Abstract:

Objective:

To describe interventions designed to promote physical activity for adults with intellectual disabilities and the effects on overall physical activity levels and on health outcomes.

Materials and methods:

A systematic review of eight databases until January 31, 2015 identified 383 citations. The inclusion criteria were: a) the study sample consisted of adults with intellectual disabilities, b) the study implemented an intervention to initiate, increase, or maintain physical activity, and c) quantitative or qualitative data were used to report the effectiveness of the intervention. Six articles from the 383 citations met this criterion.

Results:

Three studies resulted in significant increases in physical activity behaviour; however well-controlled trials designed to improve weight status by increasing physical activity did not produce significant effects.

Conclusion:

Overall, the results indicate that interventions to increase physical activity should simultaneously target the individual with intellectual disability as well as their proximal environment over a sustained period of time.

Keywords:
physical activity; intellectual disability; review; preventive health program; health promotion

Resumen:

Objetivo:

Describir las intervenciones diseñadas para promover la actividad física para adultos con discapacidad intelectual y los efectos en los niveles de actividad física en general y en los resultados de salud.

Material y métodos:

Una revisión sistemática de ocho bases de datos hasta el 31 de enero de 2015 identificó 383 citas. Los criterios de inclusión fueron: a) los participantes del estudio fueron adultos con discapacidad intelectual; b) el estudio implementó una intervención para iniciar, aumentar o mantener la actividad física; c) se usaron datos cuantitativos o cualitativos para informar la efectividad de la intervención. Seis artículos de 383 cumplieron con los criterios.

Resultados:

Tres estudios resultaron en aumentos significativos en conductas de actividad física; sin embargo, los ensayos controlados diseñados para mejorar el peso corporal al aumentar la actividad física no produjeron efectos significativos.

Conclusión:

En general, los resultados indican que las intervenciones para aumentar la actividad física deben dirigirse simultáneamente al individuo con discapacidad intelectual, así como su entorno próximo durante un periodo de tiempo sostenido.

Palabras clave:
actividad física; discapacidad intelectual; revisión; servicios preventivos de salud; promoción de la salud

Introduction

There is substantial evidence to support that regular participation in physical activity promotes health in adults. Specifically, physical activity reduces the risk for coronary heart disease, stroke, hypertension, diabetes, some cancers, and metabolic syndrome; improves bone mineral density; increases cardiorespiratory and muscular fitness; and is important for achieving a healthy weight.¹1. Warburton DE, Nicol C, Bredin SS. Health benefits of physical activity: the evidence. CMAJ 2006;174:801-809. https://doi.org/10.1503/cmaj.051351
https://doi.org/10.1503/cmaj.051351... ^,22. World Health Organization. Global recommendations on physical activity for health. Geneva: WHO, 2010. Available at: http://www.who.int/dietphysicalactivity/global-PA-recs-2010.pdf
http://www.who.int/dietphysicalactivity/... The World Health Organization’s (WHO) Global Recommendations on Physical Activity for Health ²2. World Health Organization. Global recommendations on physical activity for health. Geneva: WHO, 2010. Available at: http://www.who.int/dietphysicalactivity/global-PA-recs-2010.pdf
http://www.who.int/dietphysicalactivity/... state that adults aged 18-64 years should engage in 150 minutes of moderate intensity aerobic physical activity or 75 minutes of vigorous intensity activity each week. Bone- and muscle-strengthening activities should also be done at least twice weekly. Despite the well-established association between physical activity and health, research consistently demonstrates that levels of inactivity are rising in many countries. Physical inactivity is the fourth leading risk factor for global mortality and is a significant public health concern worldwide.³3. World Health Organization. Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva: WHO , 2009.

