As of 2023, the global population of individuals aged 60 years or older has reached approximately 1.1 billion, with projections indicating an increase to 1.4 billion by 2030 and 2.1 billion by 2050 (1). Falls are the second leading cause of accidental injury deaths globally (2), resulting in approximately 684,000 deaths annually, the majority of which occur among adults aged 60 years or older. Repeated falls can cause serious medical issues in older adults, Mgbeojedo et al. (3) including fractures and physical frailty, Kannus et al. (4) and Liston et al. (5) which may result in increased dependence on family members or assistive devices, fall-related anxiety, high economic costs, extended limitations on activity, and related issues (6, 7). Consequently, falls represent a significant risk to the wellbeing of older adults, highlighting the urgent need for effective interventions to mitigate this risk.

To mitigate the effect of falls among older adults, preventive interventions and education aimed at reducing fall risk are commonly implemented. Diverse exercise programs targeting flexibility, strength, balance, and endurance can improve mobility and physical function in older adults while reducing fall risk and related injuries (8, 9). OEP is a progressive training regimen specifically designed for older adults (10), emphasizing exercises that target balance and strength to reduce fall risk by improving physical stability (11). The OEP is a structured exercise program designed to enhance balance, strength, and mobility in older adults (12). It integrates lower limb exercises, such as single-leg stands and walking, with upper limb strength training, including arm curls, to promote overall functional stability and physical wellbeing (13). These exercises aim to strengthen core and lower limb muscles, improve coordination and reaction time, while enhancing stability during standing and walking (14, 15) By gradually increasing the difficulty and complexity of the exercises, the OEP effectively enhances the physical fitness and daily living abilities of older adults (16). The structured nature of this exercise program not only helps reduce the occurrence of falls but also significantly improves physical function in older adults, effectively lowering the risk of fall-related injuries (17).

However, the effectiveness of the OEP might vary between general older adults and those with compromised health, with existing research yielding inconsistent findings. In general older adults, studies have demonstrated significant benefits of OEP in improving mobility, physical function, and balance (18). Nonetheless, the OEP shows low to moderate certainty regarding its effectiveness in improving balance, mobility, and grip strength in frail or pre-frail older adults (19). The Otago Exercise Program enhances fall efficacy in older stroke survivors and has a positive impact on daily activities and quality of life. However, these effects do not reach statistical significance (20). When the OEP was implemented in individuals with dementia, four out of five participants improved from a higher to a lower fall risk category in at least one functional assessment measure (TUG, 30s-CST, 4-SBT, or BBS) (21). The OEP intervention for osteoarthritis (OA) led to significant improvements in balance, stability, and fall efficacy over six months. However, it did not effectively reduce the incidence of falls or prolong fall-free survival time (22). Other research suggests that the OEP has no significant effect on upper limb strength in older adults (23). These results suggest that the effectiveness of the OEP may vary based on health status, particularly in older adults with poorer health conditions, where the impact of the OEP may be limited. Therefore, this study aims to evaluate the effectiveness of the OEP in preventing falls among general older adults and those with compromised health, providing scientific evidence to optimize targeted intervention strategies.

Most existing research has primarily focused on the general older adult population, with limited comparative analysis of its effects across these two groups. It remains uncertain whether the OEP is more effective in preserving mobility and preventing falls among healthier older adults or in improving physical function and reducing fall risk in those with compromised health. Clarifying these distinctions is essential for refining fall prevention strategies tailored to diverse aging populations. Further research is needed to compare the effects of the OEP between general older adults and older adults with compromised health.

To address this, the present study systematically evaluates the effectiveness of the Otago Exercise Program (OEP) in improving fall-related outcomes and physical function through a meta-analysis, comparing its effects between two distinct groups: (1) generally healthy older adults and (2) older adults with compromised health conditions. Specifically, we examine whether OEP is more effective in preventing falls and enhancing physical function in generally healthy older adults or in reducing fall risk and improving physical function in older adults with compromised health conditions.

This study is based on the PICOS framework and follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) standards and has been retrospectively registered on the PROSPERO platform (CRD42024549302).

Meta-analysis was conducted using Review Manager (RevMan 5.4) and Stata 18.0. Effect sizes were reported as weighted mean differences (WMD) with 95% confidence intervals (CI), as all included studies measured the same continuous outcomes using a consistent unit of measurement. This approach enables direct comparison of effect sizes without standardization, preserving clinical interpretability and providing a clearer understanding of the intervention's impact. A random-effects model was employed to account for potential heterogeneity, which was assessed using I² statistic, with I²>50% indicating moderate-to-high heterogeneity.

Potential publication bias was assessed through funnel plots and Egger's regression test (24). To further adjust for potential publication bias, the Trim-and-Fill method was applied (25). This non-parametric statistical method estimates the number of missing studies due to publication bias and imputes them to produce an adjusted overall effect size. The method helps determine whether the observed results are robust even after accounting for potentially missing studies. Data visualization incorporated forest plots to illustrate effect estimates with corresponding 95% CIs for each study, while sensitivity analyses were conducted to evaluate the robustness of the findings.

