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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Item The Use of Transcranial Direct Current Simulation to Facilitate Neuroplasticity During Motor Skill Learning(2025-10) Wilson, Michaela A.; Riley, Zachary; Streepey, Jefferson; Naugle, Kelly; Metzler-Wilson, KristenThe ability of the human brain to successfully learn and perform a motor task is a fundamental part of life. Motor skill learning allows us to be able to perform everyday tasks such as writing, typing, and playing sports. Recently, progress in our understanding of how motor skill learning occurs has elucidated the underlying neural mechanisms involved in the acquisition, consolidation, and retention of motor skills. Advancements in our understanding of these mechanisms have allowed us to employ techniques such as non-invasive brain stimulation to enhance and modulate these neural mechanisms to manipulate motor skill learning. In doing so, we can potentially enhance our ability to learn new motor tasks, specifically in healthy populations. For individuals who are required to have high rates of motor learning such as athletes, pilots, musicians, and surgeons, enhancements in motor skill learning are vital. Traditionally, motor skill learning is acquired by extensive practice or repetition of a motor skill over extended periods of time to achieve peak performance. However, what if these skills could be obtained not by long, extensive periods of practice, but rather, by short reactivations of these motor skill memories? Furthermore, what if these short reactivations could be enhanced by non-invasive brain stimulation techniques such as transcranial direct current stimulation (tDCS)? If short reactivations of a motor task can cause the same or similar effects to that of extensive bouts of practice, then the possibility that this could serve as a new form of motor training for individuals who require extensive motor skill learning seems possible. This could potentially allow individuals to spend less time practicing, while still obtaining the same gains in performance. To explore this concept, the following review will extensively elaborate on the underlying neural mechanisms of motor learning, tDCS, and the effects this combination of motor learning and tDCS have on motor performance and neuroplasticity.Item The Adaptation and Validation of Best Case/ Worst Case Acute Ischemic Stroke: A Communication Tool for Neurologists to Use with Hospitalized Patients and Families(2025-08) Bartlett, Stephanie Lee; Comer, Amber R.; Fettig, Lyle P.; Templeton, Evan; Torke, Alexia M.; Williams, Linda S.Stroke is a leading cause of long-term disability in the United States. Acute stroke survivors often face significant changes in their quality of life, leading to challenges in adapting to their new circumstances. Effective prognosis communication is crucial for shared decision-making (SDM) in acute stroke care. Yet, it remains a skill many physicians struggle to implement effectively in their clinical practice. Communication tools improve patient understanding and satisfaction. Initially developed for high-risk procedures, the Best Case/Worst Case (BC/WC) communication tool aims to enhance prognostic knowledge by presenting potential outcomes. This study aims to adapt the BC/WC communication tool for use with acute ischemic stroke patients, determine the clinical acceptability of the tool among neurologists, patients, and support persons, and validate its impact on patients' and support persons' prognostic understanding. This dissertation consists of three papers, each focusing on one aspect of adapting BC/WC for use in Ischemic Stroke (BC/WC-AIS). Chapter 2 employed focus groups with neurologists to assess barriers and facilitators to using BC/WC-AIS clinically. In Chapter 3, the researchers interviewed patients and support people to determine their perceptions and acceptability of BC/WC AIS. Lastly, in Chapter 4, a quantitative study was conducted with two cohorts (1- standard care and 2- standard care and BC/WC-AIS) to compare illness uncertainty, communication adequacy, and prognostic concordance between patients and /or support persons and neurologists. Preliminary findings suggest that patients who used the BC/WC-AIS tool reported significantly higher perceived information adequacy. The tool effectively facilitated communication, aiding patients and families in remembering and understanding the prognosis. However, neurologists expressed concerns about the time required to use the tool and potential misinterpretation, highlighting the need for further research and training. Neurologists, patients with strokes, and their support people positively accepted the BC/WC-AIS communication tool. These studies' findings show the promise of BC/WC in improving the quality of communication and prognostic understanding in acute stroke care. However, its effective implementation hinges on developing standardized training programs for neurologists and hospital staff. This aspect is of the utmost importance and should be a focus of future research and implementation efforts.Item Multifocal Transcranial Direct Current Stimulation to Modulate Motor Learning(2025-03) Greenwell, Davin Ross; Riley, Zachary; Kaleth, Anthony; Naugle, Kelly; Streepey, Jake; Metzler-Wilson, KristenTranscranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that modulates neural excitability in targeted brain regions, influencing