Adults with intellectual disabilities (ID) are no exception to the rising trends of physical inactivity. The activity habits of adults with intellectual disabilities have been reasonably well-studied and there is evidence to support that this group is insufficiently active to achieve health benefits and may be even less active than the general population. In 2006, we published a review paper ⁴4. Temple VA, Frey GC, Stanish HI. Physical activity of adults with mental retardation. Review and research needs. Am J Health Promot 2006;21:2-12. https://doi.org/10.4278/0890-1171-21.1.2
https://doi.org/10.4278/0890-1171-21.1.2... that aimed to characterize the physical activity levels of adults with intellectual disabilities in an effort to inform future research. At that time, the published findings supported that adults with intellectual disabilities were predominantly sedentary and less than one-third met the physical activity guidelines for health in the country where the study was conducted. Comparisons of activity levels to the general population were weak and we reported that measurement limitations, in particular lack of valid and reliable instruments to quantify physical activity, reduced the strength of the evidence. Temple followed up with a review of studies that used objective monitors, specifically pedometers and accelerometers, to measure physical activity of individuals with intellectual disabilities in 2010.⁵5. Temple VA. Objectively measured physical activity of people with intellectual disability: Participation and contextual influences. Physical Therapy Reviews 2010;15(3):183-196. https://doi.org/10.1179/174328810X12814016178836
https://doi.org/10.1179/174328810X128140... Once again, evidence supported that a small proportion of adults with intellectual disabilities met the guidelines for physical activity and health, but results were variable and how this group compares to the general population remained unclear. Temple reported that studies using objective monitors were small scale and included mostly individuals with intellectual disabilities who had more mild limitations. Additional research has been conducted using accelerometers to objectively measure physical activity in adults with intellectual disabilities since that review was published, and the strength of results have increased concomitantly.

These recent international studies suggest that the proportion of adults with intellectual disabilities meeting national guidelines for physical activity may be lower than suggested by Temple and colleagues in 2006. Researchers in Norway examined accelerometer-determined physical activity and sedentary behaviour in a large sample of adults with Down syndrome, Williams syndrome, and Prader-Willi syndrome; all genetic conditions associated with intellectual disabilities.⁶6. Nordstrom M, Hansen BH, Paus B, Kolset SO. Accelerometer-determined physical activity and walking capacity in persons with Down syndrome, Williams syndrome and Prader-Willi syndrome. Res Dev Disabil 2013;34(12):4395. https://doi.org/10.1016/j.ridd.2013.09.021
https://doi.org/10.1016/j.ridd.2013.09.0... These authors found that individuals spent 63% of their day in sedentary activity and 3% in moderate to vigorous intensity physical activity. Although on average individuals accrued 27 minutes per day of moderate to vigorous physical activity, overall only 12% of the sample met the Nordic recommendations of physical activity. Similarly, Barnes, Howie, McDermott, and Mann ⁷7. Barnes TL, Howie EK, McDermott S, Mann JR. Physical activity in a large sample of adults with intellectual disabilities. J Phys Act Health 2013;10(7):1048-1056. https://doi.org/10.1123/jpah.10.7.1048
https://doi.org/10.1123/jpah.10.7.1048... found that adults with intellectual disabilities accumulated an average of 108.6 minutes per week of moderate to vigorous intensity physical activity, but only 23.7% of their sample of 131 adults with intellectual disabilities met the United States national physical activity recommendations of 150 minutes of moderate-to-vigorous physical activity per week. In Scotland, Matthews and colleagues ⁸8. Matthews L, Hankey C, Penpraze V, et al. Agreement of accelerometer and a physical activity questionnaire in adults with intellectual disabilities. Prev Med 2011;52(5):361-364. https://doi.org/10.1016/j.ypmed.2011.02.001
https://doi.org/10.1016/j.ypmed.2011.02.... found that adults with intellectual disabilities accumulated an average of 12.8 minutes per day of moderate intensity physical activity as measured by accelerometer which is well below the recommended amount of physical activity for health.⁸ Further, adults with intellectual disabilities were engaged in sedentary behaviour for an average of 10.2 hours per day. A comparison of accelerometer-measured physical activity and sedentary behaviour of older adults with intellectual disabilities to two groups; younger adults with intellectual disabilities and older adults without intellectual disabilities was conducted by Dixon-Ibarra and associates.⁹9. Dixon-Ibarra A, Lee M, Dugala A. Physical activity and sedentary behavior in older adults with intellectual disabilities: A comparative study. Adapt Phys Act Quart 2013;30(1):1-19. https://doi.org/10.1123/apaq.30.1.1
https://doi.org/10.1123/apaq.30.1.1... All three groups spent 60 to 65% of their day (i.e., the time that they wore the accelerometer) in sedentary activity and about four hours per day engaged in light physical activity. Although there were no significant differences among groups, older adults with intellectual disabilities and younger adults with intellectual disabilities spent an average of 10.2 and 21.0 minutes per day in moderate-to-vigorous physical activity, respectively. In this study, only 6% of older adults with intellectual disabilities and 13% of younger adults with intellectual disabilities met the physical activity standards in the United States. These accelerometer studies provide evidence to support that adults with ID generally exhibit low levels of physical activity.

