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Mental Matters: Recognizing and CSM: February 7, 2015 Supporting Clients with

Presenters

Margaret Danilovich, PT, DPT, GCS Clincal Instructor, Northwestern University, Chicago, IL. Matters: Recognizing and Supporting Clients with Anxiety Heather Feldner, PT, MPT, PCS Clinical Instructor, University of Illinois at Combined Section Meeting 2015 Chicago, Chicago, IL. February 4th-7th, 2015 Anna Russo, MSW, LSW, CADC Social Worker and Certified Drug and Alcohol Counselor, Compass Health Center, Northbrook, IL.

Course Description Course Objectives

Emerging evidence supports the strong impact of anxiety 1. Explain the etiology, symptoms, and prevalence of on client outcomes, as well as demonstrating the efficacy anxiety disorders. of as an adjunct treatment in anxiety 2. Identify appropriate screening tools for clients presenting management. However, research also indicates that with anxiety and evaluate the psychometric properties of physical therapists may not routinely screen for or these measures. adequately respond to symptoms of anxiety in their 3. Describe strategies to implement anxiety screening clients. The purpose of this course is to improve physical within a physical therapy examination and evaluate therapists’ knowledge and confidence in recognizing, findings that may necessitate referral to a mental health screening, and making referrals for clients with anxiety. professional. Participants will also practice direct intervention strategies 4. Implement strategies to facilitate and in- to facilitate motivation and in-session anxiety symptom session symptom management in clients with anxiety, management, in order to maximize the holistic health including education on the benefits of physical activity as outcomes of their clients. an adjunct treatment for anxiety.

Background Background Widespread problem affecting Economic costs to ~ 20% of the population society: ! Mental health condition recognition often ~ 75% experience a comorbid ! $42 billion/year occurs through clinical judgment vs. mental health disorder in their ! ! of costs associated validated screening tool lifetime with repeated use of (Scalzitti, 1997; Haggman et al., 2004) health care services & for Increased risk for all anxiety ! Casual talk of patients & provider relief of symptoms that disorders if: mimic physical illness ! Anxiety affects: female ! Patients with generalized low SES Treatment outcomes (Jack, 2010) have low levels of formal education higher medical costs than Adherence to treatment recommendations single (Minor and Brown, 1993) patients without anxiety (Anxiety and Depression Association of America) Missed visits = loss of revenue! (Eaton, 2006) "

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Fear vs. Anxiety vs. Anxiety Disorder Anxiety Pathways Anxiety Anxiety Disorders

Pre-morbid Injury / Illness worsened anxiety Emotional response to of a future Excessive fear and Anxiety real or perceived threat anxiety immediate danger Intervene

Muscle tension and Behavioral disturbances Surge of autonomic Injury / Anxiety worsened health necessary for vigilance, cautious outcomes fight or flight and avoidant illness

Intervene

Anxiety Pathways Anxiety and Hospitalizations

Pre-morbid Anxiety New onset Anxiety ! Injury/illness " anxiety ! In patients with burn ! In patients without a pre- ! Hospitalizations are a source of

injury, those with pre- existing condition, those Hospitals produce anxiety because of: existing psychiatric with high post-injury ! 1) real – bodily and lack of information diagnoses (including distress (but no pre- about procedures anxiety) had longer existing diagnosis) had 2) underlying conflicts – loss of identity and hospital stays, delayed similarly prolonged assuming the patient role wound healing, and more hospital stays, number of 3) cultural factors – behavior of health care surgeries. (34-40 days vs procedures, and professionals and patient behavior 13 days decreased adherence to expectations PT protocols 4) anxiety related to control of

(Ramsden and Taylor, 1988) (Tarrier et al., 2005; Wisley et al., 2010)

Anxiety Disorders Generalized Anxiety Disorder (GAD)

! Excessive anxiety and more days than not for at least 6 months for multiple events/activities

! The individual finds it difficult to control the worry

! 3 or more of the following symptoms occur more days than not for 6 months: # Restlessness, keyed up, or on edge # Being easily fatigued # Difficulty concentrating or mind going blank # # Muscle Tension # Disturbance