processes such as motor learning. While tDCS has been previously shown to benefit motor skill acquisition, much of this research has focused on relatively simple, unimanual tasks. Conversely, the effects of tDCS on more complex, bimanual motor tasks remain understudied, with existing findings often yielding mixed results. This inconsistency poses challenges for translating laboratory findings to functional, real-world motor skills, which frequently involve coordinated, two-handed movements and heightened cognitive demands. Emerging evidence suggests that multifocal tDCS paradigms, which simultaneously target multiple brain regions, may provide enhanced learning effects, particularly for complex motor tasks. Unlike traditional monofocal stimulation protocols that focus on the primary motor cortex (M1) or cerebellum individually, multifocal approaches may better address the neural dynamics underlying bimanual coordination and interhemispheric interactions. The purpose of this dissertation was to investigate the potential of multifocal tDCS to enhance motor learning in complex tasks, examining both unimanual and bimanual skill acquisition. This research involved a series of studies beginning with monofocal tDCS applied to M1 and the cerebellum during a non-dominant unimanual rhythm-timing task and culminating in a multifocal “tri-focal” stimulation protocol during a bimanual motor learning task. In Study One, we compared the effects of excitatory M1 stimulation against excitatory and inhibitory cerebellar and sham stimulation. While none of the monofocal tDCS conditions significantly enhanced learning compared to sham, small, non-significant trends were observed which informed the design of Study Two. Here, we observed that combining excitatory M1 stimulation with inhibitory cerebellar stimulation resulted in significant and robust improvements in motor learning. In Study Three, we found that bilateral M1 stimulation significantly enhanced the early stages of bimanual skill learning at lower intensities. However, Study Four revealed that increasing stimulation intensity or adding inhibitory cerebellar stimulation impaired bimanual learning. Together, these findings contribute to a growing understanding of how multifocal stimulation paradigms can be tailored to enhance motor learning in real-world tasks while underscoring the importance of carefully optimizing stimulation parameters to task-specific demands.Item Intervention Effects on Musculoskeletal Health and Physical Function in CKD-MBD Using a Rat Model(2024-12) Troutman, Ashley Danielle; Avin, Keith; Warden, Stuart; Loghmani, Terry; Schulte, MichaelChronic kidney disease (CKD) is a systemic condition that affects approximately 14% of adults in the United States. Kidney damage disrupts biochemical concentrations which can lead to a condition known as CKD-mineral bone disorder (CKD-MBD). CKD-MBD consists of altered biochemistries, vascular calcification, and bone abnormalities. Skeletal muscle impairments have also been observed in those with CKD. Bone abnormalities lead to an increased risk of fracture that is 2-100 times higher in the CKD population than the non-CKD population. In CKD, muscular atrophy in combination with muscle weakness and/or poor physical function (i.e., sarcopenia) occurs in 4-63% of patients while muscular weakness alone (i.e., dynapenia) has a prevalence of 18-46%. The collective musculoskeletal impairments lead to a reduction in physical function, increased risk of hospitalization, and increased mortality. Exercise is commonly used to treat impaired bone and skeletal muscle in non-CKD populations. However, in CKD, exercise has demonstrated inconsistent results which are likely due to the varying exercise prescriptions reported in the literature. Additionally, the prescription of exercise necessary to cause musculoskeletal adaptation may be too intense for CKD patients in the mid-to-late stages of disease, especially since many were sedentary prior to diagnosis. This suggests that exercise alone may not be sufficient to elicit the desired muscle and bone outcomes. The use of nutraceuticals such as carnitine and pharmaceuticals that act as “exercise mimetics” are becoming more popular, however their impact on musculoskeletal health in CKD has not been extensively researched.Item Understanding the Process: How Undergraduate Students Develop Constructs of Disability in Service-Learning: A Constructivist Grounded Theory Approach(2024-12) Oliver, Any Renee; Stanton, Kathleen A.; Draucker, Claire; Urtel, Mark; Munk, NikiLittle research exists on how undergraduate students develop constructs or an understanding of disability during community-engaged service-learning experiences in adapted physical activity. Many studies have been conducted on attitudinal change in undergraduates working with individuals with disabilities. The researcher conducted a previous constructivist grounded theory study (Reshaping Understanding) that used Small Moment Reflections to develop a framework to identify student constructions of disability through a service-learning experience. However, the study determined two limitations: questioning the authenticity of students’ reflections and the limited diversity of client disability. This study was conducted to resolve the identified limitations and gather data to support or refute the Reshaping Understanding framework. Data was collected using semi-structured interviews and a new sample of Small Moment