There have been efforts to understand the factors that influence physical activity among adults with intellectual disabilities in order to inform intervention strategies. Given the intellectual, behavioural, social, and motor impairments that are often associated with an intellectual disability, the factors that influence physical activity participation for these adults may differ from the general population. A particular focus has been the examination of barriers to physical activity faced by adults with intellectual disabilities. For example, adults with Down syndrome reported that no transportation, high cost, and no one to participate with were the most prevalent access barriers to exercise.¹⁰10. Heller T, Hsieh K, Rimmer J. Barriers and supports for exercise participation among adults with Down syndrome. J Gerontol Soc Work 2002;38:161-177. https://doi.org/10.1300/J083v38n01_03
https://doi.org/10.1300/J083v38n01_03... Further, lack of energy, exercise being too difficult, and exercise being boring were reported as prevalent cognitive-emotional barriers. Weather, cost, health, and feeling lazy were the most commonly reported barriers to physical activity by adults with intellectual disabilities in a study by Temple.¹¹11. Temple VA. Barriers, enjoyment, and preference for physical activity among adults with intellectual disability. Int J Rehabil Res 2007;30:281-287. https://doi.org/10.1097/MRR.0b013e3282f144fb
https://doi.org/10.1097/MRR.0b013e3282f1... A review paper of barriers to physical activity among adults with ID further supported that primary barriers were transportation, financial limitations, and lack of awareness of program options.¹²12. Bodde AE, Seo D. A review of social and environmental barriers to physical activity for adults with intellectual disabilities. Disabil Health J 2009;2(2):57-66. https://doi.org/10.1016/j.dhjo.2008.11.004
https://doi.org/10.1016/j.dhjo.2008.11.0... Interviews were conducted with a sample of adults with intellectual disabilities in an effort to determine the factors that predict low activity.¹³13. Finlayson J, Jackson A, Cooper S, et al. Understanding predictors of low physical activity in adults with intellectual disabilities. J Appl Res Intellect Dis 2009;22(3):236-247. https://doi.org/10.1111/j.1468-3148.2008.00433.x
https://doi.org/10.1111/j.1468-3148.2008... Older age, immobility, having epilepsy, having no daytime opportunities, and living in congregate care were examples of factors that contributed to the activity levels of this group. A second qualitative study examined the preferences, facilitators, and barriers to physical activity experienced by older adults with intellectual disabilities.¹⁴14. Schijndel-Speet M, Evenhuis HM, Wijck R, Echteld MA. Implementation of a group-based physical activity programme for ageing adults with ID: a process evaluation. J Eval Clin Pract 2014;20(4):401-407. https://doi.org/10.1111/jep.12145
https://doi.org/10.1111/jep.12145... The most commonly reported facilitators of physical activity were enjoyment of the activity, support from staff/family to participate, and social contact/friendship with others. Commonly reported barriers included dislike of an activity, physical discomfort, lack of support, and activity being too difficult. From these examples of studies endeavouring to explain the low physical activity levels of adults with intellectual disabilities, it is evident that the process of planning and implementing physical activity interventions for adults with intellectual disabilities may be different than for the general adult population.

The low levels of physical activity reported among adults with intellectual disabilities coupled with their unique functional limitations and additional barriers they may face, have created a pressing need to develop and test interventions. An evaluation of the work is fundamental to identifying effective strategies for increasing physical activity and health outcomes among adults with intellectual disabilities. As such, the aim of this review is to describe what characterizes interventions designed to promote physical activity for adults with intellectual disabilities; and the effects of the interventions on overall physical activity levels and on health outcomes.

Materials and methods

Literature search strategy

A systematic search for interventions to promote participation in physical activity for adults with intellectual disabilities was performed using the following literature databases: Academic Search Complete, CINAHL, Cochrane Central Register of Controlled Trials, Health Source: Nursing/Academic Edition, MEDLINE, PsycARTICLES, PsycINFO, and SPORTDiscus until January 31, 2015. Terms for the outcome of interest (physical activity or pedometer or accelerometer or global positioning system) were combined with population search terms (intellectual disability or mental retardation or learning disability or developmental disability) and (adult) as well as with the study design characteristics (intervention or program). Reference lists of relevant publications were also scanned for eligible articles.

