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Physiotherapy works: Fragility fractures and falls

File 102727Respond to the first fracture; prevent the second. Physiotherapists do both.

Fragility fractures occur as a result of normal activities, such as a fall from standing height. Hip, arm, back and wrist fractures are the most common, and frequently there is an underlying pathology of osteoporosis.

Cost and size of the problem

Half of people who have a fall will fall again within the next 12 months
  • 45,000 people aged over 65 (2009), of whom 15,500 will fall each year, 6,700 twice or more
  • 17,400 people with osteoporosis; 6,900 post-menopausal women with a previous fracture; and 1,000 post-menopausal women each year with a new fracture
  • 1,250 fragility fractures per year, with 360 of these likely to be hip fractures.(3) 

Based on 2009/10 costs each hip fracture avoided would save approximately £10,170 (*HRG HA11 -14 inpatient).

Every avoided fracture of the upper arm, back and wrist saves PbR tariff costs (combined in- and out-patients) of approximately £1,300, £3,246 and £1,082 respectively, plus a local social care reduction averaging £225 per case for back and wrist fractures.(1, 2)

Falling is serious and frequent in people aged 65 and over. Each year, 35% of over-65s experience one or more falls.

About 45% of people over 80 who live in the community fall each year. 10% – 25% of these people will sustain a serious injury.(3)

Injury due to falls is the leading cause of mortality in older people aged over 75 in the UK.(4)

Recurrent falls are associated with increased mortality, increased rates of hospitalisation, and higher rates of institutionalisation.(2)

Age UK says: “Despite costing the NHS over £4.6 million each day, adding up to £1.7 billion per year, the issue of people in later life falling over is all too often dismissed as an inevitable part of the ageing process.”(5)

Physiotherapy delivers on rehabilitation to reduce the cost burden

  • NICE guidance requires all older people with recurrent falls, or at increased risk of falling, to be considered for an individualised multifactorial intervention including evidence based strength and balance training, home hazard assessment and intervention.(8, 9)
  • *Community-based falls prevention programmes targeting older people, particularly older women, can be highly cost saving, with the value of the benefits from reduced hospital admission significantly exceeding the costs of the intervention.(10, 11)
  • Exercise programmes to prevent falls in older people at-risk are cost effective, with a cost per Quality Adjusted Life Year (QALY) of under £10,000. This is well below the level usually considered to be affordable in the NHS (about £20,000 to £30,000 per QALY).(9)
  • *Preventing in-hospital falls by adopting a targeted falls prevention intervention using physiotherapist clinical judgement is cost saving compared to no-intervention.(12)

*Only the exercise programme used British costs; however, the combined evidence is sufficiently robust to support the conclusion that clinically effective programmes, delivered to high risk patient groups, are likely to be cost saving for the NHS.

Physiotherapists work in hospitals, communities and in patients’ homes. They have core and advanced knowledge and skills in reablement through which they:

  • Prevent frailty through evidence-based exercise programmes
  • Restore independence through falls care pathways
  • Promote bone health and reduce accidents through encouraging physical activity and active lifestyles
  • Lead falls clinics where at risk people receive thorough assessment and tailored advice.(6)
  • Identify underlying pathologies, including osteoporosis, and signpost to other specialists. 

Case study

The physiotherapist-led Glasgow Falls Prevention Programme sees nearly 175 patients a month in their homes to assess risk factors and intervene on modifiable risk factors.

This compares to 20 patients a month in English falls services. Between 1998 and 2008 there was a reduction in admissions due to falls in the home of 32%, falls in residential institutions of 27% and falls in the street of nearly 40%.

Over the same period, the number of admissions for hip fractures decreased by 3.6%. This positive trend compares with a growth of hip fracture admissions of nearly 2% in England.(7)


The potential savings from fragility fracture prevention are significant for the UK health economy. Physiotherapists can lead and input into many aspects of fragility fracture and falls prevention programmes, and physiotherapy should be part of these commissioned services.


1. Department of Health. Payment by results guidance for 2010-11. London: Department of Health; 2010. URL:

2. Department of Health. Fracture prevention services: an economic evaluation. London: Department of Health; 2009. URL:

3. Department of Health. Falls and fractures: effective interventions in health and social care. London: Department of Health; 2009. URL:

4. Department of Health. Improving care and saving money: learning the lessons on prevention and early intervention for older people. London: Department of Health; 2010. URL:

5. Mitchell M. Falls in the over 65s cost NHS £4.6 million a day. Press release - 21/6/2010. London: Age UK; 2010. URL:

6. Martin F, Huck J, Foster N, et al. Older people’s experiences of falls and bone health services (England). London: Royal College of Physicians; 2008. URL:

7. Skelton DA, Neil F. NHS Greater Glasgow and Clyde strategy for osteoporosis and falls prevention 2006-2010. An evaluation 2007-2009. Glasgow: Glasgow Caledonian University; 2009. URL:

8. Department of Health. Falls and fractures: exercise training to prevent falls. London: Department of Health; 2009. URL:

9. National Institute for Clinical Excellence. Clinical practice guideline for the assessment and prevention of falls in older people. CG21. London: National Institute for Clinical Excellence; 2004. URL:

10. Beard J, Rowell D, Scott D, et al. Economic analysis of a community-based falls prevention program. Public Health. 2006 Aug;120(8):742-51.

11. Hektoen LF, Aas E, Luras H. Cost-effectiveness in fall prevention for older women. Scand J Public Health. 2009 Aug;37(6):584-9.

12. Haines T, Kuys SS, Morrison G, et al. Cost-effectiveness analysis of screening for risk of in-hospital falls using physiotherapist clinical judgement. Med Care. 2009 Apr;47(4):448-56.

Further information

CSP Enquiry Handling Unit
Tel: 0207 306 6666