Property of Feldner, Danilovich, and Russo. Not to be copied without permission. 2 Mental Health Matters: Recognizing and CSM: February 7, 2015 Supporting Clients with Anxiety

Generalized Anxiety Disorder (GAD) Trauma and Related Disorders

! The symptoms cause clinically significant distress/ and PTSD impairment in important areas of functioning. ! Patient often presents as anxious ! Not attributable to a substance or other medical condition ! Often occurs after exposure to actual or threatened , serious injury, or sexual violation ! Not better explained by another ! Trauma survivors show more physical improvement when also treated for mental health conditions

(Zatzick, 2013).

Populations with High Prevalence of Anxiety Anxiety in SCI, , and TBI ! 24-28% of patients with SCI had anxiety during the first 12 weeks of hospitalization ! Stroke ! 60% of patients with SCI had anxiety 48 weeks post- ! SCI injury (Kennedy & Rogers, 2000)

! 29% of stroke survivors met the clinical cutoff for ! Pain anxiety while still hospitalized. (Broomfield et al., 2014)

! ! 21-29% of stroke survivors had anxiety in chronic post-

stroke period (Barker-Collo, 2007; Lincoln et al., 2013) ! ICU admission and/or prolonged hospitalization ! 10.2% of patients with TBI were clinically diagnosed CAD/MI ! with GAD (Hiott & Labbate, 2002)

Anxiety & Pain Dementia and Anxiety

! 5-20% of persons with dementia have anxiety disorders Reciprocal relationship between pain and anxiety ! ! 8-71% of persons with dementia have anxiety symptoms # anxiety levels predict pain behavior and severity in acute and chronic situations ! Significant issue with diagnosis due to overlap in symptoms between dementia & anxiety (Feretti, 2001)

! Anxiety-induced hyperalgesia is thought to be mediated ! Anxiety symptoms tend to be greater in vs. Alzheimer’s by responses in the and amygdala, and ! Anxiety relatively stable across dementia severity under terminal stage poor descending pain modulation signals. ! Factors underlying a direct relationship between anxiety and dementia: # Neural degeneration responsibility for cognitive decline could also ! Pain and anxiety responses successfully controlled or limbic structures associated with emotional regulation lessened via pharmacotherapy, psychotherapeutic # Dementia symptoms overlap with anxiety - makes it hard to determine causality (Seignourel, 2009) techniques, or both in combination. (Ploghaus et al., 2001) ! Unclear if anxiety is part of a broader syndrome with agitation or depression

" ! Recommendation: Clinically assess anxiety symptoms independently (Seignourel, 2009)

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ICU / prolonged hospitalization and anxiety Anxiety and CAD/MI

! Association between anxiety and heart disease (Kawachi, 1994) ! Anxiety occurring in 12-78% of persons who have been in the ICU (Gustad et al., 2008; Lizana, 2003) ! In-hospital anxiety incidence ~ 50% in patients with ! In 6-18 months after ICU discharge, patients 30% more likely than those hospitalized but not in the ICU to report anxiety (Ringdal, 2009) ! 2.5 fold risk increase for ischemic complications in ! At one year after ICU discharge, unemployment and level of patients with anxiety following MI were independent predictors of anxiety (Myhren, 2010) ! Patients with acute MI and a high level of anxiety had a 5 ! Anxiety is more prevalent in cases of mechanical ventilation. fold increase in risk for recurrent ischemia, re-infarction, or (Gustad et al., 2008) death compared with patients with MI without high anxiety

# Early in-hospital anxiety following MI is one of the best

predictors for in-hospital complications (Thurston, 2013)

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84H[(-/A("<%)(6A'(L"" Assessing Pain

