J Intellect Disabil Res - 2023 - Lalor

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Journal of Intellectual Disability Research doi: 10.1111/jir.13066

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VOLUME PART 2023
Systematic Review
Interventions to reduce falls in community-dwelling adults

with intellectual disability: a systematic review
A. Lalor,1,2 L. Callaway,1,2 S. Koritsas,3 A. Curran-Bennett,3 R. Wong,3,4 R. Zannier3
& K. Hill1
1 Rehabilitation Ageing and Independent Living (RAIL) Research Centre, Monash University, Melbourne, Victoria, Australia
2 Department of Occupational Therapy, Monash University, Melbourne, Victoria, Australia
3 Department of Strategy and Transformation, Scope, Melbourne, Australia, Australia
4 IDEAS Therapy Services, Victoria, Australia
Abstract tutes of Health study quality assessment tools.

Reporting of the review followed Preferred Reporting
Background People with intellectual disability have a
Items for Systematic Reviews and Meta-Analyses
high risk of falls and falls-related injuries. Although
(PRISMA) guidelines.
people with intellectual disability are at increased risk
Results Seven studies were eligible for review, with a
of falls, there is a need to better understand the
total of 286 participants and mean age of 50.4 years.
efficacy of interventions that can help reduce falls and
As only one randomised trial was identified, a
address risk factors in this population. This systematic
narrative synthesis of results was undertaken. Five
review aimed to evaluate the type, nature and
studies evaluated exercise interventions, one
effectiveness of interventions undertaken to reduce
evaluated a falls clinic programme, and one evaluated
falls with community-dwelling adults with intellectual
stretch fabric splinting garments. Methodological
disability and the quality of this evidence.
quality varied (two studies rated as good, four as fair,
Method Four electronic databases were searched:
and one as poor). Exercise interventions varied in
Ovid MEDLINE, PsycINFO, CINAHL Plus and the
terms of exercise type and dosage, frequency and
Cochrane Library. Studies were included if they
intensity, and most did not align with
involved people aged 18 years or over, at least 50% of
recommendations for successful falls prevention
study participants had intellectual disability,
exercise interventions reported for older people.
participants were community-dwelling, and the study
While the majority of studies reported reduced falls,
evaluated any interventions aiming to reduce falls.
they differed in methods of reporting falls, and most
Study quality was assessed using the National Insti-
did not utilise statistical analyses to evaluate
outcomes.
Correspondence: Prof Keith Hill, Rehabilitation Ageing and Conclusion This review identified a small number of
Independent Living (RAIL) Research Centre, School of Primary and
falls prevention intervention studies for people with
Allied Health Care, Building G, Monash University (Peninsula
Campus), 47-49 Moorooduc Hwy, Frankston, 3199, Melbourne, intellectual disability. Although several studies
Victoria, Australia (e-mail: keith.hill@monash.edu). reported improvements in fall outcomes, ability to
© 2023 The Authors. Journal of Intellectual Disability Research published by MENCAP and International Association of the
Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits
use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial
purposes.
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Journal of Intellectual Disability Research VOLUME PART 2023
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draw conclusions about intervention effectiveness is Understanding falls risk factors for specific
limited by small sample sizes and few studies. Further populations is important because it informs the
large-scale research is required to implement and development of falls prevention interventions – that
evaluate falls prevention interventions specifically for is, interventions can be designed to target modifiable
adults with intellectual disability. risk factors. A number of studies have investigated
risk factors that contribute to the increased frequency
Keywords Exercise, Falls, Intellectual disability,
and severity of falls for people with intellectual
Intervention studies
disability (Ho et al. 2019b; Pope et al. 2021). The
findings of these studies have varied due to differences
in sampling (e.g. setting, type of intellectual disability,
age), methods of documenting falls (e.g. retrospective
Introduction
or prospective, recall over 12 months or use of a falls
Falls are a major public health issue globally calendar) and the risk factors that have been
(Montero-Odasso et al. 2022) and are the most investigated across studies. As has been
common cause of injury-related hospitalisation, often recommended for falls prevention research among
resulting in avoidable injuries including fractures and older people (Lamb et al. 2005), there is a need for
brain injury (Australian Institute of Health and improved standardisation of best practice falls risk
Welfare (AIHW) 2020; Frighi et al. 2022). For people factor identification and intervention methods and
with intellectual disability, falls are common and high reporting for people with intellectual disability. This is
in frequency in comparison with the general because some commonly reported falls risk factors for
population (Axmon et al. 2019; Pope et al. 2021), with people with intellectual disability are associated with
rates up to 47% being reported for people with cognitive, behavioural, sensory and/or
intellectual disability living in the community communication changes experienced as a result of the
(Smulders et al. 2013b; Ho et al. 2019b; Pope disability itself (Nankervis et al. 2020) that can
et al. 2021). This is nearly 50% higher than the rate of directly contribute to increased risk of falls, personal
falls over a 12-month period in older people (aged injury and hospitalisation (Iacono et al. 2014).
>65 years) (Dolinis et al. 1997; Montero-Odasso An additional consideration for falls prevention
et al. 2022). Recurrent falls have also been reported to interventions for people with intellectual disability is
be high for people with intellectual disability (Cox the role of informal (family) or paid disability support
et al. 2010; Finlayson et al. 2010; Ho et al. 2019b). workers. People with intellectual disability often rely
Injuries are a common consequence of falls in this on others to enable their participation in basic daily
population, with 26% experiencing an injury from activities, as well as health-promoting behaviours that
their fall and people with intellectual disability being may prevent falls (e.g. physical exercise programmes,
more likely to require specialist care after a fall than proactive management of health conditions including
the general population (Axmon et al. 2019; Ho hypotension and hypertension). Falls during basic
et al. 2019b). Furthermore, a recent retrospective daily activity (e.g. attending to personal hygiene or
matched cohort study of people with intellectual eating), for example, have been found to be twice as
disability across the lifespan highlighted higher common among people with intellectual disability
fracture rates for them, with one-third of falls when compared with the general population (Axmon
resulting in this type of injury. This study also found et al. 2019). Furthermore, research has identified that
that there was an earlier onset of fracture risk, health literacy for both the person with disability and
approximately 30 years earlier in men and 15 years their key supporters may vary, or at times be limited,
earlier in women in comparison to individuals which can negatively impact proactive identification
without intellectual disability (Frighi et al. 2022). In or management of modifiable falls risk factors (Palesy
addition to these health impacts, risk of falls may also and Jakimowicz 2020). These disability-related
lead to the use of restrictive practices with people with factors that impact risk of falls, superimposed on the
intellectual disability, including physical, mechanical typical falls risks associated with ageing, are becoming
and environmental restraint, which have both safety more evident as the population of people with
and rights implications (Chandler 2021). intellectual disability live longer (Axmon et al. 2019).
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It has also been noted that frailty associated with the incidence of dementia in people aged 65 years and
ageing occurs prematurely in this population, with older with intellectual disability being up to five times
people with intellectual disability in their 40s and 50s greater than for the general older population
reported to experience similar ageing changes to those (Strydom et al. 2013). There is growing evidence in
in their 70s in the wider population and experiencing older people with cognitive impairment that falls
earlier onset of conditions such as diabetes and prevention interventions such as exercise can be
dementia (Strax et al. 2010). However, it is not effective in reducing falls (Jensen and Padilla 2011;
disability and age-related conditions alone that impact Burton et al. 2015; Li et al. 2021), although some
falls, but other falls risk factors can also contribute. modifications to interventions may be required. For
The focus of falls research has largely been on older example, Suttanon and colleagues (2012) identified
people where there is a large and high-quality that interventions that have been shown to be effective
evidence base identifying falls risk factors (Deandrea in older people without cognitive impairment require
