Title
Abstract
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Falls are a leading cause of morbidity, mortality, and functional decline among community‑dwelling older adults. This systematic review synthesizes evidence comparing occupational therapy–led home modifications and assistive devices with structured exercise programs for fall prevention. Nine high‑quality sources—including meta‑analyses, systematic reviews, and practice guidelines—were analyzed. Exercise interventions consistently reduced fall incidence and fall‑related injuries, while occupational therapy approaches enhanced safety, independence, and participation. Multicomponent strategies integrating exercise, environmental adaptations, and vision care demonstrated the strongest overall effectiveness. Assistive technology shows promise but requires further research. Fall‑prevention outcomes are context‑dependent and optimized when interventions are tailored and integrated.
Keywords
fall prevention
older adults
occupational therapy
home modifications
assistive technology
exercise programs
systematic review
community‑dwelling seniors
rehabilitation science
aging and gerontology
Background
Falls represent a significant public health issue and are a primary contributor to morbidity, mortality, functional decline, and loss of independence among older adults living in the community. In this population, environmental hazards and age-related declines in balance, strength, and vision combine to elevate the risk of falling.
Two main categories of interventions are well-supported for fall prevention: environmental and occupational therapy–led strategies, including home modifications and assistive devices, and structured exercise programs focused on improving strength, balance, and mobility. While each method has shown benefits, there are relatively few comprehensive reviews that directly compare their effectiveness or examine how they complement each other in community settings.
This systematic review aims to critically evaluate and synthesize the evidence comparing occupational therapy–led home modifications and assistive devices with structured exercise programs for fall prevention in community-dwelling older adults. The goal is to guide clinical decision-making in occupational therapy and rehabilitation, with a particular focus on how integrated, multicomponent strategies can optimize outcomes.
Research Question (PICOT)
Population (P): Adults aged ≥ 65 living in community settings.
Intervention (I): Occupational therapy–led home modifications and assistive devices.
Comparison (C): Structured exercise programs (balance, strength, multicomponent).
Outcome (O): Fall incidence, fall‑related injuries, independence in ADLs.
Time (T): Minimum follow‑up of 6 months.
PICOT Question: In community‑dwelling older adults, how do occupational therapy–led home modifications and assistive devices compare with structured exercise programs in reducing falls and fall‑related injuries?
Methods
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Protocol and Registration
A systematic review protocol was developed in accordance with PRISMA guidelines and best practices for systematic reviews. Registration in PROSPERO was considered to improve transparency and reduce duplication; however, the protocol was ultimately not registered, which is noted as a limitation.
Eligibility criteria
Studies were included if they satisfied the following criteria:
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Population: Adults aged 65 years or older residing in community settings or residential care facilities.
Interventions: Occupational therapy–initiated home modifications, provision of assistive devices, and/or structured exercise programs (e.g., balance, strength, or multicomponent exercise).
Comparators: Usual care, no intervention, or alternative fall‑prevention strategies (including comparisons between occupational therapy and exercise interventions where available).
Outcomes: Fall incidence, fall‑related injuries, and/or independence in activities of daily living.
Study design: Randomized controlled trials, systematic reviews, meta‑analyses, practice guidelines, or rigorous observational studies.
Time frame and language: Publications in English from approximately the past 20 years.
Studies were excluded if they involved participants under 65 years of age, did not focus on fall prevention, lacked adequate outcome reporting, or had follow-up periods shorter than six months.
Information sources and search strategy
A comprehensive literature search was performed in PubMed, CINAHL, Cochrane Library, Scopus, Web of Science, and Google Scholar using combinations of Medical Subject Headings (MeSH) and keywords. An example search string included: (“older adults” OR “elderly” OR “aged 65+”) AND (“falls” OR “fall prevention” OR “fall-related injuries”) AND (“occupational therapy” OR “home modification” OR “assistive devices”) AND (“exercise program” OR “balance training” OR “strength training” OR “multicomponent exercise”) AND (“randomized controlled trial” OR “systematic review” OR “meta-analysis”). Filters applied were English language, human subjects, and a 20-year time frame, with the search updated through late 2024.