C(*"6(150%1(1",46'%F"14H[(-/A("'%)(6A'(L\" ! VAS """""](&-(11'A("L066*"06"M(.6"'%"F(%(6.2" "]6(506)(,"1K06)%(11"0M"H6(.)K" ! Faces Scale "]K(.,.-K(Q"504%,'%F"'%")K("-K(1)Q"M((2"2';("K.A'%F"."K(.6)""" """"""".^.-;" "]U.1KH.-;1"0M")6.4@./-"(A(%)" ! Qualitative Descriptions "]_%414.2"'66').H'2')*Q"'%10@%'.Q"06"K*5(6A'F'2.%-(" "]<%-6(.1(,"41(`.H41("0M"14H1).%-(1 "" " $210"'@506).%)")0"%0)("6(150%1(1"'%"'%)(6A'(L"M06\"" "]J%1()"0M"<%[46*" "]TIJa`GIJa" "]80-'.2`b(.2)K"K.H')1" "]845506)1"#"W%A'60%@(%).2"c"T(610%.2" "]+(.%'%FM42"$-/A'/(1" "]d0.21" " "

Property of Feldner, Danilovich, and Russo. Not to be copied without permission. 4 Mental Health Matters: Recognizing and CSM: February 7, 2015 Supporting Clients with Anxiety

Cognition Cardiopulmonary Function

Anxiety has been shown to negatively affect: Heightened anxiety state " of sympathetic nervous system sensory-perceptual processes (early processing and detection of stimuli) e increased incidence of QT interval prolongation (proclivity towards ventricular arrhythmia) attention/control (the ability to attend to some stimuli and ignore others) e reduced variability *Increased HR *Irregular heart rhythm memory *Increased BP (maintenance and retrieval of information) *Increased RR *Shortness of breath executive function *Chest pain (rule out other causes) (complex integrative and decision-making processes, spatial navigation) (Robinson et al., 2013) Anti-anxiety medication: Beta Blockers - HR response to exercise blunted - consider RPE A & O x 4 won’t capture many of the cognitive http://www.nimh.nih.gov/health/publications/mental-health-medications/index.shtml domains impacted by anxiety "

" "

Musculoskeletal Integumentary

Reduced flexibility and palpable trigger points due to increases in muscle tension

Kinesiophobia Association between anxiety disorder & non-suicidal self- injury(NSSI) and deliberate self-harm (DSH) Joint inflammation, instability, and stiffness (Nijs et al., 2004; Nijs et al 2013) ***only 5% of those with anxiety endorse Movement anxiety may be a factor in many health conditions for DSH & 0.6% endorse NSSI*** which PT is referred. " These symptoms may indirectly lead to decreased motor performance. "

Neuromuscular Functional Mobility

Balance: Vertigo may be reported with anxiety attacks. Reports Fear of falling in the aging population may lead to self- of lightheadedness/dizziness/unsteadiness imposed activity and mobility restrictions.

(Martin et al 2005)

Sensation: May report tingling sensation in any body region (commonly hands) during anxiety attack Fear of falling is predictive of falling (Friedman, 2005)

Anxiety symptoms are not associated with objective declines Coordination: May be delayed by effects of medication. Tremor/ in functional mobility; however symptoms are associated shaking associated as a physical symptom of anxiety with self-reported declines in functional mobility.

"""""""""""""""""7T.'%)(6Q"fONfQ"+.6/%"()".2"fOOg9" " Vision: Pupil dilation as a result of sympathetic activation - " patient may report light sensitivity or eye strain. "

(Anxiety & Depression Association of America, 2014) "

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GAD-7

Easy to administer - 7 items scored on 4 point scale

! Quick - less than 5 minutes

! Provides information about whether anxiety is present

Assists in clinical decision making and decisions to refer to a Mental Health Professional

Valid in assessing generalized anxiety as well as disorders and PTSD

OUTCOME MEASURES

GAD-7 GAD-7 in the Acute Care Setting

Cut score of 10 out of 21 is indicative of moderate anxiety and referral to a mental health professional.

Reliability: excellent internal reliability, Cronbach’s alpha = .92, good test-retest reliability ICC = .82

Validity: strongly associated with mental health index of SF-20,concurrent validity r = .72 with Beck Anxiety Inventory.

