Psychology after stroke The fear of falling

Dr Ian Kneebone Consultant Clinical Psychologist

amp Visiting Reader

Mr T

Referral from Day Hospital 83 year old man Approx 14 falls last 3 frac12 yrs Peripheral neuropathy TIAs (heavy

smoker) Ca prostate AMT 910

Fear of Falling and Stroke

Provide an overview of falls and stroke Consider fear of falling (FoF) and provide

an heuristic model Review methods to assess FoF Consider the opportunities for

management in individual and group settings

Practical trial a relaxation exercise

Falls amp Stroke

In-patients as high as 39 ( Nyberg amp Gustafson 1995)

10 years post event fall twice as often as matched controls (Jorgensen et al 2002)

Associated with greater medication usage hemi neglect reduced physical function (Mackintosh et al 2006) reduced upper limb function (Ashburn et al 2008) executive change (Liu-Ambrose et al 2007) and depression (Jorgensen et al 2002)

Falls amp Stroke

Falls associated with subsequently being lower in mood less socially active and carer stress (Forster amp Young 1995)

4 experience a fracture within two years of a stroke (Dennis et al 2002)

Fear of Falling

lsquoLe meiller secret pour ne jamais tomber

crsquoest rester toujours assisrsquo

lsquoThe best way never to fall is to remain seated at all timesrsquo

Stendhal Journal 1814

Stroke amp Fear of Falling

FoF has been described as lsquoa lasting concern about falling that leads to an individual avoiding activitiesrsquo (Tinetti amp Powell 1993)

Limited prevalence data but likely 48 in those with stroke who have fallen (Watanabe 2005)

20 of those with stroke who have not fallen report low fall related self-efficacy 11 who have fallen high falls related self-efficacy (Andersson et al 2008)

Stroke amp Fear of Falling

Associated with poor physical function (Andersson et al 2008)

Falls related self-efficacy not balance or mobility performance is related to accidental falls in stroke patients with low bone density (Pang amp Eng 2008)

Fear of Falling

- generally has been indicated to be a predictive independent risk factor for poorer quality of life (Lachman et al 1998) functional decline andor loss of independence (Tinetti et al 1990)

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Mr T

Referral from Day Hospital 83 year old man Approx 14 falls last 3 frac12 yrs Peripheral neuropathy TIAs (heavy

smoker) Ca prostate AMT 910

Fear of Falling and Stroke

Provide an overview of falls and stroke Consider fear of falling (FoF) and provide

an heuristic model Review methods to assess FoF Consider the opportunities for

management in individual and group settings

Practical trial a relaxation exercise

Falls amp Stroke

In-patients as high as 39 ( Nyberg amp Gustafson 1995)

10 years post event fall twice as often as matched controls (Jorgensen et al 2002)

Associated with greater medication usage hemi neglect reduced physical function (Mackintosh et al 2006) reduced upper limb function (Ashburn et al 2008) executive change (Liu-Ambrose et al 2007) and depression (Jorgensen et al 2002)

Falls amp Stroke

Falls associated with subsequently being lower in mood less socially active and carer stress (Forster amp Young 1995)

4 experience a fracture within two years of a stroke (Dennis et al 2002)

Fear of Falling

lsquoLe meiller secret pour ne jamais tomber

crsquoest rester toujours assisrsquo

lsquoThe best way never to fall is to remain seated at all timesrsquo

Stendhal Journal 1814

Stroke amp Fear of Falling

FoF has been described as lsquoa lasting concern about falling that leads to an individual avoiding activitiesrsquo (Tinetti amp Powell 1993)

Limited prevalence data but likely 48 in those with stroke who have fallen (Watanabe 2005)

20 of those with stroke who have not fallen report low fall related self-efficacy 11 who have fallen high falls related self-efficacy (Andersson et al 2008)

Stroke amp Fear of Falling

Associated with poor physical function (Andersson et al 2008)

Falls related self-efficacy not balance or mobility performance is related to accidental falls in stroke patients with low bone density (Pang amp Eng 2008)

Fear of Falling

- generally has been indicated to be a predictive independent risk factor for poorer quality of life (Lachman et al 1998) functional decline andor loss of independence (Tinetti et al 1990)

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Fear of Falling and Stroke

Provide an overview of falls and stroke Consider fear of falling (FoF) and provide

an heuristic model Review methods to assess FoF Consider the opportunities for

management in individual and group settings

Practical trial a relaxation exercise

Falls amp Stroke

In-patients as high as 39 ( Nyberg amp Gustafson 1995)

10 years post event fall twice as often as matched controls (Jorgensen et al 2002)

Associated with greater medication usage hemi neglect reduced physical function (Mackintosh et al 2006) reduced upper limb function (Ashburn et al 2008) executive change (Liu-Ambrose et al 2007) and depression (Jorgensen et al 2002)

