	No	No	No	No	Yes	Yes	No	Yes	Yes	5/10
Kamei T, et al. [24]	Yes	Yes	Yes	No	Yes	No	Yes	Yes	No	Yes	Yes	7/10
Liu M, et al. [25]	Yes	Yes	No	Yes	No	No	Yes	No	No	Yes	Yes	5/10
Cattaneo D, et al. [26]	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes	Yes	Yes	7/10
Nørgaard JE, et al. [27]	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes	Yes	Yes	7/10
Wetherell JL, et al. [28]	Yes	Yes	Yes	Yes	No	No	Yes	Yes	No	Yes	Yes	7/10
Whitney J, et al. [29]	Yes	Yes	No	Yes	No	No	No	No	No	Yes	Yes	4/10
Kwok, B. C. et al. [30]	Yes	Yes	Yes	Yes	No	No	No	No	No	Yes	Yes	5/10

.

4. Discussion

The findings of this systematic review underscore the effectiveness of occupational therapy (OT)-based interventions for reducing fall risk among older adults through multifaceted strategies encompassing physical, cognitive, environmental, and technological components. Although the heterogeneity in study designs and intervention modalities makes direct comparisons challenging, the overall trend indicates that interventions grounded in occupational therapy principles contribute meaningfully to enhancing balance, self-efficacy, mobility, and functional independence [11,23,25]. While some of the techniques included, such as therapeutic exercises or exergames, originated in other disciplines, their integration within occupational therapy programs is justified by OT’s capacity to adapt and contextualize such strategies into meaningful daily activities. This ensures that these modalities serve as components of broader OT interventions rather than isolated therapies. Although meta-analyses exist for specific techniques, such as Tai Chi or exercise programs, our review makes a novel contribution by synthesizing these approaches within an occupational therapy framework. This provides added value by situating the individual techniques within multimodal, OT-led strategies rather than as isolated interventions.

Exercise-based interventions, such as Pilates, Tai Chi, and aquatic therapies, consistently demonstrated positive effects on postural control and strength, both of which are critical for mitigating fall risk [18,19,20]. Importantly, these modalities promoted neuromuscular coordination and flexibility, while remaining accessible and adaptable for older adults with varying levels of physical capacity. Virtual reality (VR) and exergaming platforms introduced motivational and engagement elements, which are particularly relevant to long-term adherence to preventive strategies [11,21].

Furthermore, the cognitive–behavioral interventions and structured education improved psychological factors, such as fear of falling (FoF), self-perception, and depressive symptoms, all of which are increasingly being recognized as central determinants of fall-related disability [23].

Among the reviewed modalities, strength and resistance training stand out as universally beneficial, as they consistently improved balance, mobility, and muscle function across diverse populations of older adults. These interventions represent a core element of fall prevention programs due to their broad applicability and low resource requirements. In contrast, technology-enhanced approaches, such as virtual reality and exergames, offer additional value, particularly by increasing engagement and motivation. However, their implementation may be limited by factors such as cost, availability, and participants’ cognitive or technological literacy. Thus, rather than competing, these strategies should be viewed as complementary, with strength training forming a foundation and technology-assisted methods serving as tailored adjuncts where feasible.

A major strength of the reviewed interventions lies in their alignment with the Person–Environment–Occupation (PEO) model, the foundational framework in occupational therapy [31]. This model emphasizes the interaction between an individual’s intrinsic capabilities, their daily activities, and the environment in which they live. The interventions that addressed environmental barriers—such as cluttered homes, inadequate lighting, or unsafe flooring—produced measurable improvements in fall prevention outcomes. For example, therapist-led home modifications combined with caregiver training were found to significantly enhance the perceived safety and functional capacity of participants [24,25].

Nevertheless, some of the interventions, while promising in controlled or laboratory conditions, exhibited limited transferability to real-life situations [27]. This suggests that the ecological validity of fall prevention programs should be a priority in future research. It is also notable that one study reported significant within-group improvements but failed to show between-group differences in fall incidence, raising concerns about the sensitivity and consistency of outcome measures used [26].

4.1. Limitations

Several limitations must be acknowledged when interpreting the findings of this review. First, the methodological heterogeneity across studies was high. The variability in the sample sizes, duration, intervention type, and outcome assessment methods hindered our ability to perform meta-analytic comparisons and limits the generalizability of our findings. While most of the studies employed standardized scales (e.g., BBS, TUG, and FES), others relied on non-validated or study-specific instruments, which may have introduced bias and reduced reproducibility. Another limitation is the inclusion of heterogeneous study designs (RCTs, quasi-experimental, and observational studies). Although this approach provides a comprehensive overview of available evidence, it also reduces the overall strength of conclusions compared to reviews restricted to RCTs.

Second, the follow-up periods in most of the studies were relatively short (4 to 12 weeks), making it difficult to assess the long-term sustainability of intervention effects on fall incidence. Fall prevention is inherently a long-term goal, and transient improvements in balance or self-efficacy may not translate into reduced fall rates over time.