et al. 2010; Montero-Odasso et al. 2022) and tailoring for older people with dementia (e.g. making
supporting effective falls prevention in community modifications to instructions within exercise
settings (Gillespie et al. 2012; Hopewell et al. 2018; programmes). There is a similar need to evaluate
Sherrington et al. 2019; Montero-Odasso et al. 2022). feasible and safe interventions implemented with
A number of single interventions including exercise, people with intellectual disability to reduce falls. The
home modifications, vision correction and aim of this review was therefore to identify the type,
medication review or reducing medications associated nature and effectiveness of interventions undertaken
with high falls risk have been shown to reduce falls to reduce falls with community-dwelling adults with
risk in older people (Gillespie et al. 2012; Sherrington intellectual disability and to evaluate the quality of
et al. 2019). Additionally, multiple interventions (two this research evidence.
or more interventions where everyone receives the
same intervention) or multifactorial interventions
(where two or more interventions are tailored to the
Methods
individual’s falls risk, often based on a falls risk Reporting of this review follows the Preferred
assessment) have also been shown to be effective in Reporting Items for Systematic Reviews and
reducing falls in older people living in the community Meta-Analyses (PRISMA-P) guidelines (Moher
(Gillespie et al. 2012; Hopewell et al. 2018; et al. 2015). The protocol of this study was not
Montero-Odasso et al. 2022). Recent reviews (Burton registered in a publicly assessable database due to
et al. 2015; Lord and Close 2018) highlight that the significant delays in registration (e.g. 6 months) at the
majority of these studies of older people exclude time this review was initiated (early 2020). The
people with cognitive impairment (including protocol is available upon reasonable request to the
individuals with dementia and/or intellectual authors.
disability) and mostly target people aged over 65 years
of age. As such, this evidence may not be directly
Inclusion criteria
relevant to or translatable for the intellectual disability
population, who often experience increased falls risk Studies were eligible for inclusion in the review if they
at younger ages. met criteria according to population, intervention,
When applying interventions to reduce falls, there outcomes, research design and publication. Only
is growing recognition of the unique characteristics studies including people with intellectual disability
and needs of high falls risk populations, such as those who were aged 18 years and over and were
with cognitive impairment, which may also be community dwelling were considered. Where studies
applicable to future consideration with people with included participants of mixed populations (i.e.
intellectual disability. The nature of cognitive intellectual disability, acquired brain injury, other
impairment and severity of intellectual disability disabilities), the study was included if it was evident
experienced differ between individuals, as it does for the sample had a minimum proportion of 50% with
different types of dementia. As people with intellectual disability. For some studies identified, this
intellectual disability age, dementia can develop, with required email correspondence with the paper authors
4
for clarification. ‘Community-dwelling’ was defined they were only published as conference abstracts.
as living in a residential (rental or owned) home or Grey literature publications (e.g. government reports
group home (with no more than 6–10 individuals). or submissions) were not included.
Studies that included settings other than
community-dwelling (i.e. residential aged care or
Search strategy and study selection
other larger institutions) were excluded, as falls in
larger residential institutions may have some different The search was undertaken for articles published to
factors contributing to falls than community houses June 2023 included in four electronic databases: Ovid
or small group homes (e.g. environmental and staffing MEDLINE, PsycINFO, CINAHL Plus and the
factors contributing to falls; see, e.g. separate Cochrane Library. The search strategy was developed
Australian falls prevention guidelines for these by all authors and in consultation with an experienced
settings) (Australian Commission on Safety and university librarian. The search strategies for each of
Quality in Health Care 2009a; Australian the four databases are reported in Tables 1–3. Hand
Commission on Safety and Quality in Health searching of reference lists of included articles was
Care 2009b). Where studies included participants also undertaken. As a concurrent literature search was
from a mix of settings (i.e. home and nursing home), being undertaken by the authors evaluating falls risk
the study was included if 50% or more of the sample factors for people with intellectual disability,
were living in community dwellings, or data for those identified studies in that search were also reviewed for
living in community dwellings were reported any additional falls prevention intervention studies.
separately. Studies using an experimental or Following removal of duplicates of retrieved
quasi-experimental design were included, including articles, each title and abstract was reviewed in
single case design studies, if they reported any Covidence by two authors (AL and one of RW and
interventions aiming to reduce falls in people with AC-B) using the inclusion criteria. Full-text review of
intellectual disability in community dwellings. articles meeting inclusion following title and abstract
Interventions within included studies were classified review was undertaken independently by two authors
using the Prevention of Falls Network Europe (Pro- (KH and AL; both are qualified allied health
FaNE) fall prevention classification system (Lamb professionals with previous experience conducting
et al. 2011; Prevention of Falls Network Europe pro- systematic reviews). Where the opinions of the
ject (ProFANE) 2007). Any falls-related outcome authors differed, consensus was reached through
(e.g. falls, falls rates, proportion of fallers, fall related discussion.
injuries or hospitalisations) was included. While a
standardised definition of a fall is recommended in
Data extraction and quality assessment rating
the literature (Hauer et al. 2006) – for example ‘in-
advertently coming to rest on the ground, floor or Data from final eligible studies for review were
other lower level, excluding intentional change in extracted and populated in an evidence table (using
position to rest in furniture, wall or other objects’ Microsoft Excel) by one author (AL), with all
(World Health Organisation 2007) – there can be extracted data checked against the full text by another
various definitions used in different publications. Ir- author (KH). Data extracted included citation details,
respective of which falls definition was used in the study sample, methods, falls data/outcomes collected,
identified studies, they were included in the review, intervention details and results. Interventions were
with the details of the specific falls definition used in classified according to the ProFaNE fall prevention
each study documented. Lastly, studies needed to be classification system (Lamb et al. 2011, Prevention of
published in peer-reviewed journals, in English, from Falls Network Europe project (ProFANE) 2007) as
the year 2000 onwards. (1) single intervention; (2) multiple interventions (two
or more interventions applied to the full sample); or
(3) multifactorial (two or more interventions, with
Exclusion criteria
interventions differing between individuals, usually
Studies were excluded if they only reported changes based on a falls risk assessment). For exercise inter-
to falls risk factors (i.e. balance, medications) or if ventions, details of the characteristics of the exercise
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Table 1 Search strategy for CINAHL
EBSCOhost CINAHL Complete (1951–2022) search 6 June 2023
1. MH (“Intellectual Disability”)
2. TX (intellectual disabilit* or intellectual impairment* or learning disabilit* or learning impairment* or mental retardation or mental
impairment* or cognitive disabilit* or cognitive impairment*)
3. S1 or S2
4. MH (“Accidental Falls”)
5. TX (fall or falls or faller or fall* risk or fall* prevention)
6. TX (fall adj3 accident*)
7. S4 or S5 or S6
8. TX ((allocat* or allot* or assign* or divid*) and (condition* or experiment* or intervention* or treatment* or therap* or control* or
group*))
9. S3 and S7 and S8
10. S9 limit to 2010-2023
11. S10 limit to English language
programmes (e.g. exercise type, frequency, duration example, randomised controlled trials, pre-post study
and intensity) were also extracted. with no control group and case series studies.
The quality of studies included in the review were
assessed using the National Institutes of Health
Data analysis
(NIH) study quality assessment tools (see https://
www.nhlbi.nih.gov/health-topics/study-quality- The author group planned that where more than one
assessment-tools) (Cardiovascular Risk Assessment study reported a similar intervention type and falls
Work Group 2013). Separate tools are available for outcome measure, data would be pooled and a
evaluating the quality of different study types, for meta-analysis performed. If insufficient studies
Table 2 Search strategy for Ovid MEDLINE and PsycINFO
Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and
Versions (1946 to 1 June 2023)
APA PsycInfo (1806 to May Week 5 2023) search 6 June 2023
1. exp. Intellectual Disability/

