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Psychology after stroke: The fear of falling. Dr Ian Kneebone, Consultant Clinical Psychologist & Visiting Reader. Mr T. Referral from Day Hospital 83 year old man Approx 14 falls last 3 ½ yrs Peripheral neuropathy, TIAs (heavy smoker) Ca prostate AMT 9/10. Fear of Falling and Stroke. - PowerPoint PPT Presentation
Citation preview
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