Reflections, which included a diverse set of disability diagnoses. Using the constructivist grounded theory, the researcher analyzed the samples from both data collection methods and compared each separately to the original framework. Results from the data analysis supported the Reshaping Understanding framework in both studies. The new data supported undergraduate stages of change and threads of disability constructs with minor variations. Variations only existed when fine-tuning the coding within each stage and thread. Most codes fully supported the original framework. Some previous codes were not supported and were removed, while newly identified ones that were heavily supported were added to the existing framework. Since the stages and threads were consistent with the original framework, the researcher confirmed that a psychosocial process existed. The Reshaping Understanding framework transitioned into the Cultivating Understanding psychosocial process to better depict how the change process evolves metaphorically. While the threads remained unchanged in identification, the stages were re-identified. The results of this study provide evidence that pre-professionals working with individuals with disabilities experience a change in understanding disability as they move through service-learning experiences. This offers pedagogical implications for teaching students about disability in the classroom and through experiential learning. Additionally, it paves the way for new research studies that may help further develop the Cultivating Understanding psychosocial process.Item Obstacles to Wellness: A Study of Psychosocial Stress and Support Systems in Community Health Programming for Black Americans(2024-11) Carey, Christopher J.; Keith, NiCole; Staten, Lisa; Elmendorf, Jeffrey; Kaushal, NavinType 2 Diabetes (T2D) poses a significant public health challenge, disproportionately affecting Black Americans. This dissertation investigates the efficacy of exercise interventions tailored for the management of T2D, emphasizing the interplay of psychosocial stress and community-based support systems within this demographic. Chapter I provides details about the pathophysiology of T2D and the compounded impact of psychosocial stressors and exercise, establishing the groundwork for targeted interventions. Chapter II conducts a systematic review to ascertain the effectiveness of various exercise modalities in improving T2D health outcomes. It highlights that combined aerobic and resistance training at moderate to high intensity significantly enhances insulin sensitivity and glucose metabolism. Chapter III examines a community-based exercise program, "Max Impact," focusing on how race-related stress affects the program’s efficacy. The study reveals that while exercise improves metabolic health indicators among participants, the effects are not statistically significant. This finding emphasizes that underlining factors, such as psychosocial stress, could have mediated this relationship, which highlights the necessity of better understanding psychosocial stress’s effect on health interventions and outcomes. Chapter IV explores qualitative insights from the participants of the Max Impact program, uncovering the complex barriers and supports for physical activity. It stresses the importance of accessible and relatable health education and community support in fostering sustained engagement in physical activity. The final chapter, V, synthesizes these findings, discussing the practical implications of integrating psychosocial elements into exercise prescriptions for T2D management. It calls for more comprehensive approaches that address both the physiological and psychological facets of health disparities faced by Black Americans. This research contributes to the literature on health disparities by highlighting the critical role of culturally sensitive, community-focused interventions in managing chronic diseases like T2D.Item Exploring Exercise Outcomes, Preferences, and Barriers in Adolescent and Young Adult Cancer Survivors(2024-08) Sherman, Melissa Marie; Keith, NiCole R.; Kaushal, Navin; Naugle, Kelly; Renbarger, JamiePhysical activity (PA) improves physiology and cognition including Quality of Life (QoL), fatigue, depression, anxiety, and emotional well-being. Despite the positive effects of PA, adolescent, and young adult (AYA) cancer survivors (15-39 yrs.) do not meet the American College of Sports Medicine (ACSM) recommended PA guidelines to elicit positive health outcomes. AYA survivors may have unique physical and psychological experiences that impact motivation, barriers, and preferences for participation in PA. The overarching purpose of this dissertation is to better understand the outcomes, motivation, preferences, and barriers to exercise adherence when completing exercise and PA interventions among AYA survivors of cancer. This dissertation addresses this purpose through three distinct studies: AYA Cancer Survivors and One-on-One Exercise in an In-person setting, AYA Cancer Survivors and One-on-One Exercise in a Virtual Setting, and subsequent focus groups that utilized the participants from both virtual and in-person studies. Results indicated that the nature of cancer and cancer treatment, type of cancer, age at diagnosis, and experience within treatment (i.e. surgery, radiation, chemotherapy, stem cell transplants) varied significantly across AYA survivors of cancer. Despite the differences