2. (intellectual disability$ or intellectual impairment$ or learning disabilit$ or learning impairment$ or mental retardation or mental
impairment$ or cognitive disabilit$ or cognitive impairment$).tw
3. or/1-2
4. exp. Accidental Falls/
5. (fall or falls or faller or fall$ risk or fall$ prevention).tw
6. ((fall) adj3 (accident$)).tw
7. or/4-6
8. ((allocat$ or allot$ or assign$ or divid$) and (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or
group$)).tw
9. 3 and 7 and 8
10. limit 9 to 2010-2023
11. limit 10 to English language
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Table 3 Search strategy for Cochrane Library
Cochrane Library (1996–2023) search 6 June 2023
1. MeSH descriptor: [Intellectual Disability] explode all trees

2. (intellectual disabilit* or intellectual impairment* or learning disabilit* or learning impairment* or mental retardation or mental
impairment* or cognitive disabilit* or cognitive impairment*):ti, ab,kw
3. Or 1-2
4. MeSH descriptor: [Accidental Falls] explode all trees
5. (fall or falls or faller or fall* risk or fall* prevention): ti, ab,kw
6. (fall) adj3 (accident*):ti, ab,kw
7. Or 4-6
8. ((allocat* or allot* or assign* or divid*) and (condition* or experiment* or intervention* or treatment* or therap* or control* or
group*)):ti, ab,kw
9. 3 and 7 and 8
10. Limit 9 to: year of publication > = 2010
11. Limit 10 to: English
evaluated a similar intervention type and outcome trial (n = 1) (Table 4). As only one randomised con-
measure, then data synthesis through a narrative trolled trial was identified, a meta-analysis was not
approach would be undertaken. performed, and the results are reported as a narrative
review instead.
Results
Study quality
A total of 2911 articles were identified from the
electronic databases. Following removal of 486 Quality ratings of included articles are reported in
duplicates, titles and abstracts of the remaining 2425 Tables 5–7 (for randomised controlled trials, pre–post
articles were screened for eligibility. Full-text review studies with no control group and single case
of 26 articles was undertaken, with six articles experiments, respectively). Overall, two studies were
meeting inclusion criteria for the review. One rated as good quality (Hale et al. 2016; Finlayson
additional article (Renfro et al. 2016a) was included et al. 2018), four were rated as fair (Smulders
for review following its identification in a paper et al. 2013a; Crockett et al. 2015; Hale et al. 2019;
(Bainbridge et al. 2017) screened for a concurrent Kovacic et al. 2020), and one was rated as poor
review being undertaken to identify risk factors for quality (Renfro and Fehrer). Each of the different
falls for people with intellectual disability. Therefore, types of studies had different quality criteria. For the
seven articles were included in the review. Figure 1 pre–post study design with no control group, items
provides an overview of the process and outcome of that did not meet criteria for a good quality study or
article screening and review. were unclear across most or all of the four papers were
All seven studies included community-dwelling items 4 (i.e. ‘were all eligible participants that met the
participants with intellectual disability over 18 years of prespecified entry criteria enrolled?’), 5 (‘was the
age, in Scotland (n = 2), New Zealand (n = 2), the sample size sufficiently large to provide confidence in
Netherlands (n = 1), the United States (n = 1) and the findings?’), 8 (‘was the differential drop-out rate
Slovenia (n = 1). Six of the seven studies had 100% of between treatment groups at endpoint 15 percentage
the participant sample being people with intellectual points or lower?’) and 11 (‘were outcomes assessed
disability, while one study (Renfro et al. 2016a) had using valid and reliable measures, implemented
86.7% (n = 13) of the total sample with intellectual consistently across all study participants?’). For the
disability. All studies were peer-reviewed articles and two single case experiments, items that did not meet
predominantly used a before–after study design criteria or were unclear on at least one of the two
(n = 4), with additional study designs including single papers were items 3 (‘were the cases consecutive?’), 4
case experiments (n = 2) and a randomised controlled (‘were the subjects comparable?’), 7 (‘was the length
7
Figure 1. PRISMA flow diagram for falls prevention intervention studies.
of follow-up adequate?’) and 9 (‘were the results well- 50.4 years from five studies (where reported, n = 121),
described?’). ranging from 20 to 81 years (although one study by
Smulder and colleagues only included participants
aged 50 years and older) (Smulders et al. 2013a). In
Participants
two studies (Renfro et al 2016a; Kovacic et al. 2020),
A total of 286 (range 7–150) participants were mean age was not reported. In the study by Kovacic
included across the seven studies. The mean age was et al. (2020), 94% of participants were <40 years, and
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Table 4 Characteristics of included intervention studies (N = 7) to reduce falls risk
Sample: Diagnosis and age

Reference Country N (% M:F) Any falls (mean ± SD) years Fall measurement;
Study design inclusion criteria (inclusion range) Living arrangement (%) and fall definition used
Crockett et al. 2015 50 100% intellectual disability (1) Living with support (66%) Number of reported falls
Scotland (48:52) 58 ± 12.9 (2) Living with family (24%) by falls charts
Before-after Included only fallers (no age limit; range 28–81 (3) Alone, independently (10%) (completed by the client’s
years included) carer at home)
pre- and post-exercise
intervention
Fall definition: not defined
Journal of Intellectual Disability Research
Finlayson et al. 2018 9 100% intellectual disability (1) Living with family (67%) Daily falls chart (6 weeks
Scotland (44:56) 36 ± 11.7 (2) Supported group living (11%) pre and 6 weeks post)
Series of single Included only fallers (no age limit; range 20–59 (3) Supported independent living (22%) Fall definition: not defined
case experiments years included)
§
Hale et al. 2016 27 100% intellectual disability (1) ‘Residential’ homes (76%) Falls reported in the
New Zealand (45:55) 53 ± 10.9 (2) Supported independent living (24%) past 12 months
Uncontrolled before-after Included fallers and those (18 + years; range 29–71 Fall definition: ‘an unexpected
deemed at risk of falls years included) event in which
the participants come
to rest on the ground,
floor or lower level’
(Lamb et al. 2005) (p 1619)
Hale et al. 2019 7 100% intellectual disability (1) Alone, independently (14%) Prospective falls incident forms
New Zealand (71:29) 50.9 ± 11.9 (2) Supported independent living (58%) Fall definition: ‘an unexpected
Multi case study (including Included only fallers (18 + years; range (3) Supported group home with event in which the
qualitative study) 38–68 years included) 20 other residents (14%) participants comes to rest
(4) Supported group home on the floor, ground
(size not specified) (14%) or lower level’ (Lamb
et al. 2005) (p 1619)
Kovacic et al. 2020 150 100% intellectual disability (1) Living with parents (35%) Reporting frequency of falls
Slovenia (50:50) Mean not reported (2) Supported living (20%) (institutions) at baseline and after
RCT Included only fallers (18 + years; 94% < 40 years) (3) Group homes (max 6 people) (45%) 16 weeks intervention (no
details of how falls
data was collected)
Fall definition: not defined
Renfro et al. 2016a 15 86.7% intellectual disability (1) Living at home Self-report
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America (33:67) Mean not reported; 46.7% aged (2) Supported community environment Fall definition: not defined
Before–after Included fallers and non-fallers ≥50 years (range 27–70 years)
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Table 4. (Continued)
Sample: Diagnosis and age