Study selection and data extraction

The following inclusion criteria were defined before the systematic search was performed: a) the study sample consisted of adults with intellectual disabilities, b) the study implemented an intervention to initiate, increase, or maintain physical activity, and c) quantitative or qualitative data were used to report the effectiveness of the intervention. We opted to include all study designs, not only randomized controlled trials, to provide a more comprehensive overview of the interventions being conducted in the field. Unpublished work, review papers, meta-analyses, study protocol articles, and studies that focused on care-providers’ efficacy to implement interventions were excluded. When uncertainty about article inclusion occurred the authors came to agreement through discussion.

The systematic search identified 383 citations. Consistent with the Cochrane Handbook for Systematic Reviews of Interventions,¹⁵15. Green S, Higgins JPT. Cochrane handbook for systematic reviews of interventions. Oxford, England: Cochrane Collaboration, 2008. the identified citations were initially screened to remove obviously irrelevant reports. Eighty-three articles were retrieved following this initial screening. The abstracts were reviewed and 77 articles were excluded for the following reasons: 42 did not focus on adults with intellectual disabilities, physical activity was not a measured outcome for 19 articles, 10 studies did involve the collection of original data, three were duplicates within the databases searched, two studies did not have an experimental design, and one study focused on adolescents. Ultimately, six papers were reviewed. Characteristics of participants, study aim and design, intervention description, outcome measures, methods of analyses, and findings in terms of effect on physical activity and other health outcomes were extracted.

Results and discussion

Table I illustrates that interventions focusing on increasing physical activity and documenting these changes among adults with intellectual disability is a fairly recent phenomenon. To date, very few studies have been undertaken and these studies have generally been small in scale. Encouragingly, researchers have (on the whole) used validated approaches to document physical activity. Four studies used motion sensors (accelerometers and pedometers), which are the preferred approach to measuring physical activity among individuals with intellectual disability,⁴4. Temple VA, Frey GC, Stanish HI. Physical activity of adults with mental retardation. Review and research needs. Am J Health Promot 2006;21:2-12. https://doi.org/10.4278/0890-1171-21.1.2
https://doi.org/10.4278/0890-1171-21.1.2... since there is only a modicum of evidence that conducting surveys with persons with intellectual disabilities supported by caregivers ¹⁶16. Johnson M, Yun J, McCubbin JA. Validity evidence for self-report with assistance to measure physical activity behavior in adults with intellectual disabilities. Am J Intellect Dev Disabil 2014;52(4):273-281. https://doi.org/10.1352/1934-9556-52.4.273
https://doi.org/10.1352/1934-9556-52.4.2... or with proxy respondents ¹⁷17. Temple VA, Walkley JW. Physical activity of adults with intellectual disability. Am J Intellect Dev Disabil 2003;28:323-334. https://doi.org/10.1080/13668250310001616380
https://doi.org/10.1080/1366825031000161... can provide accurate physical activity data. One of the studies included in this review used systematic observation of physical activity behaviours, ¹⁸18. Stanish HI, McCubbin JA, Draheim CC, van der Mars H. Participation of adults with mental retardation in a video- and leader-directed aerobic dance program. Adapt Phys Act Quart 2001;18:142-155. https://doi.org/10.1123/apaq.18.2.142
https://doi.org/10.1123/apaq.18.2.142... which is certainly an adequate approach in terms of validity and reliability,¹⁹19. McKenzie TL, Sallis J, Nader PR. SOFIT: System for observing fitness instruction time. J Teach Phys Educ 1991;11:195-205. https://doi.org/10.1123/jtpe.11.2.195
https://doi.org/10.1123/jtpe.11.2.195... however it is very labour intensive and less suitable for larger studies.

