Exposure-Based CBT for Older Adults After Fall Injury: Description of a Manualized, Time-Limited Intervention for Anxiety

Fall accidents among older adults can be devastating events that, in addition to their physical consequences, lead to disabling anxiety warranting the attention of mental health practitioners. This article presents "Back on My Feet," an exposure-based cognitive-behavioral therapy (CBT) protocol that is designed for older adults with posttraumatic stress disorder (PTSD), subthreshold PTSD, or fear of falling resulting from a traumatic fall. The protocol can be integrated into care once patients have been discharged from hospital or rehabilitation settings back to the community. Following a brief description of its development, the article presents a detailed account of the protocol, including patient evaluation and the components of the eight home-based sessions. The protocol addresses core symptoms of avoidance, physiological arousal/anxiety, and maladaptive thought patterns. Because older patients face different coping challenges from younger patients (for whom the majority of evidence-based CBT interventions have been developed), the discussion ends with limitations and special considerations for working with older, injured patients. The article offers a blueprint for mental health practitioners to address the needs of patients who may present with fall-related anxiety in primary care and other medical settings. Readers who wish to develop their expertise further can consult the online appendices, which include a clinician manual and patient workbook, as well as guidance on additional resources.

Methodological challenges of multiple-component intervention: lessons learned from a randomized controlled trial of functional recovery after hip fracture

We conducted a randomized controlled trial to assess the efficacy and safety of a multiple-component intervention designed to improve functional recovery after hip fracture. One hundred seventy-six patients who underwent surgery for a primary unilateral hip fracture were assigned randomly to receive usual care (control arm, n = 86) or a brief motivational videotape, supportive peer counseling, and high-intensity muscle-strength training (intervention arm, n = 90). Between-group differences on the physical functioning, role-physical, and social functioning domains of the SF-36 were assessed postoperatively at 6 months. At the end of the trial, 32 intervention and 27 control patients (34%) completed the 6-month outcome assessment. Although patient compliance with all three components of the intervention was uneven, over 90% of intervention patients were exposed to the motivational videotape. Intervention patients experienced a significant (P = 0.03) improvement in the role-physical domain (mean change, -11 +/- 33) compared to control patients (mean change, -37 +/- 41). Change in general health (P = 0.2) and mental health (P = 0.1) domain scores was also directionally consistent with the study hypothesis. Although our findings are consistent with previous reports of comprehensive rehabilitation efforts for hip fracture patients, the trial was undermined by high attrition and the possibility of self-selection bias at 6-month follow-up. We discuss the methodological challenges and lessons learned in conducting a randomized controlled trial that sought to implement and assess the impact of a complex intervention in a population that proved difficult to follow up once they had returned to the community.

Improvement in driving reaction time after total hip arthroplasty

Decisions made regarding resumption of driving after total hip arthroplasty may be determined by a combination of factors including driving reaction time and when postsurgical precautions need no longer be adhered to. Ninety patients, ranging in age from 34 to 85 years old were recruited after total hip arthroplasty to measure driving reaction time preoperatively and from 1 to 52 weeks postoperatively. Driving reaction time worsened 1 week postoperatively for patients who had a right hip arthroplasty. The driving reaction time then improved up to 1 year postoperatively. Patients who had a left arthroplasty improved from 1 week postoperative. In general, patients reach their preoperative driving reaction time 4 to 6 weeks postoperatively and continue to improve.

The day of discharge after total hip arthroplasty and the achievement of rehabilitation functional milestones: 11-year trends

This is a report on 11 years (1990-2000) of total hip arthroplasty cases and days of discharge from one large city hospital. In 1990, patients stayed an average of 9.7 days after surgery. By 2000, patients stayed only 5.3 days. In general, women stayed longer than men, but this gap had nearly disappeared by 2000. The patients discharged in 2000 achieved fewer functional milestones during their hospital stay than those discharged in 1990.