Reference Country N (% M:F) Any falls (mean ± SD) years Fall measurement;
Study design inclusion criteria (inclusion range) Living arrangement (%) and fall definition used
Smulders et al 2013a 26 100% intellectual disability (1) Community based (92%) Monthly fall registration
Netherlands (46:54) 60.8 ± 5.6 (2) Supported independent living (8%) calendars
Before-after Included only fallers (50 + years) for 1-year follow-up
Fall definition: not specifically
stated however references
an earlier study where to fall
was ‘coming to the floor

or lower level’
Reference Country Risk factors for Intervention Intervention type

Study design falls identified Intervention combination† (ProFaNE classification) Falls outcome
Crockett et al. 2015 Nil 12-week individualised Multifactorial Exercise For individuals who completed the
Scotland physiotherapy-led exercise Environmental/assistive 12-week programme (n = 27):
Before-after programme (as part of technology
a falls pathway service), Knowledge • Number of falls reported pre-exercise
included education and intervention: 3.2 ± 2.8 (range 1–14)
home assessment • Number of falls reported post-exercise
intervention: 1.0 ± 1.2 (range 0–3)
Finlayson et al. 2018 Nil Tailored stretch Single Environmental/assistive • All participants (n = 5) wearing tailored
Scotland fabric garments technology stretch socks demonstrated reduced falls
Series of single (from mean of 8 non-epilepsy falls in
case experiments 6 weeks prior to intervention to mean
of 4 non-epilepsy falls
during 6 week intervention)
• Participants wearing tailored stretch
shorts/leggings demonstrated
reduced falls
(n = 2; mean 6 pre and mean
2 during); no change
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(n = 1; 0 falls pre or during);

and increased
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(n = 1; 1 fall pre and

2 falls during)
Hale et al. 2016 Nil Prevention of falls for Single Exercise • 22 participants had
New Zealand adults with intellectual experienced a fall in
Uncontrolled before-after disability (PROFAID) the previous 12 months;
intervention including 5 had not fallen;
(1) a training workshop 2 had unknown falls history. All were
for staff/families to considered to have a falls risk
help them support the • Fall rate during PROFAID (over 6 months)
exercise programme and was 0.90 falls per person (range 0–5 with
β
(2) 3 visits and ongoing 16 reporting 0 falls during intervention)
physiotherapy support
Hale et al. 2019 Nil PROFAID (as per Hale Single Exercise Six participants had a high falls risk
New Zealand et al. 2016) for 3 participants prior to the intervention
Multi case study (including Modified group-based During the intervention:
qualitative study) version of the Otago Exercise
Programme (OEP): Group • OEP participants (n = 3;
exercise programme 2 high falls risk):
over 8 weeks (with some 2 participants reported 1 fall
individual modifications each; 1 reported 0 falls
of exercises) for 4 participants • PROFAID participants
(n = 4): 3 participants
reported falls (4.7 ± 2.1;
range 3–7 falls); 1 reported 0 falls
Kovacic et al. 2020 Balance assessment Control group: regular Control group: Single Exercise Tukey’s HSD test showed statistically
Slovenia is a high predictor Special Olympic (SO) Treatment group 1: Multiple Exercise and knowledge significant differences between
RCT of frequency of falls, athletic training Treatment group 2: Multiple Exercise and knowledge frequency of falls in the 4 months previous
and significantly Treatment group 1: to the pre-test/post-test for:
correlates with exercise regular Special Olympic • The MBSEP (0.1 ± 0.303) and
athletic training and regular SO (1.48 ± 1.054) group
multicomponent • The MBSEP (0.1 ± 0.303) and
balance-specific exercise wellness (1.38 ± 0.878) group (p 388)
programme (MBSEP)
with educational workshops
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Treatment group 2:
regular Special Olympic

athletic training and
multicomponent
wellness program
‡
Renfro et al. 2016a Nil Modified group-based Single Exercise No falls were reported
America Increase/decrease version of the OEP: by study participants
Before–after in ‘risk’ of falls only 1-h group exercise during the study period
and home programmes
over 7 weeks OEP
Smulders et al 2013a Nil reported ‘Falls clinic’ type intervention. Multifactorial Exercise • Fall rate prior to the falls clinic
Netherlands (earlier study with cohort Individualised Medication was 1.78 falls per person per year
Before-after reported risk factors) intervention strategies based Environmental/assistive • Fall rate post the falls clinic
on extensive screening technology was 1.37 falls per person per year
Incontinence management
HSD, honestly significant difference; RCT, randomised controlled trial.