The targets of the interventions were generally adults with intellectual disabilities who were younger than 66 years of age. Only one intervention collectively targeted individuals with intellectual disabilities and their caregivers; and older adults (> 75 years of age) were the participants in one study (table I). The large age range within the other five studies was notable, and it was not evident from the intervention descriptions if activities were tailored to demographic sub-groups i.e. young adults versus those in middle or late adulthood (table II and the more expansive supplementary material online ²⁰20. Temple V, Frey G, Stanish H. Table: Description of the intervention studies included in the review for Salud Pública de México. Repositorio Dspace/Manakin. Canadá: University of Victoria. Available at: http://hdl.handle.net/1828/8142
http://hdl.handle.net/1828/8142... ). There has been concern expressed that the needs of young adults with intellectual disabilities are not adequately served by generic programming for individuals with intellectual disability.²¹21. Bhaumik S, Watson J, Barrett M, Raju B, Burton T, Forte J. Transition for teenagers with intellectual disability: Carers’ perspectives. J Policy Pract Intellect Disabil 2011;8(1):53-61. https://doi.org/10.1111/j.1741-1130.2011.00286.x
https://doi.org/10.1111/j.1741-1130.2011... ^,2222. Adams L, Beadle-Brown J, Mansell J. Individual planning: An exploration of the link between quality of plan and quality of life. Br J Learn Disabil 2006;34(2):68-76. https://doi.org/10.1111/j.1468-3156.2005.00356.x
https://doi.org/10.1111/j.1468-3156.2005... For example, 11% of participants in the Bazzano and colleagues ²³23. Bazzano AT, Zeldin AS, Diab IRS, Garro NM, Allevato NA, Lehrer D. The Healthy Lifestyle Change Program: A pilot of a community-based health promotion intervention for adults with developmental disabilities. Am J Prev Med 2009;37(6):S201-S208. https://doi.org/10.1016/j.amepre.2009.08.005
https://doi.org/10.1016/j.amepre.2009.08... study were 18-29 years and 25% were older than 50 years of age. However, it appeared that the same exercise videos were used by the peer mentors and it was unclear whether there was any individualization when participants used community facilities as part of the education sessions.

Table I illustrates that the settings for the interventions were largely service agencies. In the case of Bazzano and colleagues ²³23. Bazzano AT, Zeldin AS, Diab IRS, Garro NM, Allevato NA, Lehrer D. The Healthy Lifestyle Change Program: A pilot of a community-based health promotion intervention for adults with developmental disabilities. Am J Prev Med 2009;37(6):S201-S208. https://doi.org/10.1016/j.amepre.2009.08.005
https://doi.org/10.1016/j.amepre.2009.08... the peer mentors (adults with developmental disabilities hired as peer mentors) advised that the program be delivered at the community organization serving the needs of individuals with developmental disabilities because the venue was familiar, accessible, and centrally located with a bus service nearby. Although delivered at service agencies, the general intention of the Bazzano and colleagues,²³23. Bazzano AT, Zeldin AS, Diab IRS, Garro NM, Allevato NA, Lehrer D. The Healthy Lifestyle Change Program: A pilot of a community-based health promotion intervention for adults with developmental disabilities. Am J Prev Med 2009;37(6):S201-S208. https://doi.org/10.1016/j.amepre.2009.08.005
https://doi.org/10.1016/j.amepre.2009.08... Bodde and colleagues,²⁴24. Bodde AE, Seo D, Frey GC, Lohrmann DK, Van Puymbroeck M. Developing a physical activity education curriculum for adults with intellectual disabilities. Health Promot Pract 2012;13(1):116-123. https://doi.org/10.1177/1524839910381698
https://doi.org/10.1177/1524839910381698... and McDermott and colleagues ²⁵25. McDermott S, Whitner W, Thomas-Koger M, et al. An efficacy trial of ‘Steps to Your Health’, a health promotion programme for adults with intellectual disability. Health Educ J 2012;71(3):278-290. https://doi.org/10.1177/0017896912441240
https://doi.org/10.1177/0017896912441240... studies was to enhance general participation in physical activity. Contrastingly, the worksite intervention by Stanish and colleagues ¹⁸18. Stanish HI, McCubbin JA, Draheim CC, van der Mars H. Participation of adults with mental retardation in a video- and leader-directed aerobic dance program. Adapt Phys Act Quart 2001;18:142-155. https://doi.org/10.1123/apaq.18.2.142
https://doi.org/10.1123/apaq.18.2.142... was designed to increase physical activity while at work. The only study delivered in people’s homes was the Swedish study by Bergström and others.²⁶26. Bergström H, Hagströmer M, Hagberg J, Schafer-Elinder L. A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Res Dev Disabil 2013;34(11):3847-3857. https://doi.org/10.1016/j.ridd.2013.07.019
https://doi.org/10.1016/j.ridd.2013.07.0...

