Health and Human Sciences Theses and Dissertations

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This collection contains theses and dissertations for the Therapeutic Outcomes Research Program and the Department of Nutrition & Dietetics.

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Adherence With Home Exercise Programs 1-6 Months After Discharge From Physical Therapy By Individuals Post-Stroke
(2008-10-10T17:10:22Z) Miller, Kristine Kay; Mac Kinnon, Joyce L.; Porter, Rebecca Elaine; Riolo, Lisa
THE IMPACT OF FIBROMYALGIA ON RESOURCE USE IN THE UK PRIMARY CARE SETTING
(2008-10-10T18:19:38Z) Le, Trong Kim; Mac Kinnon, Joyce L.; Bayliss, Amy J.; Schellhase, Ellen
Fibromyalgia (FMS) is a complex, chronic condition involving persistent and widespread pain of unknown origin. FMS is sometimes mistaken as psychiatric in origin; however, the precise origin and cause of FMS is unknown (Klippel et al., 1998). Worldwide prevalence rates range from 0.18-12%, with 0.18% in the United Kingdom (UK) (Hughes et al., 2006), 2% in the United States (US) (Wolfe et al., 1997), and 12% in Spain (Carmona et al., 2001). In the UK, there is debate over the existence of FMS (Bohr, 1995), and the reluctance of a general practitioner (GP) to diagnose conditions that are poorly defined (Hughes et al., 2006). Primary symptoms of FMS include generalized muscular pain, multiple tender points, sleep disruption and excessive fatigue. Additional symptoms include headaches, memory and concentration problems, dizziness, numbness/tingling, itching, fluid retention, abdominal cramps or pelvic pain and diarrhea (Hudson et al., 1992). Clearly, these symptoms may have an immense impact on daily life, limiting an individual’s functioning and emotional well-being. FMS is associated with significant societal and health care costs. Patients with FMS may repeatedly present to the general practitioner with various symptoms before a definitive diagnosis of FMS is made. As a result, general practitioners may be more likely to diagnose FMS in patients who frequently present with symptoms related to FMS, while patients who meet the diagnostic criteria but who rarely present at the practice may be missed (Ehrlich, 2003). The condition is of unknown etiology, and this, together with the lack of verifiable diagnostic criteria (i.e. lab tests), has led some to speculate that the disease does not or is at best a surrogate marker for underlying psychosocial problems. As such, the very process of diagnosing a patient with FMS may exacerbate symptoms and lead to increased dependence on health care providers (Ehrlich, 2003). This study examined the diagnoses of FMS made in “real-life” clinical practice and recorded by general practitioners in a large primary care population in the UK.
Hospital Readmission and the Timing of Postdischarge Outpatient Follow-up
(2011-03-09) Kashiwagi, Deanne Tomie; Mac Kinnon, Joyce L.; Kirkland, Lisa; Mushi-Brunt, Christina R.
Postdischarge follow-up appointments are widely thought to improve the safety of transition for patients moving from the hospital to home. They provide an opportunity for outpatient primary care providers to detect problems or failures of postdischarge care. Readmissions can be used to reflect the quality of postdischarge or transitional care. This study evaluated whether patients with an outpatient follow-up appointment scheduled with their primary care provider within five calendar days of discharge had fewer 30-day readmissions than those patients who had appointments scheduled six days or longer from discharge. No difference in readmission rate was detected between the two groups.
ACTUAL AND PRESCRIBED ENERGY AND PROTEIN INTAKES FOR VERY LOW BIRTH WEIGHT INFANTS: AN OBSERVATIONAL STUDY
(2012-10-11) Abel, Deborah Marie; Rickard, Karyl A.; Brady, Mary Sue; Engle, William A.; Ingram, David A.; Poindexter, Brenda B.