We conducted subgroup analyses of the Otago Exercise Program (OEP) intervention to examine the effects of session duration and total intervention duration on its effectiveness. This analysis aimed to assess whether variations in intervention length influenced fall prevention outcomes. Due to the limited number of available studies, subgroup analyses based on health conditions (e.g., cognitive impairment, musculoskeletal disorders, and frailty syndrome) were not performed. Future research should consider stratified analyses to further investigate potential differences in OEP effectiveness across these specific health conditions.

This study conducted a meta-analysis to evaluate the impact of OEP on fall-related outcomes in both general older adults and older adults with compromised health. While OEP is designed to target fall susceptibility—a common risk factor among the older adults with compromised health—we acknowledge that variations in underlying health conditions may lead to subtle differences in intervention effectiveness. This study includes older adults with various conditions; however, the number of available studies was insufficient to conduct a meaningful subgroup analysis. Nonetheless, previous research has consistently demonstrated the effectiveness of OEP in reducing fall risk among individuals with cognitive impairment, musculoskeletal disorders, and frailty syndrome (19, 46, 47). Therefore, we analyzed these conditions collectively while acknowledging the potential for variations in intervention effects.

Although 17 included studies had a moderate to high risk of bias, their inclusion in the meta-analysis was essential to ensure a comprehensive synthesis of the available evidence. Excluding these studies would have significantly reduced the sample size, potentially introduced selection bias and limited the generalizability of the findings. To assess the impact of these methodological limitations, we conducted sensitivity analyses by systematically excluding these studies. The results remained consistent, confirming that their inclusion did not substantially alter the overall effect size estimates or confidence intervals. Additionally, Egger's regression test indicated significant reporting bias (p = 0.002), prompting the application of the Trim-and-Fill analysis to adjust for potential publication bias. The adjusted results remained statistically significant, further supporting the robustness of our conclusions. While certain studies exhibited biases in allocation concealment and blinding, their outcome assessments remained reliable, and these limitations were carefully considered in the interpretation of results. Therefore, despite inherent methodological concerns, the inclusion of these studies strengthens the overall analysis by maximizing available data, and sensitivity analyses affirm the stability and validity of our findings.

The results indicate that the OEP has a significant effect on improving balance, gait, and lower limb strength in older adults, although the extent of improvement varies among different populations. Consistent with previous studies, OEP has been shown to effectively enhance lower limb strength, balance, and gait in general older adults (13, 17, 48, 49). However, it does not significantly improve physical function, mobility, or upper limb strength in this population. Conversely, some studies have reported positive effects of OEP on physical function (43), mobility (23), and upper limb strength (50), highlighting the variability in outcomes across different study populations and intervention protocols. These discrepancies may be attributed to differences in participant characteristics, baseline functional levels, and variations in OEP implementation, including exercise intensity, frequency, and adherence rates.

As a fall prevention intervention, the OEP provides significant health benefits for general older adults, particularly in enhancing lower limb strength and balance. This effect may be attributed to specific exercises in the program, such as knee flexion, knee extension, and hip abduction, which are designed to strengthen leg muscles in older adults. Through cyclical contraction and relaxation, these exercises promote muscle and joint flexibility, balance, and motor control. Research has shown that the OEP is beneficial for older adults with osteoarthritis and gait balance disorders, significantly improving postural control (10).

Repeated exercises involving sitting, standing, and walking have been shown to improve lower limb strength in older adults (10). However, the results of this study indicate that its impact on physical function, mobility, and upper limb strength is not significant. Studies have shown that the OEP can improve physical function in older adults, including balance, lower limb strength, and mobility (23). This is inconsistent with the findings of the present study. This may be due to the OEP's primary focus on lower limb strength and balance training, which incorporates resistance and aerobic exercises through warm-up activities, strength training, balance exercises, and walking training (17). The program is heavily focused on lower limb strength and balance training, incorporating both resistance and aerobic exercises (28), which leads to higher intensity and frequency for lower limb and balance training. However, the upper limb strength training may not be sufficiently systematic or intense, thus failing to produce significant improvements.

This study demonstrates that OEP exhibits more significant positive effects on balance, gait, lower limb strength, and mobility in older adults with compromised health. This study demonstrates that the OEP has significant positive effects on balance, gait, lower limb strength, and mobility in older adults with compromised health.

High-quality evidence supports the effectiveness of the Otago Exercise Program in reducing fall risk among individuals with osteoarthritis (OA) (46). Additionally, OEP has been shown to benefit individuals with cognitive impairment, enhancing balance and functional mobility (51). These findings highlight OEP as a valuable intervention for older adults with varying health conditions, particularly those at higher risk of falls. The observed outcomes may be attributed to the lower baseline functional levels of older adults with compromised health, including reduced muscle strength, balance, and mobility. Additionally, these individuals often have stronger expectations for recovery, which may lead to higher engagement and adherence to rehabilitation training, thereby maximizing the benefits of OEP. Research has shown that OEP positively impacts balance, physical activity, and upper limb strength in older adults with reduced health status (19).