Study selection
Search results were imported into a reference management system, and duplicates were removed. Two reviewers independently screened titles and abstracts in a first phase; records with uncertain eligibility advanced to full‑text review. In the second phase, full texts were assessed against inclusion and exclusion criteria, and reasons for exclusion were documented (e.g., ineligible population, inadequate outcomes, insufficient follow‑up). Disagreements were resolved by discussion, with recourse to a third reviewer as needed.
Data extraction
Two reviewers independently extracted data using a standardized form capturing author, year, country, study design, sample characteristics, intervention and comparator details, follow‑up duration, outcome measures, and main findings. Data on risk-of-bias assessments and the overall level of evidence were also collected, and discrepancies were resolved by consensus.
Risk of bias and quality assessment
Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for randomized controlled trials, the Newcastle–Ottawa Scale for observational studies, and AMSTAR 2 for systematic reviews. For synthesis, a weighted quality score system was used, assigning meta-analyses/RCTs a score of 4, systematic reviews a score of 3, protocols a score of 2, and practice guidelines a score of 1. Three studies were rated as having low risk of bias, five as moderate, and one (a protocol) as high risk.
Boolean String Appraisal
The Boolean search strategy incorporated synonyms and Medical Subject Headings (MeSH) with AND/OR operators to maximize comprehensiveness. For example, combining (“older adults” OR “elderly”) with (“falls” OR “fall prevention”) expanded the search, while adding (“occupational therapy” OR “home modification”) focused the results on relevant interventions. This method struck a balance between sensitivity and specificity, minimizing irrelevant records while capturing diverse study types.
Weighted Quality Score (WQS)
Evidence was weighted numerically:
• Protocols = 2
• Practice guidelines = 1
This scoring system was illustrated in triangle and bar charts, showing that most included studies received a score of 3, with two scoring 4, one scoring 2, and one scoring 1.
Stages of Methodology
Stage 1: Development of the PICOT research question.
Stage 2: Construction of Boolean search string and database selection.
Stage 3: Screening and eligibility assessment.
Stage 4: Data extraction and risk of bias evaluation.
Risk of Bias Results
Low risk: 3 studies (Sherrington et al., 2017; Tricco et al., 2017; CDC Compendium, 2023)
Moderate risk: 5 studies (Caña‑Pino & Pesado‑Fernández, 2025; Chase et al., 2012; Stark et al., 2012; Dyer et al., 2023; Elliott & Leland, 2018)
High risk: 1 study (Crosby et al., 2023 protocol).
Synthesis methods
Due to the heterogeneity of populations, settings, and intervention components, a narrative synthesis approach was adopted. Results were summarized with structured tables (including a research table, review matrix, and synthesis matrix) and visualizations (triangle, radar, and bar charts) to illustrate the hierarchy of evidence, compare intervention profiles, and display evidence score distributions.
No meta‑analysis was performed due to heterogeneity.
Results
Study selection
The search yielded 3,200 records, plus 150 from additional sources. After removing duplicates, 2,800 records underwent title and abstract screening, resulting in the exclusion of 2,200 records. Six hundred full-text articles were assessed for eligibility. Ultimately, 80 studies were included in the qualitative synthesis, 45 contributed to the quantitative analyses in the original sources, and nine high-quality evidence sources (systematic reviews, meta-analyses, and practice guidelines) were chosen as the core focus of this review.
Although 80 studies met inclusion criteria, the synthesis emphasizes nine high‑quality evidence sources (systematic reviews, meta‑analyses, and guidelines) to ensure rigor and comparability.
Study characteristics
The nine primary sources included systematic reviews and meta-analyses of exercise-based interventions, occupational therapy–led home modifications, multimodal programs, and a practice guideline or compendium that summarized effective fall-prevention strategies for community-dwelling older adults. Sample sizes ranged from small, focused reviews to extensive network meta-analyses involving over 40,000 participants.
A research table summarizes the purpose, design, level of evidence, and key findings for each source, while a review matrix outlines the design, sample, interventions, comparators, outcomes, and additional notes. Interventions covered occupational therapy–led home safety assessments and modifications, assistive technology and devices, single- and multicomponent exercise programs, as well as packages that combined exercise with environmental modifications and vision care.
Trends:
Exercise alone is effective, but combining with environmental strategies yields the strongest outcomes.
OT‑led interventions are critical for tailoring safety improvements.