Objectives: To determine (1) whether prescribed and delivered energy and protein intakes during the first two weeks of life met Ziegler’s estimated requirements for Very Low Birth Weight (VLBW) infants, (2) if actual energy during the first week of life correlated with time to regain birth weight and reach full enteral nutrition (EN) defined as 100 kcal/kg/day, (3) if growth velocity from time to reach full EN to 36 weeks’ postmenstrual age (PMA) met Ziegler’s estimated fetal growth velocity (16 g/kg/day), and (4) growth outcomes at 36 weeks’ PMA. Study design: Observational study of feeding, early nutrition and early growth of 40 VLBW infants ≤ 30 weeks GA at birth in three newborn intensive care units NICUs. Results: During the first week of life, the percentages of prescribed and delivered energy (69% [65 kcal/kg/day]) and protein (89% [3.1 g/kg/day]) were significantly less than theoretical estimated requirements. Delivered intakes were 15% less than prescribed because of numerous interruptions in delivery and medical complications. During the second week, the delivered intakes of energy (90% [86 kcal/kg/day]) and protein (102% [3.5 g/kg/day]) improved although the differences between prescribed and delivered were consistently 15%. Energy but not protein intake during the first week was significantly related to time to reach full EN. Neither energy nor protein intake significantly correlated with days to return to birth weight. The average growth velocity from the age that full EN was attained to 36 weeks’ PMA (15 g/kg/day) was significantly less than the theoretical estimated fetal growth velocity (16 g/kg/day) (p<0.03). A difference of 1 g/kg/day represents a total deficit of 42 - 54 grams over the course of a month. At 36 weeks’ PMA, 53% of the VLBW infants had extrauterine growth restriction, or EUGR (<10th percentile) on the Fenton growth grid and 34% had EUGR on the Lubchenco growth grid. Conclusions: The delivered nutrient intakes were consistently less than 15% of the prescribed intakes. Growth velocity between the age when full EN was achieved and 36 weeks’ PMA was 6.7% lower than Ziegler’s estimate. One-third to one-half of the infants have EUGR at 36 weeks’ PMA.
Therapeutic-yoga after stroke : effect on walking recovery
(2013-12-16) Miller, Kristine Kay; Schmid, Arlene A.; Combs, Stephanie A.; Page, Stephen J.; Porter, Rebecca E.
Stroke is a sudden and devastating medical condition. People who experience a stroke tend to have long-term physical limitations including impaired walking as part of the ongoing consequences of stroke. While a variety of rehabilitation interventions have demonstrated efficacy for improving walking after stroke, none of the interventions have emerged as superior, and prior to this study, therapeutic-yoga had not been tested as an intervention to improve walking recovery after stroke. METHODS: This study was a secondary data analysis of group therapeutic-yoga on walking recovery measures including walking speed, walking distance, and spatiotemporal step parameter symmetry. The walking recovery measures were collected as secondary outcomes in a sub-sample (n=12) in a pilot randomized controlled study (n=47) designed to test the efficacy of 8-weeks of group therapeutic-yoga on balance and fear of falling. Participants in the current study completed 12-weeks of group therapeutic yoga with outcome assessments at baseline, 8-weeks, and 12-weeks. The main analysis was repeated measures ANOVA to assess the main effect of time with additional analyses including effect sizes, percent of participants achieving change greater than or equal to minimal detectable change (MDC), and mean change score comparisons between baseline and 8-weeks, 8-weeks and 12-weeks, and baseline and 12-weeks. RESULTS: Twelve people with chronic stroke enrolled in the study with 9 completing the intervention and all 3 assessments. No significant main effect of time was found on any of the variables of interest. Walking distance demonstrated a trend toward significant change (p=0.064) and step length symmetry demonstrated significant change (p=0.05) between baseline and 12-weeks. Several spatiotemporal step parameter symmetry ratios demonstrated small to medium effect sizes with the majority (91%) being a negative effect. CONCLUSION: Twelve weeks of group therapeutic-yoga appears to be feasible in a population of people with chronic stroke. Walking distance and step parameter symmetry should be tested in a larger sample. An improved understanding of the impact, progression, and remediation of walking asymmetry is needed.
Community-Based Exercise Program Attendance and Exercise Self-Efficacy in African American Women
(2014-01-29) Virgil, Kisha Marie; Mikesky, Alan E.; Keith, NiCole R.; De Groot, Mary K.; Hess, Lisa M.; Mushi-Brunt, Christina R.