Our findings align with previous studies indicating that OEP can effectively mitigate the decline in lower limb muscle strength in older adults (22). The walking exercises included in the OEP—such as backward walking, zigzag walking, side walking, straight walking, and stair climbing—likely contribute to muscle strengthening and improved coordination through continuous isometric flexion of the hip flexors and ankle joints (22). The primary goal of the Otago Exercise Program is to reduce fall risk through targeted limb strength training and balance exercises (46). These diverse gait training exercises not only enhance lower limb muscle strength but also improve balance and gait control, thereby reducing fall risk and improving mobility in daily life. However, the results regarding upper limb strength contrast with those of other studies (43). In this study, OEP did not significantly improve upper limb strength in older adults with compromised health.

The primary goal of the OEP is fall prevention, with a focus on lower limb strength, balance, and gait training, rather than systematic upper limb strength exercises. This suggests that upper limb training is not a central component of the OEP. Additionally, older adults generally have lower baseline upper limb muscle strength, indicating that more targeted and intensive training may be required to achieve significant improvements. The OEP alone may not provide sufficient stimulus for upper limb muscle adaptation and strengthening, resulting in non-significant improvements in upper limb strength. Future research should explore incorporating dedicated upper limb strength training into the OEP to enhance overall physical function in older adults. Research indicates that lower upper limb strength is directly related to impaired activities of daily living (52) and slower walking speed (53). Thus, the lack of significant improvements in physical function and the limited effects on mobility observed in this study can be attributed to this.

Additionally, the results of the subgroup analysis indicate that differences exist in study design, sample selection, data collection, and analytical methods across studies (54). The duration of the intervention has varying effects on different outcomes. Specifically, a 4-month intervention demonstrated the most stable effects on balance improvement, while the effectiveness of 3-month and 6-month interventions showed high heterogeneity. Our findings align with previous research suggesting that a training program lasting at least 12 weeks, conducted three or more times per week, with each session lasting 30 to 45 minutes, can significantly reduce fall risk and enhance postural stability (45). However, no significant differences were found between different intervention durations (p = 0.30), indicating that the effectiveness of OEP may not be solely dependent on the intervention length. This is consistent with the findings of the present study.

As research suggests, sessions lasting more than 30 min are most effective in enhancing balance among older adults (55). Based on these findings, a 45-min session duration sustained for at least six months is recommended. Conversely, shorter intervention periods (2–3 months) and 30-min sessions appear to be more effective for improving lower limb strength. This may be because balance and gait primarily rely on neuromuscular coordination (56), which typically requires long-term practice and repetition for significant improvements. In contrast, lower limb strength training primarily targets large muscle groups, which require adequate recovery time post-exercise. Therefore, shorter intervention durations and 30-minute training sessions may be more suitable for lower limb strengthening, as they help prevent overtraining and muscle fatigue.

From a clinical perspective, these findings reinforce the importance of OEP as an effective intervention for maintaining lower limb strength and mobility in aging populations. The progressive nature of OEP exercises, such as knee flexion, knee extension, and hip abduction, may contribute to improved walking ability, reduced fall risk, and enhanced functional independence in older adults. Given that longer intervention durations (≥6 months) were associated with greater improvements in lower limb strength and gait, clinical practice should consider extending the program duration to maximize benefits. Additionally, incorporating upper limb resistance training into OEP may enhance its overall effectiveness, particularly for older adults with functional limitations. Future research should explore the integration of combined training approaches and assess their impact on overall musculoskeletal health in aging populations.

Although this study provides valuable insights into the effects of OEP intervention, it has certain limitations. The relatively small sample size may reduce statistical power, potentially limiting the generalizability and reliability of the findings. Moreover, the effectiveness of OEP may be influenced by various factors, including participants' health status, age, and baseline functional levels. Some included studies did not specify the MMSE criteria used to define cognitive impairment, which may have introduced variability in participant classification and contributed to heterogeneity across studies. Given that different older adult populations may respond differently to OEP, there is a need for more personalized training approaches. In this study, older adults with varying health conditions (e.g., cognitive impairment, musculoskeletal disorders, and frailty syndrome) were categorized into a single compromised health group. Previous research (19, 46, 47) has consistently demonstrated the effectiveness of OEP in reducing fall risk across these populations, supporting its broad applicability. While these individuals share a common risk factor—fall susceptibility, which OEP is specifically designed to address—differences in underlying health conditions may contribute to subtle variations in intervention effectiveness.

However, due to the limited number of available studies, subgroup analyses were not feasible. Future research should consider conducting stratified analyses to further explore whether OEP's effectiveness varies across specific health conditions. Furthermore, future studies should aim to optimize OEP protocols by tailoring them to individuals' health profiles, baseline fitness levels, and personal preferences to maximize intervention effectiveness.

OEP has been associated with improvements in balance, gait, and lower limb strength in older adults, particularly among those with compromised health, where the effects appeared more pronounced. These findings suggest that OEP may be particularly beneficial for enhancing lower limb strength and improving balance and gait. However, its impact on upper limb strength remains limited. Future research with larger, well-controlled trials is essential to validate these findings and refine intervention protocols to maximize their effectiveness in diverse aging populations.