Sensitivity and specificity: 89% and 82% for GAD, 74% and 81% for panic disorders, 66% and 81% for PTSD. (Spitzer et al., 2006) " " http://www.adaa.org/living-with-anxiety/ask-and-learn/screenings/screening "

Other outcome measures Prognosis

! State Trait Anxiety Inventory ! Hospital Anxiety and Depression Scale - not used for In untreated or undetected mental health conditions, physical therapy outcomes are poorer and treatment diagnosis, but rather screening for referral duration increases. ! Rating Anxiety in Dementia scale (RAID Shankar, 1999) (Scalzitti 1997; Mitchell et al., 2008) ! The Worry Scale - self report for individuals with mild People with anxiety report: dementia ! GAD - Beck Anxiety Inventory (BAI) ! more fear/avoidance behaviors ! OCD - Yale-Brown Obsessive-Compulsive Scale (Y-BOCS); ! more severe medical symptoms Obsessive Compulsive Inventory-Revised (OCI-R_ ! more difficulty adjusting to their medical condition ! Acute Stress/PTSD - Davidson Trauma Scale (DTS); Impact ! more medical costs of Event Scale-Revised (IES-R) ! longer hospital stays ! prolonged recovery times ! Depression Anxiety Stress Scale (DASS-21) (http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml) ! Psychological Distress Measure (PSM-9) " " ! Screen for Child Realted Anxiety Disorders (SCARED) ! Preschool Anxiety Sclae ! Spence Children’s Anxiety Scale

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Condition-specific prognosis

! Presence of anxiety pre-surgically triples risk of hospital readmission for patients with cardiac surgery. (Tully et al., 2008)

! Symptom exacerbations requiring hospitalization were approximately twice as long in duration for patients with COPD & anxiety than patients with COPD but no anxiety. (Xu et al., 2008)

! Anxiety negatively affects patient self-reported improvement scores during PT treatment for INTERVENTIONS musculoskeletal pain. (Atalay et al., 2013)

! Long term prognosis: 5-10 years post-stroke, 29%-35% of people continued to have anxiety disorders. (Lincoln et al., 2013) " "

Intervention Strategies Motivational Interviewing Motivational Interviewing

! 80% success in changing health and physical activity Core Principles: behavior (Rubak et al., 2005; Shannon & Hillsdon, 2007)

Cognitive Behavioral Therapy ! Express ! Efficacious in managing chronic pain in adults, post-stroke depression, kinesiophobia, and post-injury anxiety. (Nijs et al., 2004; Beissner et al., 2009; Broomfield et al., 2011; Foster & Delitto, 2011) ! Roll with resistance

Progressive ! Develop discrepancy ! Significant effect in lowering HR, BP, RR, improved subjective muscle tension, and pain reports (Salt & Kerr, 1997) ! Support self-efficacy Patient Education " ! Physical activity is associated with improved physical health, life satisfaction, cognitive functioning, and psychological well- being (Carek et al. 2011)

Motivational Interviewing Motivational Interviewing Application

Traditional Approach Open-Ended Questions e What do you will be different? Expert gives advice " patient insight into condition " patient e What do you like/dislike about#? action

Works great sometimes! Affirm e You’re in pain right now and I don’t want to make it worse. e I appreciate your honesty in telling me...

Problems with treating patients with anxiety: Reflective Listening e What I hear you saying# e unresolved to change

e when only one side is spoken aloud, the internal voice is e You seem to... disputing e defensive stance is reinforced in patient Summarize e may be overt or covert e Today you were able to# e I think you have some great ideas...(say what they are).

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Cognitive Behavioral Therapy Philosophy G3E"+0,(2"

$ All psychological problems involve problems in thinking

$ The thinking is not the “cause” of psychological problems, per Negative Thinking Patterns Emerge: se “This is never going to get better.” “If only#” Baseline “I should/shouldn’t have#” Baseline $ Once a person has a psychological problem (such as depression or anxiety) – a problem in thinking is operating

Baseline Baseline

Event " Change in Anxiety physical Baseline functioning

Change in behaviors related to: -work - -self identity

PT and CBT CBT Intervention Application Cognitive Intervention: $ Complex regional pain syndromes Thought Challenging

1. Identify the negative thought $ Chronic pain “I can’t do this, so I’m not going to try.” 2. Evaluate evidence for and against $ Somatization Ask “Have you been successful with similar tasks in the past?” 3. Replace the negative thought with a more balanced, validating, and realistic thought $ Prevention of long-term disability “This feels hard now, and I will do this to the best of my ability.”