†
Grouped by combination: single, multiple, multifactorial (Prevention of Falls Network Europe project (ProFANE) 2007).
‡
Study mentioned a home assessment was offered to each participant at the conclusion of the study; however, the study did not report how many participants received the assessment or what actions or
modifications were undertaken therefore the classification is a ‘single’ intervention rather than a ‘multiple’ intervention; RCT: randomised controlled trial.
§
Study by Hale et al. (2016) included residential homes of up to 8 people.
β
Falls rates during intervention clarified via personal communication with corresponding author of Hale et al. (2016).
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†
Table 5 Quality rating: randomised controlled trial (NIH study quality assessment tools)
Criterion Kovacic et al. 2020
1. Was the study described as randomised, a randomised trial, a randomised clinical trial or an RCT? √
2. Was the method of randomization adequate (i.e. use of randomly generated assignment)? √
3. Was the treatment allocation concealed (so that assignments could not be predicted)? √
4. Were study participants and providers blinded to treatment group assignment? √
5. Were the people assessing the outcomes blinded to the participants’ group assignments? √
6. Were the groups similar at baseline on important characteristics that could affect outcomes √
(e.g. demographics, risk factors, co-morbid conditions)?
7. Was the overall dropout rate from the study at endpoint 20% or lower of the number U
allocated to treatment?
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage U
points or lower?
9. Was there high adherence to the intervention protocols for each treatment group? U
10. Were other interventions avoided or similar in the groups (e.g. similar background treatments)? √
11. Were outcomes assessed using valid and reliable measures, implemented consistently √
across all study participants?
12. Did the authors report that the sample size was sufficiently large to be able to detect a U
difference in the main outcome between groups with at least 80% power?
13. Were outcomes reported or subgroups analysed prespecified (i.e. identified before √
analyses were conducted)?
14. Were all randomised participants analysed in the group to which they were originally assigned, U
i.e. did they use an intention-to-treat analysis?
‡
Overall quality rating Fair
†
https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools.
‡
Good/fair /poor; √=criterion met; X = criterion not met; U = unclear/not recorded; N/A = not applicable.
in the Renfro et al. (2016a) study, 46.7% were aged pyruvate dehydrogenase deficiency syndrome and
≥50 years (range 27–70 years). Fifty two per cent of fenilcetonuria (Finlayson et al. 2018; Kovacic
participants across the studies were female. et al. 2020).
Both studies by Hale et al. (2016, 2019) included a Each study varied in how and what other
definition of intellectual disability, being that of the demographic factors or co-morbidities were reported,
New Zealand legislation [ID (Compulsory Care and including epilepsy, medical conditions, orthopaedic
Rehabilitation) Act, 2003]: ‘a permanent impairment conditions, vision issues, hearing issues, mood
that results in significantly sub-average general intel- disorders, behavioural issues, physical disabilities,
ligence – IQ of 70 or less’ (p. 37) (New Zealand incontinence, communication and weight issues. One
Ministry of Health 2003). Six studies reported in- study additionally reported participants’ daily activity
cluding participants with different severity of intel- (hours per week), paid work, arts and crafts and
lectual disability including mild, moderate, severe and sporting activity (Smulders et al. 2013a). All studies
profound, although only four of these studies re- included details regarding living arrangements,
ported the breakdown of participants across severity although definitions of settings varied and only four
of intellectual disability (Smulders et al. 2013a; studies included the breakdown of the settings
Crockett et al. 2015; Hale et al. 2016; Hale et al. 2019). participants lived in. Most commonly participants
Two studies reported participant diagnoses, including were living with family, or living with support
participants with Down syndrome, cerebral palsy, (including in group homes). Approximately one in
autism spectrum disorder, Prader–Willi syndrome, five participants (20.8% of n = 245) from five studies
Apert syndrome, Williams syndrome, fragile X syn- were identified as requiring a walking aid or support
drome, fetal alcohol syndrome, Dravet’s syndrome, to mobilise (including crutches, ankle-foot orthoses,
13
†
Table 6 Quality rating: pre–post (before–after) study with no control group (NIH study quality assessment tools)
Crockett Hale Renfro Smulders

Criterion et al. 2015 et al. 2016 et al, 2016a et al, 2013a
1. Was the study question or objective clearly stated? √ √ X √

2. Were eligibility/selection criteria for the study √ √ √ √
population prespecified and clearly described?
3. Were the participants in the study representative √ √ U √
of those who would be eligible for the test/service/
intervention in the general or clinical population of interest?
4. Were all eligible participants that met the prespecified √ U U X
entry criteria enrolled?
5. Was the sample size sufficiently large to provide X √ X X
confidence in the findings?
6. Was the test/service/intervention clearly described U √ √ √
and delivered consistently across the study population?
7. Were the outcome measures prespecified, clearly defined, √ √ √ √
valid, reliable and assessed consistently across all study participants?
8. Were the people assessing the outcomes blinded to the X U U X
participants’ exposures/interventions?
9. Was the loss to follow-up after baseline 20% or less? X √ √ √
Were those lost to follow-up accounted for in the analysis?
10. Did the statistical methods examine changes in outcome √ √ √ X
measures from before to after the intervention? Were
statistical tests done that provided p values for
the pre-to-post changes?
11. Were outcome measures of interest taken X X X X
multiple times before the intervention and multiple
times after the intervention (i.e. did they use
an interrupted time-series design)?
12. If the intervention was conducted at a group N/A N/A N/A N/A
level (e.g. a whole hospital, a community, etc.) did the
statistical analysis take into account the use of individual-level
data to determine effects at the group level?
‡
Overall quality rating Fair Good Poor Fair
†
‡
Good/fair/poor; √=criterion met; X = criterion not met; U = unclear/not recorded; N/A = not applicable.
four-wheeled walker or mobility scooter) (Crockett et al. 2016a; Finlayson et al. 2018; Hale et al. 2019;
et al. 2015; Hale et al. 2016; Finlayson et al. 2018; Hale Kovacic et al. 2020), and (2) multifactorial interven-
et al. 2019; Kovacic et al. 2020). tions (n = 2) (Smulders et al. 2013a; Crockett
et al. 2015).
Six of the seven studies reported exercise
Type and nature of interventions
interventions (Smulders et al. 2013a; Crockett
Using the ProFaNE falls prevention classification et al. 2015; Hale et al. 2016; Hale et al. 2019; Kovacic
system (Lamb et al. 2011; Prevention of Falls Network et al. 2020). Delivery setting and programme type for
Europe project (ProFANE) 2007), interventions in the exercise interventions varied across studies
included studies were classified as (1) single inter- including either home-based (Smulders et al. 2013a;
ventions (n = 5), most commonly exercise (although Crockett et al. 2015; Hale et al. 2016; Finlayson
two of the three exercise groups could be considered et al. 2018; Hale et al. 2019; Kovacic et al. 2020) or
multiple interventions, as they received additional group-based (Renfro et al. 2016a; Hale et al. 2019;
healthy lifestyle education) (Hale et al. 2016; Renfro Kovacic et al. 2020) settings and either individualised
14
†
Table 7 Quality rating: case series studies (NIH study quality assessment tools)
Criterion Finlayson et al. 2018 Hale et al. 2019
1. Was the study question or objective clearly stated? √ √