Falls amp Stroke

Falls associated with subsequently being lower in mood less socially active and carer stress (Forster amp Young 1995)

4 experience a fracture within two years of a stroke (Dennis et al 2002)

Fear of Falling

lsquoLe meiller secret pour ne jamais tomber

crsquoest rester toujours assisrsquo

lsquoThe best way never to fall is to remain seated at all timesrsquo

Stendhal Journal 1814

Stroke amp Fear of Falling

FoF has been described as lsquoa lasting concern about falling that leads to an individual avoiding activitiesrsquo (Tinetti amp Powell 1993)

Limited prevalence data but likely 48 in those with stroke who have fallen (Watanabe 2005)

20 of those with stroke who have not fallen report low fall related self-efficacy 11 who have fallen high falls related self-efficacy (Andersson et al 2008)

Stroke amp Fear of Falling

Associated with poor physical function (Andersson et al 2008)

Falls related self-efficacy not balance or mobility performance is related to accidental falls in stroke patients with low bone density (Pang amp Eng 2008)

Fear of Falling

- generally has been indicated to be a predictive independent risk factor for poorer quality of life (Lachman et al 1998) functional decline andor loss of independence (Tinetti et al 1990)

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Falls amp Stroke

In-patients as high as 39 ( Nyberg amp Gustafson 1995)

10 years post event fall twice as often as matched controls (Jorgensen et al 2002)

Associated with greater medication usage hemi neglect reduced physical function (Mackintosh et al 2006) reduced upper limb function (Ashburn et al 2008) executive change (Liu-Ambrose et al 2007) and depression (Jorgensen et al 2002)

Falls amp Stroke

Falls associated with subsequently being lower in mood less socially active and carer stress (Forster amp Young 1995)

4 experience a fracture within two years of a stroke (Dennis et al 2002)

Fear of Falling

lsquoLe meiller secret pour ne jamais tomber

crsquoest rester toujours assisrsquo

lsquoThe best way never to fall is to remain seated at all timesrsquo

Stendhal Journal 1814

Stroke amp Fear of Falling

FoF has been described as lsquoa lasting concern about falling that leads to an individual avoiding activitiesrsquo (Tinetti amp Powell 1993)

Limited prevalence data but likely 48 in those with stroke who have fallen (Watanabe 2005)

20 of those with stroke who have not fallen report low fall related self-efficacy 11 who have fallen high falls related self-efficacy (Andersson et al 2008)

Stroke amp Fear of Falling

Associated with poor physical function (Andersson et al 2008)

Falls related self-efficacy not balance or mobility performance is related to accidental falls in stroke patients with low bone density (Pang amp Eng 2008)

Fear of Falling

- generally has been indicated to be a predictive independent risk factor for poorer quality of life (Lachman et al 1998) functional decline andor loss of independence (Tinetti et al 1990)

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Falls amp Stroke

Falls associated with subsequently being lower in mood less socially active and carer stress (Forster amp Young 1995)

4 experience a fracture within two years of a stroke (Dennis et al 2002)

Fear of Falling

lsquoLe meiller secret pour ne jamais tomber

crsquoest rester toujours assisrsquo

lsquoThe best way never to fall is to remain seated at all timesrsquo

Stendhal Journal 1814

Stroke amp Fear of Falling

FoF has been described as lsquoa lasting concern about falling that leads to an individual avoiding activitiesrsquo (Tinetti amp Powell 1993)

Limited prevalence data but likely 48 in those with stroke who have fallen (Watanabe 2005)

20 of those with stroke who have not fallen report low fall related self-efficacy 11 who have fallen high falls related self-efficacy (Andersson et al 2008)

Stroke amp Fear of Falling

Associated with poor physical function (Andersson et al 2008)

Falls related self-efficacy not balance or mobility performance is related to accidental falls in stroke patients with low bone density (Pang amp Eng 2008)

Fear of Falling

- generally has been indicated to be a predictive independent risk factor for poorer quality of life (Lachman et al 1998) functional decline andor loss of independence (Tinetti et al 1990)

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Fear of Falling

lsquoLe meiller secret pour ne jamais tomber

crsquoest rester toujours assisrsquo

lsquoThe best way never to fall is to remain seated at all timesrsquo

Stendhal Journal 1814

Stroke amp Fear of Falling

FoF has been described as lsquoa lasting concern about falling that leads to an individual avoiding activitiesrsquo (Tinetti amp Powell 1993)

Limited prevalence data but likely 48 in those with stroke who have fallen (Watanabe 2005)

20 of those with stroke who have not fallen report low fall related self-efficacy 11 who have fallen high falls related self-efficacy (Andersson et al 2008)

Stroke amp Fear of Falling

Associated with poor physical function (Andersson et al 2008)

