The research team considered many EBFP programs for validation in this population. The best program would have the highest tier evidence with well-documented outcomes to decrease fall-related risk, fall rates, and/or fall-related injuries (23). The best program would also have the capability to be widely disseminated in many geographic areas of the U.S. In addition, easily accessible training modules were necessary to close the gap between knowledge and dissemination (24). The selected EBFP would be easily adaptable to wide variations in physical and cognitive functioning and include exercise for lower extremity strength and standing balance, both known to improve fall risk for the population (25). We placed a heavier emphasis on physical activity than on education because educational components might present difficulties to translation and teaching for this population. The selected EBFP needed to be easily translated into an effective home exercise program to achieve 50 h/6 months or 2 h/week at a minimum, of progressively challenging balance exercise to improve balance (26). In addition, the selected EBFP would offer flexibility to individualize the exercises based upon the participants’ current balance and strength.

Following review of over 25 EBFP programs, the principal investigators’ (PIs) final decision was to utilize the Otago Exercise Program (OEP). OEP is a menu-driven individualized program delivered one-to-one by a physical therapist (PT) to one patient in the home setting with a method for independent progression of the exercises to increase challenge and outcomes (27). The advantages of OEP include, but are not limited, to the following: it is highly individualized; it has a focus on physical activity; and it includes limited educational material and/or didactic learning. PTs can be trained online as OEP leaders at a nominal cost, and training is designed for ongoing independent program use and progression. The disadvantage in using OEP for this project is that OEP is usually offered one-to-one using billable PT services, which limits access to service and dissemination of OEP to this marginalized population. OEP leader training is focused on PTs and PTAs only in the U.S. (28); however, nurses in New Zealand and Australia offered OEP successfully.

The research team felt that OEP was the best program to provide with the least amount of modification to meet the diverse needs of the IDD population. We modified the program for this population, offering group programs with individualized programing. OEP allows for individualized intervention based upon variations in physical functioning and independence. Given the varied functional levels of the adults with IDD, OEP was a natural selection. These group programs improved social interaction while serving more people with less staff and limited travel time.

The PIs looked for a community partner who provided services to a group of adults with IDD within an accessible, centrally located building that provided ease of access for the potential participants, participating students, and PIs. The facility would need to provide an exercise room that was of adequate size, safety, and was available at various times convenient for use (including an administration willing to participate in this weekly project over a 10-week period). Many providers and fitness centers were considered and approached. Opportunities Resources, Inc. (ORI) met all of the project’s needs and was a willing partner (29). ORI employs over 350 trained professionals who provide employment, living skills, and support, plus a broad array of educational, recreational, and companion services to nearly 700 adults with disabilities, as well as case management to over 1,500 persons with IDD, mental illness, physical disabilities, and/or TBI. ORI was able to provide their fitness room to provide classes and a meeting room for pre- and posttesting.

This research project was approved by the IRB of the University of Montana (IRB # 235-15) prior to any participant recruitment. Participants to be included were individuals with IDD aged 18 years or older who lived at home or in supported community environments. The investigators contacted ORI, who was interested in engaging in this project and arranged a meeting with their supported living staff. The investigators explained the OEP, the project, and the inclusion/exclusion criteria. Staff members were provided the opportunity to become OEP certified via the online training program. https://www.med.unc.edu/aging/cgec/exercise-program.

Participants who met inclusion criteria and were interested in the program were requested to sign a Participant Information and Consent that had been approved by the IRB. Trained research staff or supervised students explained the project and the consent form to each participant. Participants who consented were also asked to sign an authorization to use and disclose medical information for research purposes so we could access their medical histories. If the participant was not their own guardian, the legally designated representative was engaged to sign both forms. Once these forms were signed, participants were given an identifying number for confidentiality prior to starting the program. The project had 18 initial participants. One participant completed pretesting, then dropped from the program, one completed pre-post testing, but not the program, and one participant did not complete post-testing. Thus, we had 15 active participants in the program. Participants (male = 5; female = 10) were between the ages of 27 and 70 years. The majority of the participants had a diagnosis of IDD. One participant had mental illness, and one participant had a TBI. Six participants (one with TBI, one with mental illness, and four with IDD) also had physical disabilities including hemiparesis, arthritis, and cerebral palsy.

Of the 15 participants, 46.7% were age 50 years and older. Approximately, 67% of participants were females and 93.3% reported one or more chronic condition diagnosis (see Table 1).