$ The roles of psychological factors in treatment Behavior Intervention: outcomes: Pleasant Activity Scheduling $ Attributions of change Plan out one small pleasant activity per day $ Self-efficacy 1. aim to be less than 10 minutes $ 2. NOT unhealthy activities 3. increases positive emotions, decreases negative thoughts (Baranoff, et al, 2013; Beissner, et al, 2009; Linton, et al, 2005; Lee, et al, 2002; Kroenke & Swindle, 2000) 4. can build/rebuild confidence, mastery, accomplishment "

Patient Education Provision of Patient Education Psychoeducation: Benefits of Exercise and Therapeutic Exercise

! In hospitalized patients, education as an intervention significantly What modifications to education and patient instruction potentially reduced anxiety levels at discharge and 2 months post-discharge. need to be made in working with clients with anxiety? (Aghakhani et al., 2013) ! Recognize your own beliefs and potential biases! ! Small effect for exercise in reducing anxiety in children/ adolescents. ! Create an inviting clinic space (Larun, 2006) # Be prepared to listen ! Immediate reduction in anxiety after qigong exercise. # Keep instructions constructive, specific, brief (Wang, et al, 2014) # Consider a distraction free environment ! Tai Chi has benefits for anxiety, , and exercise self-efficacy but larger studied needed. ! Provide overview of the session (Wang et al., 2014) # Helps to reduce anxiety about what is expected and helps to keep attention ! No support for use of as an effective treatment by # Break tasks into smaller components itself for anxiety disorders. (Bartley, Hay, and Bloch, 2013) ! Empower patient to be part of the goal setting process ! Exercise AND lifestyle change is beneficial. (Jayakody, Gunadasa, Hosker, 2014) ! Embrace multiple learning styles (British Columbia Ministry of Education 2001) ! Yoga has been shown to reduce anxiety symptoms by ~40%. " (Skowronek, Mounsey, & Handler, 2014)

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Progressive muscle relaxation Progressive Muscle Relaxation

Relaxation is a process that decreases the effects of stress on ! Essentially we want breath input and output to balance your mind and body. with what our body needs. ! Anxiety puts this out of balance. Relaxation techniques help with everyday stress and stress related to health problems. (Mayo Clinic, 2014) For a handout explaining the correlation between breath

and : Consists of a systematic progression of alternating isometric tensing and releasing of muscles, focus on deep breathing and http://psychology.tools/how-breathing-affects-feelings.html body awareness/control. (Salt & Kerr, 1997) " Resource for Further Information/Script: The Anxiety and Workbook Paperback, 5th ed. by Edmund J. Bourne

When to Refer? Green Yellow Red Referral ! Asking ! Repetitively asking ! Observing questions questions intoxication/ about their ! Exaggerated startle substance Social Worker condition response abuse Psychologist ! Engaged in ! Reported substance use (medication or PT POC ! Appearing or reporting: otherwise) Professional Counselor ! Showing a ! Feeling nervous, anxious, ! Psychiatrist trend of or on edge ! Comments Peer Counselor progress ! Body tension about toward goals ! Restlessness or difficulty Peer Support Group or discharge sitting still ! Feeling or Irritability ! over repeated instructions ! Feeling overwhelmed ! Fatigue ! Sleep disturbance ! Chest pain

(DSM-V, 2013)