Falls related self-efficacy not balance or mobility performance is related to accidental falls in stroke patients with low bone density (Pang amp Eng 2008)

Fear of Falling

- generally has been indicated to be a predictive independent risk factor for poorer quality of life (Lachman et al 1998) functional decline andor loss of independence (Tinetti et al 1990)

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Stroke amp Fear of Falling

FoF has been described as lsquoa lasting concern about falling that leads to an individual avoiding activitiesrsquo (Tinetti amp Powell 1993)

Limited prevalence data but likely 48 in those with stroke who have fallen (Watanabe 2005)

20 of those with stroke who have not fallen report low fall related self-efficacy 11 who have fallen high falls related self-efficacy (Andersson et al 2008)

Stroke amp Fear of Falling

Associated with poor physical function (Andersson et al 2008)

Falls related self-efficacy not balance or mobility performance is related to accidental falls in stroke patients with low bone density (Pang amp Eng 2008)

Fear of Falling

- generally has been indicated to be a predictive independent risk factor for poorer quality of life (Lachman et al 1998) functional decline andor loss of independence (Tinetti et al 1990)

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Stroke amp Fear of Falling

Associated with poor physical function (Andersson et al 2008)

Falls related self-efficacy not balance or mobility performance is related to accidental falls in stroke patients with low bone density (Pang amp Eng 2008)

Fear of Falling

- generally has been indicated to be a predictive independent risk factor for poorer quality of life (Lachman et al 1998) functional decline andor loss of independence (Tinetti et al 1990)

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Fear of Falling

- generally has been indicated to be a predictive independent risk factor for poorer quality of life (Lachman et al 1998) functional decline andor loss of independence (Tinetti et al 1990)

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FoF as a risk factor for future falls Longer term risk

Low falls self-efficacy

Negativethoughts

Bodily awareness

Reduced activityavoidance

Negative beliefs

Distraction Stiffening Poor self- perception

Lowered body strength

Increased risk of falling

Immediate risk

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FoF Assessment

FOF may be hard to recognize in some clients as they may already have cut out all the activities that demonstrate the problem by the time they are referred for intervention

Some clients may also lack awareness or avoid discussion of their fear

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FoF Assessment

Important to differentially identify post fall PTSD

Characterised by

- Intrusive recollection eg dramatic re-experiencing dreams etc

- Avoidance eg of associated stimuli numbing of responsiveness

- Hyperarousal hypervigilance irratibility

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FoF Assessment Scales

lsquoFalls Efficacy Scale-Internationalrsquo FES-I (Tinetti Richman amp Powell 1990) or the lsquoSurvey of Activities and Fear of Falling in the Elderlyrsquo (SAFE Lachman Howland Tennstedt Jette Assman amp Peterson 1998)

These scales ask individuals about how confident or afraid they feel about carrying out a number of specific activities of daily living

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Falls Efficacy Scale - International

lsquoNow we would like to ask some questions about how concerned you are about the possibility of falling Please reply thinking about how you usually do the activity If you currently donrsquot do the activity (eg if someone does your shopping for you) please answer to show whether you think you would be concerned about falling IF you did the activity For each of the following activities please tick the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activityrsquo

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FES-I

1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned

1 Cleaning the house (eg sweep vacuum or dust) 1 1048710 2 1048710 3 1048710 4 1048710

2 Getting dressed or undressed 1 1048710 2 1048710 3 1048710 4 1048710

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FES-I

Scores range from 16 to 64 The higher the score the greater is

the concern about falling

Low 16-22 High 23-64 Low 16-19 Moderate 20-27 High 28-64

(Delbaere et al 2010)

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Other Measures

Activity-specific Balance Confidence Scale

lsquobalance confidencersquo with respect to specific activities (Powell amp Meyers 1995)

Consequences of Falling Scale lsquooutcome expectancyrsquo with respect to falls

(Yardley amp Smith 2002)

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FoF Observations

Observation of the client during physical therapy sessions and discussion with the clientrsquos relatives to gain their opinions as to whether an individual has tended to increasingly avoid activities

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FoF Multi-factorial Treatment

cognitive therapy to change attitudes about the risk of falling

education about the fear of falling and that it is controllable

goal setting to increase relative activity levels of participants and to manage a graduated exposure to fearful situations

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FoF Multi-factorial Treatment

environmental modification to reduce the risk of falling

increasing physical exercise

and maximising strength and balance

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

FoF Treatments

Systematic review of treatments for community living older people -multi-factorial -tai chi interventions -exercise interventions -hip protector intervention

(Zijlstra et al 2007)

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Realistic Goals and Fear of Falling

- allowing open discussion of the clientrsquos valid fears and give the client lsquopermissionrsquo to admit to falls without feeling they will be blamed for a preventable incident

-assists staff to conceptualise realistic goals thus

maintaining their motivation for the intervention

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Realistic Goals and Fear of Falling