2. Was the study population clearly and fully described, including a case definition? √ √
3. Were the cases consecutive? √ U
4. Were the subjects comparable? √ X
5. Was the intervention clearly described? √ √
6. Were the outcome measures clearly defined, valid, reliable and implemented √ √
consistently across all study participants?
7. Was the length of follow-up adequate? U N/A
‡
8. Were the statistical methods well-described? N/A X
9. Were the results well described? √
§
Overall quality rating Good Fair
†
‡
Qualitative results well described; but falls results not well described (no pre data).
Good/fair/poor; √=criterion met; X = criterion not met; U = unclear/not recorded; N/A = not applicable.
§
(Smulders et al. 2013a; Crockett et al. 2015; Hale approach, involving multidisciplinary assessments
et al. 2016; Hale et al. 2019; Kovacic et al. 2020) or (physician and physiotherapist), and individualised
generic programmes (Renfro et al. 2016a; Hale treatments, advice or referrals for interventions not
et al. 2019; Kovacic et al. 2020). Exercise able to be delivered by the clinic staff (Smulders
interventions most commonly focused on promoting et al. 2013a). Most common recommendations and
balance, strength (particularly lower extremity) and referrals in this study (N = 26) were referral to general
aerobic exercise. Intensity of exercises were not practitioner for management of health issues (n = 17),
reported in any study; however, exercise sessions were general health advice (n = 14), physiotherapy referral
predominantly 1 h in duration and undertaken weekly (n = 6), diet changes (n = 5), ophthalmology referral
or twice weekly. Table 8 summarises the (n = 4) and medication review (n = 2).
characteristics of the exercise interventions from
articles included in the review.
Two studies reported an intervention type other Effectiveness of interventions
than exercise. One of these investigated the effect of Falls were reported to be reduced as a result of the
tailored stretch fabric garments (Finlayson interventions in most studies (Table 4), but samples
et al. 2018). The rationale for use of tailored stretch were small, and in most studies, statistical analyses
fabric garments was that the firm support offered by were not conducted. In the randomised controlled trial
the garment may increase sensory and proprioceptive by Kovacic et al. (2020), however, falls were
awareness through their mechanical compressive significantly reduced across the 14-week intervention
effect, which may in turn improve balance and (main effect for falls in a two-way ANOVA), and there
mobility. Stretch fabric garments can be made to fit was a significant interaction effect between the three
various body segments, from small areas such as socks intervention groups and time (with increased falls in a
through to full body suits. In Finlayson et al. (2018), FUNFitness group, but similar falls rates over time for
participants used limited stretch fabric garments, with the Wellness group and the Special Olympics group)
five of the nine participants wearing socks or socks (Kovacic et al. 2020). Participants also experienced less
with shorts and four participants wearing only shorts falls during the stretch fabric garments intervention,
or leggings. The compliance criterion for this study particularly in all five participants who wore stretch
was to wear the stretch fabric garments for at least 5 h fabric socks (Finlayson et al. 2018). By comparison,
per day, at least 5 days per week. The other non- falls were reduced for only two of four participants who
exercise-focussed intervention was a falls clinic wore stretch fabric shorts.
15
Table 8 Characteristics of exercise interventions in included studies
Type of exercise
Study Intervention outline Warm up/Cool down Balance Strength Aerobic
Crockett 2015 √ √ √ √
12-week tailored physiotherapy-led exercise programme with client choice of 2–3 exercises and min. 3 physiotherapy visits
Finlayson 2018
Tailored stretch fabric garments
Hale 2016 √ √ √
PROFAID: 3× physiotherapy visits, client choice of 2–3 exercises and ongoing support
Hale 2019 √ √ √
PROFAID group: 3× physiotherapy visits, client choice of 2–3 exercises and ongoing support for 3 months
Otago Exercise Programme (OEP) group: for 8 weeks √ √
Kovačič 2020 ? ? ? ?
Control group: Regular Special Olympic athletic training
Treatment group 1: Multicomponent balance-specific exercise programme
Treatment group 2: Multicomponent wellness programme √ √ √
Renfro 2016a √ √ √ √
‡
Modified OEP
Smulders 2013a √ √ √ √
Individualised programme (multifactorial)
Setting Programme type
Other Individual Group Individual-
Study Intervention outline Intervention(home) (community)ised Generic Frequency Duration Intensity
Crockett 2015 √ √ Dependent onDependent onDependent on

12-week tailored physiotherapy-led exercise programme with individual – notindividual – notindividual – not
client choice of 2–3 exercises and min. 3 physiotherapy visits recorded recorded recorded
Finlayson 2018 √ √ √ Min. 5 days per weekMin. 5 h per day
Tailored stretch fabric garments
Hale 2016 √ √ Daily As part of usual
PROFAID: 3× physiotherapy visits, client choice of 2–3 exercises √ √ Weekly routine
VOLUME PART
and ongoing support
2023
16
Setting Programme type
Other Individual Group Individual-

Study Intervention outline Intervention(home) (community)ised Generic Frequency Duration Intensity
Hale 2019 √ √ Daily As part of usual

PROFAID group: 3× physiotherapy visits, client choice of 2–3 √ √ Weekly routine
exercises and ongoing support for 3 months
†
Otago Exercise Programme (OEP) group: for 8 weeks √ √ √ Weekly
Kovačič 2020 √ √ √ √ Weekly 1h Not reported
Control group: Regular Special Olympic athletic training 2× weekly 1h Not reported
Treatment group 1: Multicomponent balance-specific exercise √ √ √ √ Weekly 1h Not reported
programme 2× weekly 1h Not reported
Treatment group 2: Multicomponent wellness programme √ √ Weekly 15 min Not reported
Weekly 35 min Not reported
Weekly 10 min Not reported
Renfro 2016a √ √ 2× weekly 50–60 min Not reported
‡
Modified OEP
Smulders 2013a √ √ √ Dependent onDependent onNot reported
Individualised programme (multifactorial) individual – notindividual – not
reported reported
√ indicates if included; ? indicates exercise included but not explicitly outlined.
PROFAID, Prevention of falls for adults with intellectual disability.
†
Some individual modifications were enabled for participants via participation at own level and independence.
‡
Modifications included 7-week programme rather than 12 months, group-based rather than home-based, and addition of pre- and post-tests from the Stopping Elderly Accidents, Deaths, and Injuries (STEADI).
VOLUME PART
2023
17
Implementation challenges Kovacic et al. 2020). There was diversity in the