Third, the selection of participants may have introduced bias. Several studies excluded individuals with cognitive impairment, significant disability, or comorbid conditions—populations that are among the most vulnerable to falls. This exclusion limits the ecological validity of the findings and calls into question the applicability of these interventions in real-world geriatric settings. Another limitation relates to language bias, since only English and Spanish studies were included. Although this decision was made to ensure accurate interpretation by the review team, it may have excluded evidence published in other languages, potentially narrowing the global scope of findings.

Fourth, only a few studies implemented blinding of assessors, and allocation concealment was often not reported. These factors can lead to performance and detection bias, especially in interventions that include motivational or psychosocial components where placebo effects may influence the outcomes.

Lastly, there is a notable underrepresentation of occupational therapy-specific techniques in the literature. While OT principles were often embedded within broader interventions, few studies clearly delineated the unique contributions of occupational therapy as opposed to general rehabilitation or physical training.

In contrast to physiotherapy, which often emphasizes physical exercise and biomechanical aspects, or nursing, which may focus on monitoring, education, and safety, occupational therapy integrates these dimensions into a person-centered framework that prioritizes engagement in meaningful occupations. By addressing the interaction between individual capacities, daily activities, and environmental contexts, OT provides a unique and holistic contribution that complements other rehabilitation disciplines in fall prevention.

4.2. Clinical Applications

Despite these limitations, the review offers important clinical insights. First and foremost, it affirms that occupational therapy plays a pivotal role in multidimensional fall prevention strategies for older adults. The profession’s emphasis on tailoring interventions to a person’s daily life context, habits, and environment is essential for achieving sustainable improvements.

Clinically, OT practitioners can integrate these findings by (a) conducting comprehensive home assessments to identify environmental fall risks; (b) implementing structured balance and mobility training using both traditional and technology-supported methods; (c) applying cognitive–behavioral coaching to address fear of falling and self-confidence; (d) designing individualized activity-based programs that incorporate meaningful occupations to increase motivation and adherence; and (e) collaborating in multidisciplinary teams to reinforce safety through consistent messaging across care providers.

Particularly promising are interventions using virtual reality or gamification, which not only improve motor outcomes but also enhance engagement—a key barrier in older populations. Likewise, the integration of assistive technologies, such as fall-detecting smart belts, shows potential to reduce injury severity and improve emergency responses in institutional settings.

Furthermore, OT can serve as a bridge between clinical recommendations and lived experience, translating evidence-based knowledge into practical strategies that fit seamlessly into older adults’ lifestyles and environments.

Beyond their clinical benefits, occupational therapy interventions have important financial implications. Strategies such as home hazard modification, caregiver training, and community-based exercise programs have been associated with reduced hospital admissions, shorter lengths of stay, and fewer fall-related injuries. These outcomes translate into substantial healthcare cost savings while simultaneously improving participants’ quality of life. Considering the rising economic burden of falls in aging societies, the cost-effectiveness of OT-based interventions is a key strength. Nevertheless, further research is needed to provide robust economic evaluations and support large-scale implementation.

4.3. Future Research Directions

Future research should aim to overcome the current limitations by (a) standardizing the outcome measures to allow for better comparisons across studies and enable meta-analytic syntheses; (b) extending the follow-up durations to evaluate the long-term effectiveness and sustainability of interventions, especially regarding actual fall incidence; (c) including more diverse populations, particularly those with cognitive impairments, frailty, or multimorbidity—groups most likely to benefit from fall prevention strategies; (d) clarifying the specific role of occupational therapy, distinguishing it from other professions, and documenting the therapist-specific intervention components; (e) evaluating the cost-effectiveness, especially for interventions involving technology or home modifications, to support their integration into public health systems; and (f) leveraging digital health tools (e.g., telehealth, wearable sensors, and home monitoring) for real-time feedback, remote supervision, and adaptive programming.

In addition, the research should explore cultural adaptations of fall prevention programs, as aging populations grow across diverse geographic and socioeconomic contexts. The integration of patient and caregiver perspectives into intervention designs may further enhance their adherence and relevance. Finally, given the evidence supporting muscle-strengthening activities, resistance training should be considered a foundational element of occupational therapy programs aimed at fall prevention. Future studies are encouraged to further explore its application within OT-specific protocols, especially in community-dwelling and frail populations.

5. Conclusions

This systematic review highlights the significant role of occupational therapy in the prevention of falls among older adults through diverse and multidisciplinary interventions. The evidence supports that OT-based approaches—ranging from balance-focused exercise programs and virtual reality platforms to cognitive–behavioral coaching and home environment adaptations—contribute meaningfully to improving physical stability, functional independence, and psychological well-being.

Despite some methodological limitations, the reviewed studies suggest that occupational therapy, particularly when personalized and context sensitive, can effectively address the multifactorial nature of fall risk. Its unique focus on the interaction between the person, activity, and environment positions OT as a central discipline within comprehensive fall prevention strategies.

Future research should aim to refine these interventions by standardizing the outcome metrics, evaluating their long-term sustainability, and expanding the inclusion criteria to better reflect the diversity of the aging population. With a growing global emphasis on aging in place and autonomy, occupational therapy offers both the theoretical foundation and clinical tools to support safer, more independent lives for older adults.