Ferretti, L., McCurry, S.M., Logsdon, R., Gibbons, L., Teri, L. (2001). Anxiety and Alzheimer’s disease. References Spring;14(1):52-8. Aghakhani, N., Sharif, F., Khademvatan, K., Rahbar, N., Eghtedar, S., et al. (2011). The reduction in anxiety Foster, N. E., & Delitto, A. (2011). Embedding psychosocial perspectives within clinical management of low and depression by education of patients with . International Cardiovascular Research back pain: Integration of psychosocially informed management principles into physical therapist practice-- Journal, 5(2), 66-68. challenges and opportunities. PTJ, 91(5), 790-803. doi:10.2522/ptj.20100326 Anxiety and Depression Association of America. “Facts and Figures”. 2014. Retrieved from Gustad, L. T., Chaboyer, W., & Wallis, M. (2008). ICU patient's transfer anxiety: A prospective cohort study. http://www.adaa.org/about-adaa/press-room/facts-statistics. Australian Critical Care, 21(4), 181-189. doi:10.1016/j.aucc.2008.07.002 Atalay, N. S., Akkaya, N., Konukcu, S., Balci, C. S., & Sahin, F. (2013). Psychic predictors of outcomes of Haggman, S., Maher, C.G., Refshauge, K.M. (2004). Screening for symptoms of depression by physical physical therapy. Journal of Back and Musculoskeletal Rehabilitation, 26(1), 71. therapists managing . PTJ. 84(12):1157-66. Barker-Collo, S. L. (2007). Depression and anxiety 3 months post stroke: Prevalence and correlates. Archives Hart, D.L., Werneke, M.W., Deutscher, D., George, S.Z., Stratford, P.W.,Mioduski, J.E. (2011). Using intake of Clinical Neuropsychology, 22(4), 519-531. doi:10.1016/j.acn.2007.03.002 and change in multiple psychosocial measures to predict functional status outcomes in people with lumbar Bartley, C.A., Hay, M., Bloch, M.H. (2013). Meta-analysis: aerobic exercise for the treatment of anxiety spine syndromes: A preliminary analysis. Physical Therapy, 91(12), 1812-25. disorders. Prog Neuropsychopharmacol Biol . Aug 1;45:34-9. Hart, D. L., Werneke, M. W., George, S. Z., Matheson, J. W., Wang, Y., Cook, K. F., . . . Choi, S. W. (2009). Beissner, K., Henderson, C.R. Jr., Papaleontiou, M., Olkhovskaya, Y., Wigglesworth, J., Reid, M.C. (2009). Screening for elevated levels of fear-avoidance beliefs regarding work or physical activities in people Physical therapists' use of cognitive-behavioral therapy for older adults with chronic pain: A nationwide receiving outpatient therapy. Physical Therapy, 89(8), 770-785. survey. PTJ, 89(5), 456-69. Hiott, D. W., & Labbate, L. (2002). Anxiety disorders associated with traumatic brain injuries. Bonanno, G. A., Kennedy, P., Galatzer-Levy, I. R., Lude, P., & Elfström, M. L. (2012). Trajectories of Neurorehabilitation, 17(4), 345-355. resilience, depression, and anxiety following spinal cord injury. Rehabilitation Psychology, 57(3), 236-247. Jack, K., McLean, S., Moffett. J., Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy British Columbia Ministry of Education. (2001). Teaching students with mental health disorders resources for outpatient clinics: a systematic review. Man Ther. 15(3-2):220-228. teachers. Vol. 2. Jayakody, K., Gunadasa, S., Hosker, C. (2014). Exercise for anxiety disorders: a systematic review. Br J Broomfield, N. M., Quinn, T. J., Abdul-Rahim, A. H., Walters, M. R., & Evans, J. J. (2014). Depression and Sports Med. 48(3):187-96. anxiety symptoms post-stroke/TIA: Prevalence and associations in cross-sectional data from a regional stroke Kawachi, I., Colditz, G., Ascherio, A., Giovannucci, E., Stampfer, M., Willett. (1994). Prospective study of registry. BMC Neurology, 14(1), 198-198. doi:10.1186/s12883-014-0198-8 phobic anxiety and risk of coronary heart disease in men. May;89(5):1992-8. Carek P., Laibstain S., Carek S. (2011). Exercise for the treatment of depression and anxiety. The Kennedy, P., & Rogers, B. A. (2000). Anxiety and depression after spinal cord injury: A longitudinal International Journal of Psychiatry in Medicine, 41(1), 15-28. doi:10.2190/PM.41.1.c analysis. Archives of Physical Medicine and Rehabilitation, 81(7), 932-937. doi:10.1053/apmr.2000.5580 Eaton, W. (2006). Epidemiology of anxiety disorder. Lecture conducted at Johns Hopkins University, Baltimore MD.

