Table 1 Overview of the FIT-HIP intervention

Guided exposure – rationale

Guided exposure is the graded and repeated exposure to situations that give rise to fear (of falling). As recurrent exposure to the feared situation or activity is performed under supervision and in a manner that is predictable and controllable, this leads to the positive experience that the fear gradually fades out as the activity is practiced more often. After the fear for this specific situation has subsided, the exposure can be extended to the ‘next level’, practicing the activity in a manner that leads to a greater level of fear (fear hierarchy for graded exposure). For fear of falling (FoF), the feared activities will be situations concerning physical activity. In the rehabilitation after hip fracture, this will predominantly be basic activities in daily living, such as transferring, standing and walking.

Implementation in the FIT-HIP intervention

In the FIT-HIP intervention the physiotherapist helps the participant assess situations that give rise to FoF (within the first week of admission to geriatric rehabilitation (GR)). For each ‘feared’ activity the physiotherapist and participant draft a fear hierarchy, designed as a ‘fear ladder’ (template example published in protocol) [21]. The FIT-HIP fear ladder consists of six ‘steps’, each step representing a functional goal. The functional goal describes in which manner the activity is practiced/performed. The goals are ranked with an increasing level of FoF as the activity gets more complex (or has to be performed with less assistance). The FIT-HIP fear ladders are the guiding principle for the multidisciplinary approach to apply guided exposure for all aspects of mobilization. The physiotherapist evaluates the fear ladders with the participant weekly and the fear ladders are revised on the basis of progress (reduction of FoF).

Intervention provider(s)^a

Physiotherapists during physical therapy sessions. As applicable, by nursing staff when assisting patients in basic activities of daily living that give rise to FoF. Nursing staff assisting participants in practicing ‘fearful’ activities as ‘homework assignments’ after physical therapy.

Schedule

Incorporated in all physical therapy sessions (and nursing care activities) for the duration of inpatient multidisciplinary GR as long as FoF persists.

Cognitive restructuring - rationale

Thoughts (and associated beliefs) influence how a person feels and accordingly how a person appraises and responds to a situation. Excessive concern to fall (fear of falling) can be based on unrealistic thoughts and beliefs with regard to (risk of) falling. This excessive FoF may lead to avoidance of (physical) activity and consequently fortify the FoF. Cognitive restructuring is a technique used to explore thoughts and beliefs and therefore to identify, challenge and modify unrealistic thoughts. In the FIT-HIP intervention participants are coached to explore their thoughts concerning physical activity and fall risk. In doing so they are encouraged to identify maladaptive and unrealistic thoughts and in turn formulate and apply more realistic thoughts. The principle of (un) realistic thoughts is also incorporated into the relapse prevention plan (see below).

Implementation in the FIT-HIP intervention

Physiotherapists are trained to guide the participant in exploring their thoughts concerning physical activity and (risk of) falling. A worksheet is used to structure the process of cognitive restructuring and to provide the participant insight in this process (analyzing the situation and the associated thoughts, feelings, behavior and consequences and subsequently formulating more realistic thoughts).

Intervention provider(s)^a

Physiotherapists. A psychologist is trained as a ‘buddy’ to coach the physiotherapists in these principles as when additional help is needed.

Schedule

During at least one physical therapy session the cognitive restructuring is applied and practiced with the participant. Subsequently, the participant is encouraged to fill in the worksheet as a ‘homework assignment’. This is reviewed and discussed during the next therapy session. These ‘key’ thoughts can briefly be recapitulated in situations when the FoF is noticeable in the physical therapy sessions. The process of cognitive restructuring can be repeated as needed (when the FoF persists).

Psychoeducation - rationale and implementation in the FIT-HIP intervention

The psycho-education is used to reinforce the various elements of the FIT-HIP intervention. In the initial phase of GR the participant receives information on anxiety, (consequences and treatment of) FoF and the rationale and background of guided exposure and cognitive restructuring. In the final phase of GR, when discharge home is being planned, the psycho-education focusses on home safety. The information on home safety is also processed in the relapse prevention plan (see below).

For detailed information of the psychoeducation, see the topic list presented in Additional file 1

Intervention provider(s)^a

Physiotherapists discuss the information with the participant.

Schedule

During at least two physical therapy sessions (one in the initial phase of rehabilitation; the other preceding the discharge home). As applicable, the psycho-education can additionally be incorporated in the therapy sessions, related to situations occurring during therapy (for example fall prevention).

Relapse prevention - rationale

The relapse prevention is aimed at helping the participant to anticipate and cope with relapse to FoF.

Implementation in the FIT-HIP intervention

In the FIT-HIP intervention the relapse prevention is designed to optimize the transition to predominantly independent living circumstances after discharge home. For this purpose, a ‘relapse prevention plan’ is composed together with the participant. This ‘Staying Active Plan’ aims at preparing the participant for challenging situations in which there is a risk for relapse to FoF and activity restriction. The ‘Staying Active Plan’ consists of (information on) 1. General home safety and fall prevention; 2. Individualized advice for safe ambulation and how to stay active; 3. Preventing, recognizing and dealing with a relapse (including notice of (mal)adaptive) thoughts). The information is discussed together with the participant and presented in writing as a reference book.

In addition, a telephonic booster is conducted 6 weeks after discharge from GR. The telephonic booster is aimed at evaluating the FoF (and activity restriction). If necessary advice is given how to deal with FoF, in addition to the prior advice formulated in the ‘Staying Active Plan’.

Intervention provider(s)^a

Both the ‘Staying Active Plan’ and telephonic booster are conducted by physiotherapists.

Schedule

During at least one physical therapy session during GR (‘Staying Active Plan’) and one telephonic booster session after discharge home.

Motivational interviewing

Physiotherapists are trained^a in motivational interviewing techniques to assist the participant in the process of behavior change. These techniques help the physiotherapist gain insight into the participant’s extrinsic and intrinsic motivation and explore which rehabilitation goals are important for the participant, in order to personalize treatment goals in the FIT-HIP intervention.