Balance, Falls and Physiotherapy

Falls are the most common cause of injury in older Australians. Around one in four people aged 65 and over has at least one fall a year, and the cost to health, confidence and independence adds up fast. There is good news. The evidence is strong that the right exercise program can lower fall risk, and Physiotherapy is the discipline that builds and runs that program around you.

01 · Why falls matter

Why falls matter for older adults and people with disability

Falls are not a small problem. They are the single biggest cause of injury hospitalisation in Australia, and people aged 65 and over are far more likely to be hospitalised after a fall than younger adults (AIHW Injury in Australia: Falls). About one in four people aged 65 and over has at least one fall each year (HealthDirect Australia).

A fall is more than the immediate injury. It can lead to fractures, head injuries and time off your feet. It can also chip away at confidence, which leads many people to do less, which itself reduces strength and balance, which then raises the risk of another fall. That cycle is well documented, and breaking it early matters.

The risk is not limited to older adults. People with disability, people recovering from stroke or brain injury, and people with conditions that affect the muscles, joints, vestibular or sensory systems all carry a higher baseline risk. The strategies that help are largely the same, with the program adjusted to the person in front of us.

02 · What balance is

What balance actually is

Balance is the act of controlling the position of your centre of mass over your base of support. When the centre of mass sits over the base of support, you are balanced. When it moves outside that base, you start to fall, unless you move quickly to bring it back.

Your centre of mass is the point where your body’s mass is concentrated. In an upright adult it sits inside the pelvis, a little below the navel. Your base of support is whatever part of you is in contact with the ground. Standing on a flat floor, the base of support is the area inside and between your two feet, centred around the midfoot.

This sounds abstract until you try it. Stand up, lean forward onto your toes, and notice what your arms do. They swing back to keep your centre of mass over your base of support. Now lean back onto your heels, and your arms swing forward. Balance is a constant, automatic correction. You only notice it when it stops working.

03 · The three systems

The three body systems behind balance

Three body systems feed the brain the information it needs to keep you upright. They work together. When one is affected, the others have to work harder, and balance becomes harder to hold.

• Somatosensory system. The sense of where your limbs are in space, also called proprioception. Receptors in your skin, joints and muscles tell your brain whether your foot is flat, whether your knee is bent, and whether your weight is forward or back. It needs intact skin sensation and joint position sense. Conditions like peripheral neuropathy can blunt it.
• Visual system. Sight gives your brain a moving map of the world: where the floor is, where the edge of the step is, where the door frame is. Vision matters more when somatosensory input drops, which is why people often feel less steady at night or on uneven ground.
• Vestibular system. The inner ear tells your brain where your head is in space and how it is moving. It is what stops the room spinning when you turn your head, and it triggers the reflexes that catch you if you trip. Inner-ear conditions like BPPV, vestibular neuritis and Meniere’s disease can affect balance.

The brain pulls all three streams together in real time and triggers the right muscles to keep you upright. With ageing, with some medications, and with certain health conditions, one or more of these systems can be affected. The muscles and joints matter too. If leg strength or ankle movement is limited, the body’s ability to act on the brain’s correction signal is reduced.

04 · The assessment

How a Physiotherapy assessment finds what is driving the risk

Falls prevention starts with an assessment. The point is to work out which system or systems are contributing, so the program can target them directly.

A Physiotherapy balance assessment usually covers:

• Functional tasks. Standing up from a chair, walking, turning, stepping over an obstacle, reaching. These show how balance holds up under real demand.
• Strength. Lower-limb strength, particularly hip, quadriceps, calf and ankle, is closely tied to fall risk.
• Coordination and proprioception. Joint position sense, single-leg stance and tandem stance show how well the somatosensory system is feeding the brain.
• Vision and vestibular screening. Quick screens for visual acuity, gaze stability and head-movement tolerance. Anything that looks off is referred on to your GP, optometrist or an ENT for further assessment.
• Validated falls-risk tools. Tools like the Timed Up-and-Go, the Four-Square Step Test, the Berg Balance Scale and the Falls Efficacy Scale give a baseline we re-test to track progress.

From there we build a tailored program. The evidence supports balance and strength training that includes task-specific practice (sit-to-stand, stepping, walking with head turns) and is challenging enough to push the balance system, not so easy that nothing changes. A 2023 systematic review of community-dwelling older adults found that balance exercise reduced the rate of injurious falls and improved balance, lower-limb strength and mobility. A 2019 Cochrane review of exercise for falls prevention found that exercise reduced the rate of falls by around 23 per cent, and rated that finding as high-certainty.

Falls prevention is the right exercise, at the right dose, aimed at the system that is letting you down.