Effects on physical activity

Table II (and the supplementary table online ²⁰20. Temple V, Frey G, Stanish H. Table: Description of the intervention studies included in the review for Salud Pública de México. Repositorio Dspace/Manakin. Canadá: University of Victoria. Available at: http://hdl.handle.net/1828/8142
http://hdl.handle.net/1828/8142... ) illustrates that three of the six studies reported significant improvement in physical activity post-intervention.¹⁸18. Stanish HI, McCubbin JA, Draheim CC, van der Mars H. Participation of adults with mental retardation in a video- and leader-directed aerobic dance program. Adapt Phys Act Quart 2001;18:142-155. https://doi.org/10.1123/apaq.18.2.142
https://doi.org/10.1123/apaq.18.2.142... ^,2323. Bazzano AT, Zeldin AS, Diab IRS, Garro NM, Allevato NA, Lehrer D. The Healthy Lifestyle Change Program: A pilot of a community-based health promotion intervention for adults with developmental disabilities. Am J Prev Med 2009;37(6):S201-S208. https://doi.org/10.1016/j.amepre.2009.08.005
https://doi.org/10.1016/j.amepre.2009.08... ^,2626. Bergström H, Hagströmer M, Hagberg J, Schafer-Elinder L. A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Res Dev Disabil 2013;34(11):3847-3857. https://doi.org/10.1016/j.ridd.2013.07.019
https://doi.org/10.1016/j.ridd.2013.07.0... Stanish and colleagues found that participants were able to engage in moderate-vigorous physical activity at work when a video aerobic dance program was available (with or without a leader). The B-A-B-A design of that study lends some confidence to the findings, and the study demonstrated that there is the potential to have a positive impact on opportunities for, and participation in, physical activity in a discrete environment. Results from the Healthy Lifestyle Change Program ²³23. Bazzano AT, Zeldin AS, Diab IRS, Garro NM, Allevato NA, Lehrer D. The Healthy Lifestyle Change Program: A pilot of a community-based health promotion intervention for adults with developmental disabilities. Am J Prev Med 2009;37(6):S201-S208. https://doi.org/10.1016/j.amepre.2009.08.005
https://doi.org/10.1016/j.amepre.2009.08... also suggested increases in both the duration and frequency of physical activity. However the lack of a control group and the lack of detail about how physical activity was assessed limit our understanding of the meaningfulness and generalizability of these findings. However, Bazzano and colleagues’ study ²³23. Bazzano AT, Zeldin AS, Diab IRS, Garro NM, Allevato NA, Lehrer D. The Healthy Lifestyle Change Program: A pilot of a community-based health promotion intervention for adults with developmental disabilities. Am J Prev Med 2009;37(6):S201-S208. https://doi.org/10.1016/j.amepre.2009.08.005
https://doi.org/10.1016/j.amepre.2009.08... was a pilot project, and as such, their findings are encouraging and it would be useful for this study to be replicated using a more robust research design and an objective measure of physical activity. The third study demonstrating a significant effect on physical activity participation was conducted by Bergström and others.²⁶26. Bergström H, Hagströmer M, Hagberg J, Schafer-Elinder L. A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Res Dev Disabil 2013;34(11):3847-3857. https://doi.org/10.1016/j.ridd.2013.07.019
https://doi.org/10.1016/j.ridd.2013.07.0... This cluster randomized control design study sought to influence the personal behaviours of individuals with intellectual disabilities as well as influence their social and physical environments by impacting the caregivers’ knowledge, skills, and work routines. In terms of physical activity, this intervention had a significant effect at two levels. Firstly, there was a significant improvement in s caregivers’ work routines in relation to the promotion of physical activity for residents, and secondly the residents (individuals with intellectual disability) significantly increased their steps per day by 1 203 steps compared to the control group.