Measuring recovery after a hip fracture using the SF-36 and Cummings scales

The objective of this study was to assess outcomes of traditional treatment of fractures using the SF-36 and the Cummings Hip Scale. In designing randomized clinical trials, it is necessary to determine the timing of assessment either for progress or for the main outcome. We set out to document the recovery of patients after surgery for hip fracture using current standard methods of medical care. This was a prospective study of a cohort of patients. Patients who were receiving standard medical care completed the SF-36 and the Cummings Hip Scale at previously determined times postoperatively. The SF-36 has eight subscales, including assessments of physical function, physical role behaviors, bodily pain, mental health, social role, emotional role, vitality and general health. Thirty-eight patients completed the questionnaires at 1 year postoperatively as well as previous time points. On the Cummings Hip Scale and the physical function, bodily pain, mental health, social function, emotional role, vitality and general health subscales of the SF-36, recovery is near complete at 6 months. Only the physical role subscale differs, with a statistically significant difference between the values at 6 months and 1 year, (p = 0.02). Patients attained over 90% of the 1 year value by 6 months for all except the physical role subscale. The physical role subscale reached 85%. For a hip fracture patient who is on the road to recovery, the majority of the recovery has therefore taken place by 6 months.

General overview of rehabilitation in the rheumatoid patient

This article provides a general overview of rehabilitation in the rheumatoid patient. It discusses the physical therapy management of both the systemic musculoskeletal involvement of RA and of the specific postoperative rehabilitation associated with total joint arthroplasty. It is intended to highlight the major components of treatment and to guide the clinician in assessing these challenging, yet rewarding cases. Its emphasis is to support a multidisciplinary approach to patient care.

Randomized trial of epidural versus general anesthesia: outcomes after primary total knee replacement

To compare the effects of epidural anesthesia and general anesthesia on early postoperative outcomes after unilateral primary total knee replacement, 262 patients were randomly assigned to receive either epidural or general anesthesia. All patients received a common rehabilitation protocol including a standardized assessment of progress. One hundred eighty-eight patients received a common thromboembolic prophylaxis protocol with postoperative aspirin, and had a standardized surveillance protocol to detect thromboembolic complications. Deep vein thrombosis was determined by venography on the operative limb, and pulmonary embolism was determined by comparison of preoperative and postoperative lung perfusion scans. The epidural anesthesia group reached all rehabilitative milestones earlier postoperatively than did the general anesthesia group, with a statistically significant earlier attainment of stair climbing. The incidence of deep vein thrombosis was 40% with epidural anesthesia, and 48% with general anesthesia. There were no clots proximal to the popliteal veins. The incidence of pulmonary embolism on lung scan was 12% with epidural anesthesia and 9% with general anesthesia. Epidural anesthesia is associated with more rapid achievement of postoperative in hospital rehabilitation goals after total knee replacement. A minor reduction in postoperative deep vein thrombosis rate was observed with epidural anesthesia, but this did not reach statistical significance. No difference in early postoperative pulmonary embolism was observed between the 2 types of anesthesia.

Sexual function after total hip arthroplasty

Eighty-six patients who had successful total hip replacement completed questionnaires on their sexual activity. Preoperatively, 46% of patients attributed significant sexual difficulties to their hip disease, whereas only 1% felt that their hips remained a significant source of problems postsurgery. The majority (55%) of patients were able to resume intercourse one to two months postoperation. Male patients were statistically more likely to resume intercourse sooner than their female counterparts. Patients were also questioned about which coital positions they found comfortable after arthroplasty. The supine position (patient on bottom) was the most preferred. The next most comfortable position for males was prone (patient on top), yet for female it was sidelying on the nonoperative hip. In addition, 89% of patients desired more information regarding sexual function postarthroplasty, preferably in the form of a booklet. Therefore, a booklet was written specifically for postoperative patients and their sexual partners.

Physical therapy management of familial dysautonomia

This paper describes physical therapy programs to assist physical therapists in the rehabilitation of patients with familial dysautonomia. There have been no reports in the literature about a physical therapy program for patients with this disease. A retrospective analysis of the clinical manifestations in 80 patients in a dysautonomia clinic was performed. Scoliosis and kyphosis were found in 92 percent of the patients, 93 percent had ataxia, 74 percent had feeding difficulties, 69 percent had frequent pneumonias, and 63 percent exhibited delayed developmental milestones. Cardiovascular, gastrointestinal, pulmonary, musculoskeletal, and neurological symptoms and treatments are discussed.