Rates of chronic disease and physical inactivity are disproportionately high among African American women. Despite the known benefits of physical activity and an increasing number of programs designed to increase activity, attendance rates to many exercise programs remain low. There is much to learn about program types, such as healthy lifestyle programs (HLP); individual factors, such as self-efficacy; and mediating variables that may influence exercise program attendance. An observational study design was used to compare exercise self-efficacy and attendance in a community-based exercise program in African American women who were enrolled in a HLP (N = 53) to women who were not (N = 27). Exercise program attendance was gathered across six months; demographics, self-efficacy and physical activity behaviors were assessed through surveys; and physiological variables (resting heart rate and blood pressure, height, and weight) and physical fitness (muscular strength and endurance and cardiovascular endurance) were measured at baseline. Descriptive statistics were used to describe participants and groups were compared using T-tests, chi-square and non-parametric statistics. Finally, mediation analyses were conducted using multiple regression models to assess self-efficacy as a potential mediator to exercise program attendance. Women who enrolled in this study were of low income (61% having an annual income less than $20,000), obese with a mean (standard deviation) body mass index (BMI) of 37.7 (7.6), pre-hypertensive with a mean (standard deviation) systolic blood pressure of 125.9 (14.4), and scored poorly and marginally on two fitness tests. On average, women reported being Moderately Confident in their ability to exercise regularly, yet had low attendance in the exercise program with a median number .5 days over six months and there were no significant differences in exercise self-efficacy (p = .23) or attendance in the exercise program between groups (p = .79). Additionally, exercise self-efficacy was not a mediating variable to program attendance. Women in this study had little discretionary income and several chronic disease risk factors, yet exercise program attendance was low even in those enrolled in a HLP. Identifying factors that increase exercise self-efficacy and factors that influence attendance beyond self-efficacy may help future program design and attendance.
Adapted dance- connecting mind, body and soul
(2014-01-29) Swinford, Rachel R.; Ellett, Marsha L.; Sloan, Rebecca S.; Crabtree, Jeffrey L.; Horton-Deutsch, Sara L.; Stanton-Nichols, Kathleen A.
Using Heideggerian interpretive phenomenology, this study illuminates the lived experience of an adapted dance program for individuals with Down syndrome and their family members. The overall pattern from both dancers and family members was adapted dance: connecting mind, body and soul. The primary theme from dancer interpretations was expressing a mosaic of positive experiences, and the primary theme from family member interpretations was experiencing pride in their loved ones. The dance program provided dancers an opportunity to express their authentic self while experiencing moments of full embodiment in the connection of their mind, body and soul. While dancers experienced the connection of mind-body-soul, family members recognized the importance of this connection in their loved one. This research is instrumental in advocating for opportunities for individuals with Down syndrome to experience dance as a social, physical and intellectual activity that results in learning and increasing social interactions. The research findings from this study can support future initiatives for dance programs that may influence a population that has limited access to physical activity and dance. The study’s teaching strategies, dance activities, class procedures and sequences, and feedback techniques can be used by other professionals who teach individuals with intellectual disabilities.
The relationship between touch sensation of the hand and occupational performance in individuals with chronic stroke
(2014-07-11) Hill, Valerie A.; Fisher, Thomas; Crabtree, Jeffrey L.; Page, Stephen J.; Schmid, Arlene A.
Stroke is the main cause of disability in the United States. Individuals with stroke commonly report sensory impairment affects their recovery. Motor recovery and sensory impairment are related and impact individuals’ ability to perform valued occupations. Despite the prevalence of sensation impairment after stroke, many occupational therapists fail to include sensation assessment and intervention in treatment planning. The exclusion of sensation in occupational therapy interventions during stroke rehabilitation may be due to the lack of literature supporting the association between sensation and occupational performance. The current study aimed to determine the relationship between touch sensation of the affected hand and occupational performance and satisfaction in individuals with chronic stroke. Using a cross-sectional study design, this study associated factors related to hand sensation and function in individuals with chronic stroke. Fifty individuals with chronic stroke participated in a one-time testing session in which assessments related to sensation, movement of the hand and engagement in daily activities were administered. Correlation analyses were utilized to determine relationships between touch sensation of the affected hand with individuals’ abilities to engage in valued daily activities, arm and hand disability, and manual abilities. The main finding of the study was that individuals with intact sensation reported greater ability to perform valued occupations and satisfaction with their performance, as compared with individuals with touch sensation impairment. For individuals with impaired touch sensation of the affected hand, impairment of touch sensation of the hand did not correlate with individuals’ performance or satisfaction with valued occupations, arm or hand movement, or manual abilities. Collectively, the results of this study reflect the complex interaction between touch sensation, occupational performance, motor functioning, and manual abilities of the affected hand for individuals’ who have experienced a stroke. This study informs therapists, rehabilitation scientists, and other healthcare professionals that client-centered, individualized approaches, including a wide array of clinical assessments and intervention, including assessment of occupational performance and sensation, remain important components in stroke rehabilitation.