Two of the health promotion programs that did not have a significant effect on participation in physical activity were directly targeted to individuals with intellectual disability and involved one session per week for eight weeks.²⁵25. McDermott S, Whitner W, Thomas-Koger M, et al. An efficacy trial of ‘Steps to Your Health’, a health promotion programme for adults with intellectual disability. Health Educ J 2012;71(3):278-290. https://doi.org/10.1177/0017896912441240
https://doi.org/10.1177/0017896912441240... ^,2727. Bodde AE, Seo D, Frey GC, Van Puymbroeck M, Lohrmann DK. The effect of a designed health education intervention on physical activity knowledge and participation of adults with intellectual disabilities. Am J Health Promot 2012;26(5):313-316. https://doi.org/10.4278/ajhp.100408-ARB-112
https://doi.org/10.4278/ajhp.100408-ARB-... It is possible that each of these interventions involved an insufficient ‘dose’ to have a significant effect, but it is also likely that an intervention that targets only individuals with intellectual disability is insufficient to sustain change. Change for an individual does not occur in isolation, it also involves interactions with the immediate or closest aspects of the environment such as with caregivers, family, and community organizations.²⁸28. Bronfenbrenner U, Morris PA. The bioecological model of human development. In: Lerner RM, Damon W, (eds). Handbook of child psychology. Vol 1, Theoretical models of human development. 6th ed. Hoboken, NJ: John Wiley & Sons Inc, 2006:793-828. The evidence from Bergström and colleagues²⁶26. Bergström H, Hagströmer M, Hagberg J, Schafer-Elinder L. A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Res Dev Disabil 2013;34(11):3847-3857. https://doi.org/10.1016/j.ridd.2013.07.019
https://doi.org/10.1016/j.ridd.2013.07.0... suggests that to be effective in producing change in physical activity, both individual and environmental constraints need to be addressed concurrently.

The third study that did not lead to a significant increase in physical activity was a comparison of an innovative mobility intervention to the usual practice mobility intervention for older adults with intellectual disabilities.²⁹29. VanSwearingen JM, Perera S, Brach JS, Wert D, Studenski SA. Impact of exercise to improve gait efficiency on activity and participation in older adults with mobility limitations: a randomized controlled trial. Phys Ther 2011;91(12):1740-1751. https://doi.org/10.2522/ptj.20100391
https://doi.org/10.2522/ptj.20100391... Although there was not a significant effect (p = .09) on physical activity at the end of 12 weeks, there was a significant effect on the energy cost of walking, gait efficacy, and lower extremity functioning. Again, the duration and/or frequency of the intervention may have been insufficient for the effects on gains in functioning to translate into significant improvements in physical activity.

Effects on other health outcomes

Except for the Stanish and colleagues ¹⁸18. Stanish HI, McCubbin JA, Draheim CC, van der Mars H. Participation of adults with mental retardation in a video- and leader-directed aerobic dance program. Adapt Phys Act Quart 2001;18:142-155. https://doi.org/10.1123/apaq.18.2.142
https://doi.org/10.1123/apaq.18.2.142... study, which solely focused on physical activity outcomes, each of the interventions was designed to positively impact other aspects of health in addition to physical activity, specifically: BMI and waist circumference, healthy eating, self-efficacy toward making doctor’s appointment, life satisfaction, and knowledge about physical activity. While the Bazzano and colleagues ²³23. Bazzano AT, Zeldin AS, Diab IRS, Garro NM, Allevato NA, Lehrer D. The Healthy Lifestyle Change Program: A pilot of a community-based health promotion intervention for adults with developmental disabilities. Am J Prev Med 2009;37(6):S201-S208. https://doi.org/10.1016/j.amepre.2009.08.005
https://doi.org/10.1016/j.amepre.2009.08... pilot study indicated there was a significant effect on BMI and waist circumference, neither of the randomized controlled trials ²⁵25. McDermott S, Whitner W, Thomas-Koger M, et al. An efficacy trial of ‘Steps to Your Health’, a health promotion programme for adults with intellectual disability. Health Educ J 2012;71(3):278-290. https://doi.org/10.1177/0017896912441240
https://doi.org/10.1177/0017896912441240... ^,2626. Bergström H, Hagströmer M, Hagberg J, Schafer-Elinder L. A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Res Dev Disabil 2013;34(11):3847-3857. https://doi.org/10.1016/j.ridd.2013.07.019
https://doi.org/10.1016/j.ridd.2013.07.0... significantly impacted BMI. Nor did Bergström and colleagues ²⁶26. Bergström H, Hagströmer M, Hagberg J, Schafer-Elinder L. A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Res Dev Disabil 2013;34(11):3847-3857. https://doi.org/10.1016/j.ridd.2013.07.019
https://doi.org/10.1016/j.ridd.2013.07.0... find a significant effect for waist circumference, dietary quality, or satisfaction with life. Clearly there is not a sufficient weight of evidence to be definitive about any of these interventions and outcomes so far. However, the studies in this review with the strongest research designs (i.e. RCTs) did not show significant effects for weight status measures or dietary quality.