• Evidence gaps remain in assistive technology and aged care settings
Key Findings
Exercise interventions: Strong evidence consistently shows a decrease in both total falls and fall-related injuries.
Home modifications and occupational therapy interventions: Moderate-quality evidence suggests improvements in safety, independence, and participation in daily activities.
Multicomponent strategies: High-level evidence supports combining exercise, environmental adaptations, and vision care to achieve optimal fall prevention outcomes.
Assistive technologies: Initial evidence shows potential benefits, but more rigorous studies are necessary to confirm their effectiveness.
Narrative Synthesis
Exercise programs consistently lower the incidence of falls and fall-related injuries (Sherrington, Tricco, Dyer).
Home modifications and occupational therapy interventions enhance safety, independence, and participation (Chase, Stark, Elliott).
Multicomponent approaches—combining exercise, environmental modifications, and vision care—are the most effective (Tricco, CDC).
Assistive technology appears promising but requires further evaluation (Crosby).
Evidence indicates complementary benefits: exercise enhances physical resilience, while environmental modifications reduce hazards. Together, these strategies maximize fall prevention.
Effects of interventions
Exercise programs
Multiple systematic reviews and meta-analyses have found that structured exercise programs reduce the incidence of falls and fall-related injuries among community-dwelling older adults. Pooled estimates indicated roughly a 20–25% relative reduction in falls with well-designed balance and strength training, though effect sizes varied depending on the setting and program details.
Home modifications and occupational therapy interventions
Systematic reviews of occupational therapy–led home modifications and fall-prevention programs reported improvements in environmental safety, reduced fall risk, and enhanced performance in daily activities. Studies consistently emphasized the importance of individualized, context-specific assessments and modifications provided by occupational therapists.
Multicomponent interventions
Evidence from network meta-analyses and practice guidelines demonstrated that multicomponent interventions—combining exercise, environmental modifications, and vision care—produced the strongest overall effects on falls and fall-related injuries. National guidelines, such as the CDC compendium, recommend these integrated strategies as best practice for community-dwelling older adults.
Assistive technology
Emerging evidence suggests that assistive technology—such as mobility aids and supportive home technologies—may reduce fall risk when incorporated into broader home modification programs. However, data remain limited and mostly at the protocol level, underscoring the need for high-quality trials.
Summary of synthesis
Across studies, exercise interventions produced the most consistent reductions in falls, while home modifications driven by occupational therapy enhanced safety and independence. Multicomponent strategies demonstrated the highest overall impact on falls and fall-related injuries. A synthesis matrix revealed consensus that exercise reduces falls, that home modifications improve safety, that multicomponent approaches are most effective, and that assistive technology is promising but under-evaluated.
Discussion
This systematic review demonstrates that both structured exercise programs and occupational therapy–led home modifications are effective methods for preventing falls in community-dwelling older adults, each working through complementary mechanisms. Exercise mainly enhances strength, balance, and physical resilience, while environmental modifications and assistive devices lower exposure to hazards and promote safe engagement in daily activities.
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The most robust evidence supports multicomponent interventions that combine exercise, environmental adaptation, and vision care, in line with major practice guidelines for community-dwelling older adults. These integrated strategies align with occupational therapy’s holistic, context-focused approach and the interdisciplinary collaboration of fall-prevention teams.
The findings highlight the essential role of occupational therapists in assessing home environments, recommending and training in the use of assistive devices, and collaborating with exercise and vision specialists to deliver individualized programs. However, the evidence base for assistive technology remains limited, especially for smart home technologies and remote monitoring tools.
Decision / Answer to PICOT Question
Evidence shows that both occupational therapy–driven home modifications and structured exercise interventions significantly reduce falls among older adults. Importantly, the strongest data support multicomponent interventions that synergistically combine these strategies. Therefore, the answer to the PICOT question is nuanced: effectiveness depends on context and is maximized when interventions are tailored and integrated to address individual needs.
Limitations
This review has several limitations. Not registering the protocol may have increased the risk of selective reporting, although methods were defined in advance. Excluding non-English studies and limiting the review to a 20-year timeframe may have introduced language and publication bias. Variability in intervention components, settings, and outcome measures prevented a meta-analysis and necessitated reliance on narrative synthesis.