-ensure a reality base to intervention that is

facilitate the adoption of a philosophy of falls reduction rather than falls prevention

-assurance the programme has face validity with

clients who may be skeptical falls can be prevented

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Individual TreatmentSteps

1 acknowledge the validity of their fear whilst reminding them that there are factors in their control that can reduce the risk of them falling

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Individual Treatment Steps

2 Motivational interviewing (Prochaska amp DiClemente 1982) may help in the establishment of a commitment to proceed with therapy

Acknowledge their choice to proceed however you inform that choicehellip

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Decisional Balance

AVOIDANCE + -feel safe relaxed -easier -tasks done for me AVOIDANCE -

-weak frail -constipation -dependence (care

risk)

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Individual Treatment Steps

3 Initial education can involve presenting the heuristic model

4 Control management not eradication of fear is the goal of intervention

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Individual Treatment Steps

5 Physical arousal associated with anxiety is contained using relaxation

6 Helpful attitudes for use during mobilization trials are achieved through motivational interview and cognitive disputation Attention is directed away from anxiety provoking thoughts to behaviours that will potentiate success

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

CBT Structure

Physical Relaxation and breathing

Cognitive Pre-prepared responses to negative thoughts

Behavioural What I need to do to walk well

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Relaxation amp Breathing

3 Part Breathing

Progressive muscle relaxation

Autogenic training

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Cognitive

lsquoSure there is a risk of falling but if I concentrate well and relax its less likelyrsquo

Can be based on motivational interview

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Behavioural

How to look ahead breathe properly lift their frame etc

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Case example Mrs W

In-patient referral 86 year old woman L hemi AF CCF Hi BP f UTI L NOF 99

OA Recent further L DHS amp leg shortening

Commenced on sertraline (anti ndashdepressant)

MMSE 2130

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Jack

Client 80 years of age poor mobility increasingly frail mild strokesmall vessel disease heart failure glaucoma postural hypotension

Referral Day hospital concerned about

general anxiety and marked fear of falling that was interfering with rehabilitation progress

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Jack

Assessment Adjustment reaction with mixed features of anxiety and depression Precipitated by physical decline and difficulty with falls Reaction included insomnia suicidal ideas (without planning or action) Fear of falling evident on account of a falls history and conviction the next fall would be a bad one that would leave him lsquoworse offrsquo lsquoIrsquoll do it wrong Irsquoll fall and it will be a bad onersquo

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Jack

Reinforced by relief he feels at discontinuing efforts to mobilise

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Jack

Intervention 10 sessions 1 Decision to focus on FoF because so

prominent 2 Motivational interview safe from falls

vrsquos loss of independence decline in health increased constipation etc

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Jack

3 Relaxation general and specific 4 Cognitive coping self-statements 5 Physio goal setting and instructions

lsquoWhat is it I have to do to walk wellrsquo 6 Home visits X 2 Physio Plus follow-

up by HV elderly

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Jack

Relaxation general and specificAutogenic and 3 part breathing

Cognitive coping self-statements

lsquoOK I might fall but if I relax and think about what I need to do its less likelyrsquo lsquoBreathersquo

lsquoIts important I do this to stay independent and keep the bowels from seizing up completelyrsquo

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Jack

Now what is it I have to do to walk wellhelliprsquo

lsquoHead up bottom in lift the frameoff I gorsquo

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Jack

Outcome Mobilised to goal level set with Physiotherapist Mood improvement Sleep remained impaired bladder difficulty

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Case Study Mary

CASE STUDY 1 Fear of Falling

Client Female 79 years of age stroke 3 years prior to NOF Painful experience History of 3 ndash 5 falls prior

to fall that resulted in Referral Physiotherapy very concerned complete

refusal to mobilise stand or attempt walking when lsquoclearlyrsquo physical ability was in place

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Mary

Assessment Psychological assessment confirmed FoF

99 convinced if she attempted to stand or walk she would fall and experience a further painful event

Clear negative adversarial interaction between physios and patient characterised by repeated entreaties and refusals

lsquoYa will ya will ya willrsquo

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Mary

Intervention

Took the pressure off completely

-Physio (or student) would come and just talk

-Clarified the decision to participate in recommended rehabilitation tasks was entirely hers

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Mary

Intervention

Discussion with physios were centred around what they were doing and why

- -Mapped out programme in detail)

- -Considered the potential consequences of non participation (dependence institutional accommodation)

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Mary

OutcomeAfter 2-3 sessions agreed to start initial stage of

intervention Subsequently she progressed in line with normal expectation Discharged to own home

Major aspects leading to change Changed

nature of interaction from adversarial to collaborative gave control choice to patient

Fear of falling after stroke

Questions

ikneebonenhsnet

Fear of falling after stroke

Questions

ikneebonenhsnet