Editorial: Multifactorial balance assessment, falls prevention and rehabilitation

Dimitrios Kikidis¹Brooke Nairn²Christos Nikitas¹Marousa Pavlou²Nattawan Utoomprurkporn^3*Doris- Eva Bamiou²

• ¹National and Kapodistrian University of Athens, Athens, Greece
• ²The Ear Institute, University College London, London, United Kingdom
• ³Chulalongkorn University Faculty of Medicine, Bangkok, Thailand

Falls remain a major public health challenge, particularly among adults aged 65 and older, with one-third experiencing at least one fall annually and nearly 10 % suffering recurrent events (WHO Global Report, 2007; Sui et al. 2025). Multifactorial in origin, involving vestibular, visual, central nervous and proprioceptive systems, falls are correlated with several comorbidities, requiring multidisciplinary assessment. This special issue underscores the multifactorial nature of balance impairment, combining age-related sensorimotor decline, concurrent diagnoses and the possible effect of cognitive impairment. Epidemiological data indicate that fall rates increase with advancing age and multimorbidity, while injury-related morbidity, hospital admissions, and mortality continue to rise globally (Wang et al. 2025; Choo et al. 2025). The burden is both clinical and economic: substantial direct costs (hospitalizations, rehabilitation) accompany indirect sequelae (effect on quality of life, loss of independence, fear of falling, social isolation, caregiver strain), highlighted the need for preventive strategies and interventions. Despite evidence-based recommendations supporting balance-based fall interventions, critical gaps persist. Chief among these is the underdevelopment of comprehensive assessment tools capable of capturing cognitive, sensory, and motor domains simultaneously, limiting the individualisation of therapy. There is also limited integration of dual-task and neurocognitive training into standard rehabilitation protocols, creating a barrier to addressing real-world fall risk. Moreover, adherence remains problematic with many older adults disengaging early, with up to a 50 % dropout rates from standard falls and balance programs, suggesting a mismatch between intervention design and patient-centered factors. Finally, the full value of indirect benefits including reduced caregiver burden and enhanced self-confidence, remains largely uncaptured in current evaluations, impeding policy buy-in. Current trends in clinical practice reflect a gradual shift from single-domain interventions toward multifactorial programs tailored to individual needs (Elrod and Wong, 2025). Established exercise protocols such as Otago (Wang and Kim, 2025) are being supplemented with dual-task and cognitive components to more holistically and personalized address fall risk (Nairn et al. 2024) Emerging studies highlight integration with telerehabilitation and augmented reality, offering scalable and remotely deliverable care models, especially vital in underserved regions (Gulline et al. 2025). Yet real-world adoption remains variable: many clinics continue to focus on generic exercise modules without adjusting for cognitive load, comorbidities, or patient lifestyle, indicating a need for stronger implementation frameworks. Looking forward, future directions must harness emerging technologies and methodological refinements to bridge existing gaps while meeting patient needs. Wearable biosensors and marker less motion analysis systems offer promise for dynamic, real-time risk stratification. Advanced computational models integrating environment, physiology, and patient behavior may enable predictive analytics and personalized intervention pathways . Virtual reality solutions have recently become commercially available however their role is limited by default since they cannot serve walking exercises which are essential for the reestablishment of mobility. Intense research has been implemented with cutting edge technology of augmented reality in the context of three EU funded projects (HOLOBALANCE, SMART BEAR and currently TELEREHAB DSS). A platform able to project in real space a surrogate physiotherapist in terms of an avatar, which indicates programmed exercises. It also captures movements with sensors and is able to provide real time feedback to the patients in case their performance is not correct. Preliminary work has already been completed, investigating these platforms acceptability, feasibility and effectiveness. Results have shown promise, in terms of cost effectiveness, patient acceptability and usability among MCI (Bovornratanaraks et al. 2024; Utoomprurkporn et al. 2023) and stroke patients (Nairn, Koohi and Bamiou, 2025) and preliminary feasibility using IMU's, pressure-sensitive wellness mats and the ehealth literacy application (Georgas et al. 2025). Market analysis has also proven, that these telerehabilitation solutions fill many existing gaps, make rehabilitation more accessible and engaging, with TeleRehabilitation of balance and economic clinical decision support system (TeleRehab DSS) standing out as superior in terms of AI-decision support, objective data collection and real-time feedback (Nairn et al. 2025). Other pressing issues highlighted by this issue include the need for standardized outcome metrics. Currently, measures vary widely making study comparison difficult. A unified core outcome set would advance research coherence and meta-analytic capacity. Equally, workforce development requires attention: implementing multifactorial programs demands training physiotherapists in cognitive assessment and dual-task facilitation, on top of dedicated skills for balance physiotherapy which are not currently part of the relevant curricula and creating multidisciplinary teams with clearly delineated roles while avoiding siloed delivery. Lastly, equity considerations are paramount: older adults with neurological comorbidities or from socioeconomically disadvantaged backgrounds face the greatest fall risk, yet are often excluded from trials. Future research must emphasize inclusion and access to ensure interventions reach those most in need. In summary, this special issue provides a timely and rigorous examination of multifactorial balance assessment and rehabilitation. By highlighting epidemiology, identifying intervention gaps, outlining current practice and trends, and charting future opportunities, it offers a roadmap for translating science into sustainable, equitable fall prevention strategies.