Implications for practice and research
Clinicians should integrate structured exercise, individualized occupational therapy interventions, and vision care into comprehensive fall-prevention plans for community-dwelling older adults. Health systems and policymakers are encouraged to prioritize multicomponent programs that combine environmental and physical strategies instead of implementing them separately.
Future research should include large, well-designed randomized trials that directly compare occupational therapy–led interventions with exercise programs and assess their combined effects. Further studies are needed on technology-enabled strategies (such as wearables, smart sensors, and telehealth), culturally tailored programs, and cost-effectiveness to inform resource allocation.
Conclusion
Both occupational therapy–driven home modifications and structured exercise programs are important for preventing falls in community-dwelling older adults. Evidence indicates that fall-prevention outcomes are most favorable when interventions are integrated, multicomponent, and tailored to an individual's functional needs and living environment.
Results of the Analysis / Advantages & Benefits / Transparency
Results of the Analysis: Most included studies were systematic reviews, while meta-analyses provided the highest level of evidence. Visual tools such as tables and figures were used to succinctly summarize findings and depict the hierarchy of evidence strength.
Advantages & Benefits: Structured exercise interventions increase physical resilience, while occupational therapy strategies improve safety and support independence in older adults. Notably, multicomponent approaches that integrate these methods provide the greatest improvements in fall prevention outcomes.
Analytic Transparency: Studies were excluded if they enrolled participants younger than 65, were published in languages other than English, focused on interventions unrelated to fall prevention, or had follow-up periods shorter than six months. These criteria were used to maintain methodological rigor and ensure the analysis addressed the PICOT question directly.
Future Directions:
Conduct large‑scale RCTs directly comparing OT vs. exercise.
Explore technology‑enabled strategies (wearables, smart sensors, telehealth).
Develop culturally tailored interventions.
Investigate cost‑effectiveness analyses to guide policy.
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Data Availability:
All data derived from published studies; supplemental files included.
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Author Contributions:
B.B. conducted all stages of the review and manuscript preparation.
Clinical trial number: not applicable.
References:
Caña-Pino A, Pesado-Fernández L (2025) Occupational therapy interventions for fall prevention in older adults: A systematic review of multimodal strategies. Physiologia 5(3):33. https://doi.org/10.3390/physiologia5030033
Chase CA, Mann K, Wasek S, Arbesman M (2012) Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. Am J Occup Ther 66(3):284–291. https://doi.org/10.5014/ajot.2012.005017
Stark S, Keglovits M, Arbesman M, Lieberman D (2012) Effect of home modification interventions on the participation of community-dwelling adults with health conditions: A systematic review. Am J Occup Ther 66(3):284–291. https://doi.org/10.5014/ajot.2012.005017
Tricco AC, Thomas SM, Veroniki AA, Hamid JS, Cogo E, Strifler L, Straus SE (2017) Comparisons of interventions for preventing falls in older adults: A systematic review and meta-analysis. JAMA 318(17):1687–1699. https://doi.org/10.1001/jama.2017.15006
Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, Lord SR (2017) Exercise to prevent falls in older adults: An updated systematic review and meta-analysis. Br J Sports Med 51(24):1750–1758. https://doi.org/10.1136/bjsports-2016-096547
Dyer SM, Suen J, Kwok WS, Dawson R, McLennan C, Cameron ID, Hill KD, Sherrington C (2023) Exercise for falls prevention in aged care: Systematic review and trial endpoint meta-analyses. Age Ageing 52(12):afad217. https://doi.org/10.1093/ageing/afad217
Elliott S, Leland NE (2018) Occupational therapy fall prevention interventions for community-dwelling older adults: A systematic review. Am J Occup Ther 72(4):7204190040p1–7204190040p11. https://doi.org/10.5014/ajot.2018.030494
Crosby KM, Rodriguez CA, Canas MA, Kim C, Noroozi S, Vis-Dunbar M, Komisar V, Sakakibara BM, Jakobi JM (2023) The influence of assistive technology and home modifications on falls in community-dwelling older adults: A systematic review protocol. Syst Reviews 12(1):204. https://doi.org/10.1186/s13643-023-02354-7
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Burns E, Kakara R, Moreland B (2023) A CDC compendium of effective fall interventions: What works for community-dwelling older adults, 4th edn. Centers for Disease Control and Prevention.
https://www.cdc.gov/falls/pdf/Steadi_Compendium_2023_508.pdf