It is clear from this review that experimental research focused on increasing participation in physical activity and promoting physical activity to improve the health of adults with intellectual disabilities is in its infancy. What is very encouraging is that well-controlled trials are now being implemented, plus researchers are publishing study protocols and formative evaluations ¹⁴14. Schijndel-Speet M, Evenhuis HM, Wijck R, Echteld MA. Implementation of a group-based physical activity programme for ageing adults with ID: a process evaluation. J Eval Clin Pract 2014;20(4):401-407. https://doi.org/10.1111/jep.12145
https://doi.org/10.1111/jep.12145... ^,2424. Bodde AE, Seo D, Frey GC, Lohrmann DK, Van Puymbroeck M. Developing a physical activity education curriculum for adults with intellectual disabilities. Health Promot Pract 2012;13(1):116-123. https://doi.org/10.1177/1524839910381698
https://doi.org/10.1177/1524839910381698... ^,3030. Elinder LS, Bergström H, Hagberg J, Wihlman U, Hagströmer M. Promoting a healthy diet and physical activity in adults with intellectual disabilities living in community residences: Design and evaluation of a cluster-randomized intervention. BMC Public Health 2010;10:761-767. https://doi.org/10.1186/1471-2458-10-761
https://doi.org/10.1186/1471-2458-10-761... ^,3131. Prez-Cruzado D, Cuesta-Vargas AI. Improving adherence physical activity with a Smartphone application based on adults with intellectual disabilities (APPCOID). BMC Public Health 2013;13(1):1-11. https://doi.org/10.1186/1471-2458-13-1173
https://doi.org/10.1186/1471-2458-13-117... (that are yet to be published as randomized controlled trials) which will help with broader program implementation and hopefully the state of the intervention and implementation literature in the near future.

Conclusions

Despite evidence that regular participation in physical activity promotes physical and psychosocial health in adults, the available evidence suggests that among adults with intellectual disabilities, physical activity levels are low, levels of sedentary behaviour are high, and less than one-quarter meet national guidelines for physical activity. Despite the potential benefits of physical activity and low levels among adults with intellectual disabilities, this review demonstrates that research to document the process and outcomes of physical activity interventions is sadly lacking. The modicum of evidence that does exist demonstrates that short- and medium-term improvements in physical activity levels are possible. The evidence to date demonstrates that a targeted intervention in the workplace can improve physical activity levels in that discrete context,¹⁸18. Stanish HI, McCubbin JA, Draheim CC, van der Mars H. Participation of adults with mental retardation in a video- and leader-directed aerobic dance program. Adapt Phys Act Quart 2001;18:142-155. https://doi.org/10.1123/apaq.18.2.142
https://doi.org/10.1123/apaq.18.2.142... but to achieve a more pervasive increase in physical activity among adults with intellectual disabilities a ‘multi-pronged’ and sustained approach is needed. ²³23. Bazzano AT, Zeldin AS, Diab IRS, Garro NM, Allevato NA, Lehrer D. The Healthy Lifestyle Change Program: A pilot of a community-based health promotion intervention for adults with developmental disabilities. Am J Prev Med 2009;37(6):S201-S208. https://doi.org/10.1016/j.amepre.2009.08.005
https://doi.org/10.1016/j.amepre.2009.08... ^,2626. Bergström H, Hagströmer M, Hagberg J, Schafer-Elinder L. A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Res Dev Disabil 2013;34(11):3847-3857. https://doi.org/10.1016/j.ridd.2013.07.019
https://doi.org/10.1016/j.ridd.2013.07.0... It seems clear that programs of a relatively short duration (i.e. 8-12 sessions) targeting a single context are insufficient to produce substantive changes in physical activity behaviour among adults with intellectual disabilities. However, Bergström and colleagues ²⁶26. Bergström H, Hagströmer M, Hagberg J, Schafer-Elinder L. A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: A cluster randomised controlled trial. Res Dev Disabil 2013;34(11):3847-3857. https://doi.org/10.1016/j.ridd.2013.07.019
https://doi.org/10.1016/j.ridd.2013.07.0... did demonstrate that by working with both caregivers and individuals with intellectual disabilities for more than a year, significant and meaningful changes in physical activity could be achieved. Although some improvements in other outcome variables were noted among the studies in this review, the most common outcome of interest in these physical activity studies i.e. weight status, showed little change. What is necessary to increase physical activity and subsequently improve weight status remains unclear. Thus, from this review, we recommend that programs designed to increase physical activity among adults with intellectual disabilities simultaneously target the individual with intellectual disabilities as well as their proximal environment (e.g. caregivers) over a sustained period of time.

References

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