Posttraumatic stress disorder and chronic musculoskeletal pain : how are they related?
(2014-07-11) Peng, Xiaomei; Bair, Matthew J.; Kroenke, Kurt; Faries, Douglas E.; Mac Kinnon, Joyce
Symptoms of post-traumatic stress disorder (PTSD) are a common comorbidity in veterans seeking treatment of chronic musculoskeletal pain (CMP). However, little is known regarding the mutual influence of PTSD and CMP in this population. Using cross-sectional and longitudinal data from a randomized clinical trial evaluating a stepped care intervention for CMP in Iraq/Afghanistan veterans (ESCAPE), this dissertation examined the relationships between PTSD and CMP along with other factors including depression, anxiety, catastrophizing and health-related quality of life. The Classification and Regression Tree (CART) analysis was conducted to identify key factors associated with baseline PTSD besides CMP severity. A series of statistical analyses including logistical regression analysis, mixed model repeated measure analysis, confirmatory factor analysis and cross-lagged panel analysis via structural equation modeling were conducted to test five competing models of PTSD symptom clusters, and to examine the mutual influences of PTSD symptom clusters and CMP outcomes. Results showed baseline pain intensity and pain disability predicted PTSD at 9 months. And baseline PTSD predicted improvement of pain disability at 9 months. Moreover, direct relationships were found between PTSD and the disability component of CMP, and indirect relationships were found between PTSD, CMP and CMP components (intensity and disability) mediated by depression, anxiety and pain catastrophizing. Finally, the coexistence of PTSD and more severe pain was associated with worse SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Together these findings provided empirical support for the mutual maintenance theory.
Effect of Learning Preference on Performance in an Online Learning Environment among Nutrition Professionals
(2014) Myatt, Emily Laura; Contino, Lisa; Ernst, Judith A.; O'Palka, Jacquelynn M.
Background: Online courses in healthcare programs like Dietetics have increased in availability and popularity. Objective: The purpose of this study was to investigate the connections between online learning environments and Myers-Briggs Type Indicator (MBTI) dimensions among Nutrition Professionals. This research will add to the knowledge base of educators responsible for the design and development of online nutrition courses and will enhance Nutrition Professionals’ academic and professional outcomes. Design: Semi-experimental study design. Subjects/Setting: Thirty-one Nutrition Professionals with mean age of 29 years old. All elements of the study were done online. Statistical Analysis: MBTI dimension summaries were done for descriptive statistics. Fisher’s Exact Test was used to compare frequency of MBTI dimensions in the learning modules (LM) and to analyze learning modality preference based on MBTI dimensions. Two-Sample T-Tests compared test scores for LM groups and test scores for extraverts and introverts. Paired T-Test assessed improvement in test scores related to LM preference. Chi-Square Test compared preferences for the second learning module for both LM groups. Results: The majority of participants’ MBTIs were ESFJ at 35% or ISFJ at 19%. There were more extraverts (71%) compared to introverts (29%). Both LM groups had similar MBTI dimensions. Extraverts and introverts had similar improvements in scores and LM preferences. LM groups performed similarly and in general participants preferred the second learning module they were assigned. Preference for the second LM could be because participants enjoyed the first LM and wanted to learn more information. Both LM groups significantly improved their scores (P=<.0001) in their first and second learning modules regardless of learning module design. Participants were highly motivated to learn as evidenced by their enrollment in this study and completion of 10 hours of learning modules. Motivation to learn may have been the strongest reason performance significantly improved. Conclusion: LM groups significantly improved their LM scores and learned similar amounts. MBTI dimensions extravert and introvert and preferred learning modality had limited impact on performance for this sample of Nutrition Professionals. These results indicate that motivation may be the key to increasing performance in online nutrition courses.

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