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Kessler RC, Berglund PA, Demler O, Jin R, Walters EE. Lifetime prevalence and age of-onset distributions of Overmeer, T., Boersma, K., Main, C. J., & Linton, S. J. (2009). Do physical therapists change their beliefs, DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry. attitudes, knowledge, skills and behaviour after a biopsychosocially orientated university course?Journal of 2005 Jun;62(6):593-602. Evaluation in Clinical Practice, 15(4), 724-732. Kneebone, I. I., Neffgen, L. M., & Pettyfer, S. L. (2012). Screening for depression and anxiety after stroke: Painter, J., Allison, L., Dhingra, P., Daughtery, J., Cogdill, K., Trujillo, L. (2012). Fear of falling and its Developing protocols for use in the community. Disability and Rehabilitation, 34(13), 1114-7. relationship with anxiety, depression, and activity engagement among community-dwelling older adults. AJOT. Vol 66, 169-176. Larun, L., Nordheim, L.V., Ekeland, E., Hagen, K.B., Heian, F. (2006). Exercise in prevention and treatment of anxiety and depression among children and young persons. Cochran Database Syst Rev. 19(3). Pedersen, T. (2013). Anxiety Symptoms Often Accompany Chronic Pain. Psych Central. Retrieved on October 15, 2013, from http://psychcentral.com/news/2013/05/11/anxiety-symptoms-often-accompany-chronic-pain/ Lemyre, L., & Lalande-Markon, M. (2009). Psychological stress measure (PSM-9): Integration of an evidence- 54716.html based approach to assessment, monitoring, and evaluation of stress in physical therapy practice. Physiotherapy Theory & Practice, 25(5-6), 453-462. Player, M.S. (2011). Anxiety disorders, hypertension, and cardiovascular risk: A review. International Journal of Psychiatry in Medicine, 41(4), 365-77. Lincoln, N.B., Brinkmann, N., Cunningham, S., Dejaeger, E., De Weerdt, W., Jenni W. et al. (2013). Anxiety and depression after stroke: a 5 year follow-up. Disabil Rehabil. Jan;35(2):140-5. Ploghaus, A., Narain, C., Beckmann, C., Clare, S., Bantick, S., Wise, R. et al. (2001). Exacerbation of pain by anxiety is associated with activity in a hippocampal network. J of Neuroscience. 21(24):9896-9903. Lizana, F., Bota, D., Cubber, M., Vincent, J. (2003). Long-term outcome in ICU patients. Intensive Care Medicine. 29(8):1286-1293. Quale, A.J.,Schanke, A.K. (2010). Resilience in the face of coping with a severe physical injury: A study of trajectories of adjustment in a rehabilitation setting. Rehabilitation Psychology, 55, 12-22. Martin, F., Hart, D., Spector, T., Doyle, D., Harari, D. (2005). Fear of falling limiting activity in young-old women is associated with reduced functional mobility rather than psychological factors. Age Ageing. May;34(3):281-7. Ramsdan, E. and Taylor, J. (1998). Stress and anxiety in the diabled patient. PTJ. 68:992-996. Minor M.A., Brown J.D. (1993). Exercise maintenance of persons with arthritis after participation in a class Ringdal, M., Plos, K., Lundberg, D., Johansson, L., Bergborn, I. (2009). Outcome after injury: memories, experience. Health Education Quarterly. 20(1):83–95. health-related , anxiety, and symptoms of depression after intensive care. J Trauma. 66(4): 1226-33. Myhren, H., Ekeberg, O. Toien, K., Karlsson, S., Stokland, O. (2010). Posttraumatic stress, anxiety, and depression symptoms in patients during the first year post intensive care unit discharge. Crit Care. 14(1):R14. Robinson, O. J., Vytal, K., Cornwell, B. R., & Grillon, C. (2013). The impact of anxiety upon cognition: Perspectives from human threat of shock studies. Frontiers in Human Neuroscience, 7, 203. doi:10.3389/ Nielsen, M., Keefe, F. J., Bennell, K., & Jull, G. A. (2014). Physical therapist-delivered cognitive-behavioral fnhum.2013.00203 therapy: A qualitative study of physical therapists' perceptions and experiences. Physical Therapy,94(2), 197. Rubak S, Sandbaek A, Lauritzen T, Borch-Johnsen K, Christensen B,. (2006). An education and training Nijs, J., Vanherberghen, K., Duquet, W. (2004). : Lack of association between pain- course in motivational interviewing influence: GPs' professional behaviour--ADDITION denmark. Br J Gen related fear of movement and exercise capacity and disability. Phys Ther. 84(8), 696-705. Pract. 56(527), 429-36. Overmeer, T., Boersma, K., Denison, E., & Linton, S., J. (2011). Does teaching physical therapists to deliver a Salt, V. L., & Kerr, K. M. (1997). Mitchell's Simple Physiological Relaxation and Jacobson's Progressive biopsychosocial treatment program result in better patient outcomes? A randomized controlled trial.Physical Relaxation Techniques: A comparison. Physiotherapy, 83,4, 200-207. Therapy, 91(5), 804-819.