On average from baseline to follow-up, participants increased from 8.60 to 10.27 rises in the 30-Second Chair Stand Test. The trend of this change was approaching significance (t = −1.60, P = 0.132). On average from baseline to follow-up, participants increased from 114.43 to 194.62 steps in the 2-Minute Walk Test. The trend of this change was significant (t = −3.80, P = 0.002). On average from baseline to follow-up, participants advanced their ability to perform greater on the 4-Stage Balance Test (from 1.87 to 2.20 out of 4 stages). The trend of this change was approaching significance (t = −2.09, P = 0.055) (see Table 2).

When examining the proportion of participants who improved their functional assessment scores, 53.3% of participants improved on the 30-Second Chair Stand Test. The change in this proportion of participants was approaching significance (z = −1.42, P = 0.156). Approximately 67% of participants improved on the 2-Minute Walk Test. The change in this proportion of participants was significant (z = −2.54, P = 0.011). Approximately 27% of participants improved on the 4-Stage Balance Test (the remaining 73.3% remained the same from baseline to follow-up). The change in this proportion of participants was approaching significance (z = −1.89, P = 0.059) (see Table 3).

Using repeated measures ANOVA, improvements in functional assessments were examined over time controlling for age group (see Figure 1). Despite general gains for the 30-Second Chair Stand Test, rates of improvement were more dramatic for participants in the younger age group (f = 2.31, P = 0.152). Despite general gains for the 2-Minute Walk Test, rates of improvement were more dramatic for participants in the younger age group (f = 14.05, P = 0.002). Despite general gains for the 4-Stage Balance Test, rates of improvement were more dramatic for participants in the younger age group (f = 0.24, P = 0.063).

Using repeated measures ANOVA, improvements in functional assessments were examined over time controlling for sex (see Figure 2). Despite general gains for the 2-Minute Walk Test, rates of improvement were more dramatic for male participants (f = 13.19, P = 0.003). Despite general gains for the 4-Stage Balance Test, rates of improvement were more dramatic for female participants (f = 3.00, P = 0.107).

This project presented several strong implications for practice. First, development of partners is vital to program success. A dedicated partner who can facilitate recruitment of participants and perhaps provide exercise space is the key. Their clients will be more interested and amenable to participation if they feel the organization is supportive, and if they feel comfortable in familiar space that is convenient to their daily lives.

Second, although supervision of a PT is essential to OEP activity progression during the intervention and training of class leaders, other professionals may be well suited to lead the group classes (e.g., PT assistant, medical assistant, and nurse) (62). These allied health professionals may benefit from the experience of hosting OEP with IDD participants, and being exposed to use of progressive balance exercises. Such experience can teach professionals the importance of balance for various populations and demonstrate how best to improve balance and educate population groups who have cognitive impairments with concomitant physical disabilities.

The experience of this project highlighted the possibility of the effective use of peer leaders in a specific population (63). As the IDD participants became more engaged with the leaders and their fellow participants, several stepped forward to either count or lead exercises during each class, which was met with the enthusiasm of their peers.

Third, because of the unique needs of adults with IDD, this pilot study reinforced the notion of starting to work on balance and falls risk early. We noted greater improvements among our younger participants with IDD (<50 years); therefore, implementing the intervention at an earlier age might reduce fall risk, delay the onset of falls, and reduce the overall number of falls.

Finally, the key to maintaining low fall risk is the use of ongoing balance exercise that is progressively more challenging. Hence, the issue of program sustainability is vital. Developing infrastructure including staff support can maintain the programing and provide internal sustainability for clients. Program internalization can further improve client safety by lowering fall risk and reducing falls in their daily and living environments. Online training in OEP can be supplemented by additional tailored training, via class, telehealth, or webinar, to address the specific issues of clients with intellectual disabilities. Finally, providing ongoing mentorship and consultation by PT professionals also creates a resource for staff.

Major strengths of this project were its positive outcomes and potential for replicability. However, this pilot project had several weaknesses, which present implications for future research. First, the project had a small number of participants, so it may have been underpowered to detect all significant changes among participants. We recommend that future studies replicate the program with larger numbers of participants and with more diversity (e.g., age, IDD diagnoses, and comorbidities) to validate findings of this community case study and advance the literature/knowledge in this area.

Second, the course of this program was quite short (7 weeks). Replication of the program over a longer period would assist with defining a minimum program length capable of yielding significant improvements among participants. Further, collecting follow-up data after a longer period would enable researchers to determine if initial intervention effects are maintained over time and whether more tangible outcomes can be seen (e.g., number of falls, fall injury rates, and medical costs).

Third, the addition of other process and outcome measures has the potential to increase what is known about broad spectrum fall prevention programs for adults with IDD. Currently, there is little research about the built environment of IDD participants’ home and work, which has potential to increase or suppress falls risk among this population. Research indicates that safety and “fit” of the built environment are factors that can reduce falls (64). Beyond environmental fit, exploration of the support needed for maintenance of maximum independence of this population in their environment is indicated.