characteristics of the exercise interventions, including
Three studies highlighted potential challenges
the type of exercises, how they were undertaken
regarding acceptability, usability and sustainability of
(individual or group interventions), who delivered
exercise programmes for people with intellectual
them (e.g. a health professional or trained disability
disability (Smulders et al. 2013a; Hale et al. 2016;
support workers), whether the exercises were
Hale et al. 2019). Hale et al. (2016) highlighted that,
individualised to the person’s physical performance
irrespective of an individual’s severity of intellectual
impairments or were generic (i.e. the same
disability, support staff were required to provide a
programme applied to all participants) and the
high level of assistance. Hale et al. (2019), in a
amount of exercise (e.g. duration or frequency of
subsequent study, further emphasised educating both
sessions, duration of the overall programme).
support workers and people with intellectual disability
Some of the studies focussing on exercise also
of the importance of regular exercise as key strategies
reported strategies to improve suitability of, and
to maximise participation. They also reiterated the
information access within, programmes for people
challenges for the success of both programmes
with intellectual disability. For example, Renfro
regarding the need for high levels of support and
et al. (2016a) described including provision of plain
commitment to prioritise exercises so they occurred
language or photo instructions. The instruction mode
safely and as prescribed (i.e. frequency). In a falls
(i.e. pictorial, video or written instructions) and
clinic evaluation by Smulders et al. (2013a), logistics
information accessibility (i.e. plain language, level of
(including scheduling meetings, ensuring support
literacy demand, colour contrast) provided in both
staff accompanied the participant) and the need for a
exercise-based and other falls prevention programmes
screening tool for identification of individuals who
is important not only for people with intellectual
would benefit from attending the clinic were the
disability but also for people who support them to
major challenges reported.
engage in such interventions (e.g. family or paid
supporters). It has been noted that people with
intellectual disability need high levels of support to
Discussion
participate in exercise-based falls prevention
Although the frequency of falls is higher for people programmes, and this is most often provided by
with intellectual disability than the general population disability support workers (Hale et al. 2016).
(Ho et al. 2019a; Pope et al. 2021), and there is Consideration of both written and digital – as well as
evidence of effective falls prevention interventions for health – literacy of people with intellectual disability
other at-risk populations (e.g. older adults) and their key supporters is therefore important.
(Montero-Odasso et al. 2022), this systematic review Disability support workers often receive little formal
has identified only seven falls prevention intervention preparation or training for their roles, and education
studies for people with intellectual disability, levels of these workers vary. The knowledge and
reporting 10 interventions. Although some promising ability of some support workers to implement or aid
results were reported, indicating some reduction in health-promoting activities like exercise for falls
falls in intervention samples, no firm conclusions management, and their own broader health literacy,
about the effectiveness of any of these interventions in may therefore be limited (Palesy and
reducing falls could be drawn. There is a pressing Jakimowicz 2020). Recent research has highlighted
need for large well-powered studies to further factors influencing health literacy for people with
evaluate falls prevention interventions, and evidence intellectual disability (Vetter et al. 2022) and
to inform practice to impact both health and identified approaches to improving health literacy for
participation outcomes, for people with intellectual this population (e.g. modification of communication
disability. strategies, utilising multi-modal methods), family and
Exercise was the most common falls prevention support workers (Latteck and Bruland 2020; Dam
intervention evaluated in the studies that met et al. 2022; Aller et al. 2023). These approaches need
inclusion criteria for the review (Crockett et al. 2015; to be considered in design of future fall prevention
Hale et al. 2016; Renfro et al. 2016a; Hale et al. 2019; interventions for people with intellectual disability.
18
The findings of the current review highlight the identified in the current review provided support for
importance of not only the participation in exercise by further exploration or trialling of exercise
people with intellectual disability but also the interventions to reduce falls in people with intellectual
additional planning, expertise and resourcing (e.g. disability. There may be value in greater focus on the
health professional input), required to set up such criteria for successful falls prevention exercise studies
engagement. While some free and evidence-informed in older people (Sherrington et al. 2017) for future
falls prevention and exercise resources exist in the exercise trials for people with intellectual disability.
public domain for older people (see. e.g. https://www. Falls risk assessment is often considered an
safeexerciseathome.org.au/), this review did not important first step in planning interventions for falls
identify any such resources targeted for people with in fall prevention guidelines (Australian Commission
intellectual disability and their key supporters. To on Safety and Quality in Health Care 2009a;
ensure the application of evidence-based falls Montero-Odasso et al. 2022). In comparison to the
interventions that are likely to have impact, sufficient large number of interventions that have been shown
resources are needed to purchase exercise programme to be successful for older people (Montero-Odasso
assessment and development, usually offered by a et al. 2022), this review identified only a small number
health professional. However, these resources may of intervention types specifically targeting people with
not be available to all people with intellectual intellectual disability (mainly exercise interventions).
disability. To identify intrinsic and extrinsic falls risk factors to
Given the limited evidence identified through this inform intervention decision making, falls risk
review, it is important to look more broadly at other assessment and environmental audit tools (to evaluate
falls prevention research (Montero-Odasso home environments for safety from a falls risk
et al. 2022). In an extensive systematic review of perspective) have been used for other populations
exercise interventions to reduce falls in older people (Russell et al. 2008; Nunan et al. 2018; Park 2018;
(mainly samples without cognitive impairment), key Romli et al. 2018). However, no interventions were
criteria associated with successful outcomes in identified in this review utilising falls risk or
reducing falls were that the exercise programme had a environmental falls risk assessment tools for people
moderate challenge to balance and that dosage was with intellectual disability. Further research is
high (positive outcomes most likely to be associated required to test, evaluate and document the feasibility
with three or more exercise sessions each week and of use of falls risk assessment and environmental audit
long-term participation in the exercise programme) tools with people with intellectual disability and their
(Sherrington et al. 2017). Of the evidence identified key supporters to inform targeted falls prevention
through the current review, only four of the studies interventions. Consideration of tools that are simple
with an exercise component clearly documented the and time efficient to administer will be important if
inclusion of balance exercises, and they were all use is to be replicated and scaled with community
limited to exercise once or twice a week, thus not dwelling people with intellectual disability.
meeting the recommended frequency from the The current review identified two non-exercise
general population research for effective falls intervention types (a falls clinic approach and stretch
prevention exercise programmes. fabric garments). It is important both from a falls risk
It is important to also note that not all exercise perspective and a quality of life perspective to
approaches are likely to reduce falls. For example, consider timely application of other interventions that
walking as an exercise approach is beneficial for many have been shown to be effective in older people (but
health benefits, but does not reduce the risk of falls in have not been evaluated to date in people with
older people (Voukelatos et al. 2015). Sherrington intellectual disability) (Renfro et al. 2016b). For
et al.’s (2017) review of exercise interventions to example, timely review of vision and interventions for
reduce falls in older people included a number of vision correction (including cataract surgery) have
studies with high falls risk samples (e.g. persons with a been shown to reduce falls in older people (Harwood
recent discharge from hospital, individuals with et al. 2005), as has changing from multifocal or
Parkinson’s disease or those with impaired cognition), bi-focal glasses for outdoors walking (Haran
with minimal adverse events reported. The research et al. 2010). Medication review to reduce level of
19
polypharmacy, or consider alternatives to high falls considered exercise or physical activity programmes,
risk medications, has been shown to be effective in environmental safety modifications, prescription of
reducing falls in older people (Pit et al. 2007; Hill and assistive mobility devices (gait aids) and education on
Wee 2012). Vitamin D and calcium supplementation safe mobility as most likely to reduce falls. The need
for people who are vitamin D deficient has also been for interventions to be acceptable to individuals and
shown to offer benefits (Dyer et al. 2019). Finally, their informal or paid support networks, in order to
home safety assessments (from a falls risk perspective) maximise likely adherence to interventions, was
and home safety modifications, often undertaken by highlighted. It was reported that a ‘one size fits all’
an occupational therapist and taking into account an solution, which did not consider personalisation of
individual’s capacity to manage within their the interventions to need, was less likely to be
environment have demonstrated falls reduction effective. Challenges were reported with sustained
impacts (Day et al. 2014). These are all intervention engagement with interventions such as exercise.
approaches to consider for investigation in future It is acknowledged that this review is limited by the
research with people with intellectual disability, which small number of studies identified, that samples were
have yet to be reported on based on the findings from generally small and underpowered to appropriately
this review. evaluate falls outcomes and that one of the identified
Interventions can also include a plan of action to studies included a mixed sample (not all participants
implement when a fall occurs. In hospital settings, a with intellectual disability). In addition, several
post-fall ‘huddle’ or team review of the falls different definitions of falls were utilised across the
circumstances and consequences and considerations studies in this review, and some studies did not report
for changes to care plan to minimise risk of a future the definition of falls utilised. If different definitions
fall has been shown to have some positive effect for are used, this would not affect within study results,
older in-patients (Jones et al. 2019). Best practice falls but may limit comparisons of falls-related outcomes
prevention guidelines for older people recommend a between studies. If no falls definition was used, there
review by a doctor or other health professional when a is likely to be moderate variability in what is and is not
fall occurs, to determine if there are any new or reported as a fall, thereby affecting study outcomes. It
previously untreated falls risk factors to address is important for a standard definition of fall to be
(Australian Commission on Safety and Quality in utilised in fall prevention studies, which improves
Health Care 2009a; Montero-Odasso et al. 2022). For accuracy of fall reporting (Lamb et al. 2005).
people with intellectual disability living at home with While some studies included in this review reported
family, this may involve a review by the general improved outcomes on risk factors for falls in samples
practitioner or other health professional; for those of people with intellectual disability (e.g. balance or
living in group housing, which have organisational mobility performance), the focus in this review was
infrastructure, this may involve a post-fall review the outcome of change in falls measures. Changes in
process, with relevant staff and management. any falls risk factors reported in included studies were
However, there is no research to date evaluating the not evaluated in this review, as change in one or more
effectiveness of post fall interventions for people with risk factors is not necessarily associated with reduced
intellectual disability, aiming to reduce future falls falls (see Luukinen and colleagues, a large
risk. randomised falls prevention trial of older adults)
Preventing falls in high falls risk groups including (Luukinen et al. 2007).
people with intellectual disability is complex and
challenging and, unless proactively managed, may
Conclusion
lead to reduced participation and increased use of
restrictive practices (Chandler 2021). A qualitative This review identified seven studies evaluating
study exploring the perceptions, experiences and interventions to reduce falls risk in
opinions of eight therapists (four occupational community-dwelling adults with intellectual
therapists and four physiotherapists) in trying to disability. Exercise was the most researched
reduce and prevent falls for people with intellectual intervention and several interventions were reported
disability (Pal et al. 2013) reported that the therapists to reduce falls outcomes. These results, however,
20
need to be interpreted with caution because of the literacy trainings for caregivers. Intellectual and
Developmental Disabilities 61, 49–64.
small number of studies and sample sizes, differing
intervention approaches (even within a single Australian Commission on Safety and Quality in Health
Care (2009a) Preventing falls and harm from falls in older
intervention type such as exercise) and varied people - best practice guidelines for Australian community
approaches to outcome (falls) reporting. Given the care. Available at: https://www.safetyandquality.gov.au/
health, participation, quality of life and care costs of sites/default/files/migrated/Guidelines-COMM.pdf
falls for people with intellectual disability, as well as Australian Commission on Safety and Quality in Health
the increased frequency of falls in this population, Care (2009b) Preventing falls and harm from falls in older
there is a need for adequately powered high-quality people - best practice guidelines for Australian Residential
Care Facilities. Available at: https://www.safetyandquality.
studies building on this small base of research. gov.au/publications-and-resources/resource-library/
Future large-scale research should focus on preventing-falls-and-harm-falls-older-people-best-
exploring interventions that have been shown to be practice-guidelines-residential-aged-care-facilities
effective in other populations such as older people, Australian Institute of Health and Welfare (AIHW) (2020)
although some adaptations may be required to Australia’s health 2020: in brief. Australia’s health series
ensure suitability, acceptability and safety for people no. 17 Cat. no. AUS 232. Canberra: AIHW.
with intellectual disability. Such research will inform Axmon A., Ahlström G. & Sandberg M. (2019) Falls
resulting in health care among older people with
strategies to reduce falls risk in adults with intellectual disability in comparison with the general
intellectual disability and assist to translate this population. Journal of Intellectual Disability Research 63,
evidence base into practice across the intellectual 193–204.
disability sector. Bainbridge D., Hale L., Renfro M. & Maring J. (2017)
Addressing the issue of fall risk for all adutls with
intellectual developmental disabilities. Part III: creating
Acknowledgements solutions with community fall prevention and inclusive
recreation programs for adults with intellectual
Nil.
developmental disabilities. GeriNotes 24, 16–20.
Open access publishing facilitated by Monash
Burton E., Cavalheri V., Adams R., Browne C. O., Bovery-
University, as part of the Wiley - Monash University Spencer P., Fenton A. M. et al. (2015) Effectiveness of
agreement via the Council of Australian University exercise programs to reduce falls in older people with
Librarians. dementia living in the community: a systematic review and
meta-analysis. Clinical Interventions in Aging 10, 421–34.
Source of funding Cardiovascular Risk Assessment Work Group (2013)
Assessing cardiovascular risk systematic evidence review
Funding to support this review being conducted was US Department of Health and Human Services - National
provided by Scope. Institutes of Health; National Heart Lung and Blood
Institute. Available at: https://www.nhlbi.nih.gov/sites/
default/files/media/docs/risk-assessment.pdf
Conflict of interest Chandler K. (2021) The regulation of restrictive practices on
The authors declare no conflicts of interest related to people with intellectual impairment: the challenges and
opportunities posed by a rights based approach. In:
this manuscript.
Restrictive Practices in Health Care and Disability Settings:
Legal, Policy and Practical Responses (eds B. McSherry & Y.
Data availability statement Maker), pp. 68–90. Trans. Routledge, New York, NY.
Data sharing not applicable to this article as no Cox C. R., Clemson L., Stancliffe R. J., Durvasula S. &
Sherrington C. (2010) Incidence of and risk factors for
datasets were generated or analysed during the
falls among adults with an intellectual disability. Journal of
current study. Intellectual Disability Research 54, 1045–57.
Crockett J., Finlayson J., Skelton D. A. & Miller G. (2015)
Promoting exercise as part of a physiotherapy-led falls
pathway service for adults with intellectual disabilities: a
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Accepted 16 June 2023
Health 19, 16052.
Voukelatos A., Merom D., Sherrington C., Rissel C.,
Cumming R. G. & Lord S. R. (2015) The impact of a