Scalzitti, D. (1997). Screening for psychological factors in patients with low back problems: Waddel’s Wang, F., Lee, E. O., Wu, T., Benson, H., Fricchione, G., Wang, W., et al. (2014). The effects of tai nonorganic signs. PTJ. 77:306-312. chi on depression, anxiety, and psychological well-being: A systematic review and meta-analysis. Seignourel, P., Kunik, M., Snow, L., Wilson, N., Stanley, M. (2008). Anxiety in dementia: a critical International Journal of Behavioral Medicine,21(4), 605-617. doi:10.1007/s12529-013-9351-9 review. Clin Psychol Rev. 28(7):1071-1082. Wisely, J. A., Wilson, E., Duncan, R. T., & Tarrier, N. (2010). Pre-existing psychiatric disorders, Shannon, R., Hillsdon, M. (2007). Motivational interviewing in musculoskeletal care. Musculoskeletal psychological reactions to stress and the recovery of burn survivors. Burns, 36(2), 183-191. doi: Care, 5(4), 206-15. 10.1016/j.burns.2009.08.008 Skowronek, I., Mounsey, A., & Handler, L. (2014). Clinical iniquiry: can yoga reduce symptoms of Zatzick, D., Jurkovich, G., Rivara, F. P., Russo, J., Wagner, A., Wang, J., et al. (2013). A randomized anxiety and depression? Journal of Family Practice, 63(7), 398-407. stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Annals of Surgery, 257(3). doi: 10.1097/SLA.0b013e31826bc313 Spitzer, R.L., Kroenke, K., Williams, J.B., Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. May 22;166(10):1092-7. Sullivan, M.J.L., Adams, H. (2010). Psychosocial treatment techniques to augment the impact of physiotherapy interventions for low back pain. Physiotherapy Canada, 62,180–189. Tarrier, N., Gregg, L., Edwards, J., & Dunn, K. (2005). The influence of pre-existing psychiatric illness on recovery in burn injury patients: The impact of and depression. Burns,31(1), 45-49. doi: 10.1016/j.burns.2004.06.010 Tully, P. J., Baker, R. A., Turnbull, D., & Winefield, H. (2008). The role of depression and anxiety symptoms in hospital readmissions after cardiac surgery. Journal of Behavioral Medicine, 31(4), 281-290. doi:10.1007/s10865-008-9153-8 Vong, S. K., Cheing, G. L., Chan, F., So, E. M., & Chan, C. C. (2011). Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 92(2), 176-183 Vriezekolk, J. E., Geenen, R., van den Ende, C. H. M., Slot, H., van Lankveld, W. G. J. M., & van Helmond, T. (2012). Behavior change, acceptance, and coping flexibility in highly distressed patients with rheumatic diseases: Feasibility of a cognitive-behavioral therapy in multimodal rehabilitation. Patient Education and Counseling, 87(2), 171-177.

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