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Journal of Intellectual Disability Research doi: 10.1111/jir.13066

Interventions to reduce falls in community-dwelling adults

Abstract tutes of Health study quality assessment tools.

Table 1 Search strategy for CINAHL

EBSCOhost CINAHL Complete (1951–2022) search 6 June 2023

Table 2 Search strategy for Ovid MEDLINE and PsycINFO

APA PsycInfo (1806 to May Week 5 2023) search 6 June 2023

1. exp. Intellectual Disability/

Table 3 Search strategy for Cochrane Library

Cochrane Library (1996–2023) search 6 June 2023

1. MeSH descriptor: [Intellectual Disability] explode all trees

Figure 1. PRISMA ﬂow diagram for falls prevention intervention studies.

Table 4 Characteristics of included intervention studies (N = 7) to reduce falls risk

Sample: Diagnosis and age

Sample: Diagnosis and age

was ‘coming to the ﬂoor

Reference Country Risk factors for Intervention Intervention type

(n = 1; 0 falls pre or during);

Reference Country Risk factors for Intervention Intervention type

(n = 1; 1 fall pre and

Reference Country Risk factors for Intervention Intervention type

regular Special Olympic

HSD, honestly signiﬁcant difference; RCT, randomised controlled trial.

Criterion Kovacic et al. 2020

Crockett Hale Renfro Smulders

1. Was the study question or objective clearly stated? √ √ X √

Criterion Finlayson et al. 2018 Hale et al. 2019

1. Was the study question or objective clearly stated? √ √

Table 8 Characteristics of exercise interventions in included studies

Study Intervention outline Warm up/Cool down Balance Strength Aerobic

Setting Programme type

Other Individual Group Individual-

Crockett 2015 √ √ Dependent onDependent onDependent on

and ongoing support

Setting Programme type

Other Individual Group Individual-

Hale 2019 √ √ Daily As part of usual

Implementation challenges Kovacic et al. 2020). There was diversity in the

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