in experience, cancer-related fear and anxiety were common among participants but were offset by a sense of control and accountability experienced during the larger study. Working one-on-one with a wellness coach or exercise trainer provided participants with a sense of accountability and a sense of control that otherwise was missing post-cancer treatment and remission. The extra support is needed to help alleviate fears and anxiety and to promote accountability, acceptability, and adherence to exercise. A multi-disciplinary approach with wellness coaching and individualized PA guidance is suggested for future programming in this population group. While AYA survivors of cancer are an often understudied population, future research must target more racially and ethnically diverse groups to understand this group as a whole better.Item Reliability of Dynamic Soft Tissue Pain Assessment Using Novel Methodology and Technology(2024-05) Noel, Zachary Dewaun, Jr.; Loghmani, Mary T.; Kaushal, Navin; Sohel, AnwarSoft tissue manipulation (STM) is a form of manual therapy used to treat chronic conditions such as myofascial pain. There is a need to address how myofascial tissues contribute to chronic pain, which is critical for future biomarker development. An important step is the creation of Quantifiable Soft Tissue Manipulation (QSTM®). The purpose of this study is to determine the reliability of Quantifiable Soft Tissue Manipulation (QSTM®) devices on dynamic pain threshold assessment, and to determine effects of soft tissue assessment on secondary clinical outcomes in different body regions. In this observational study, 4 trained clinicians (2 novice, 2 experienced) treated patients with the QSTM® system Q1 and Q2 devices. The clinicians tested a total of 44 subjects (21 male and 23 female). Subjects were excluded if BMI was <19 or >30 kg/m2. All subjects were placed into age groups: young adults (18-30) and older adults (50-75). Secondary clinical outcomes were also measured. For average peak and maximum peak 3-dimensional resultant force, the interclass correlation coefficient (ICC) demonstrated good inter-rater (0.65-0.73), and intra-rater (ICC 0.62-0.91) reliability for all subjects, however the inter-rater reliability was less for older adults (0.53 - 0.72). For the rate and angle, the intra-rater (ICC 0.15-0.94) was less than fair to excellent depending on the examiner, but greater than the inter-rater (ICC 0.18-0.34) reliability. The inter-rater reliability was less for older adults (ICC 0.00-0.19). Dynamic pain threshold assessment can be reliably assessed but the methodology needs to further be standardized, i.e., performed at a standardized rate and angle of force application, to improve reliability of this testing method.Item Application of Transcranial Direct Current Stimulation During Motor Skill Acquisition(2024-03) Meek, Anthony Wilhite; Riley, Zachary; Munk, Niki; Naugle, Kelly; Streepey, JakeTranscranial direct current stimulation has been used to influence the acquisition of motor skills; however, most studies investigate relatively simple laboratory based motor skills tasks. Since the regions where structural and functional changes support motor learning are dependent on the qualities of the task, translation of the findings to real-world skills has been limited. In general, anodal current stimulation is associated with functional facilitation and cathodal current is associated with functional inhibition. The purpose of this dissertation is to explore the effect of transcranial direct current stimulation of the primary motor cortex and the cerebellum upon the acquisition of novel motor skills that possess varied demands comparable to everyday tasks. In order to study motor skill learning, we investigated 4 unilateral tasks made novel by using the non-dominant hand, ensuring a discernible fast phase of learning in which to observe skill acquisition. In study one, anodal stimulation applied over the primary motor cortex during a 20 minute practice session skill acquisition in a complex dart throwing task compared to cathodal motor cortex stimulation or SHAM. In study two, 20 minutes of anodal motor cortical stimulation while practicing a dexterous tweezer task significantly reduced postpractice pin-placing time compared to SHAM. In study three, anodal motor cortical stimulation during 20 minutes practicing a dexterous rhythmic-timing video game led to significantly higher performance scores compared to SHAM. In study four, in the same videogame task, concurrently stimulating the primary motor cortex with 2 milliamp anodal current while stimulating the cerebellum with 2 milliamp cathodal current during 20 minutes of practice led to significantly higher performance scores compared to SHAM, whereas 2 milliamp anodal primary motor cortex, anodal cerebellar, and cathodal cerebellar stimulation alone was not different than SHAM. These data altogether show that motor cortical transcranial direct current stimulation can facilitate skill acquisition in everyday tasks with a range of gross, fine, and visuomotor demands. They also provide the first evidence of a synergistic effect on motor learning from concurrent primary motor cortex and cerebellar stimulation, which may contribute to the development of novel stimulation protocols.Item Augmenting the Health Belief Model to Promote Knee Massage as Self-Management Among Individuals with Knee Osteoarthritis: A Roadmap for Future Research and Intervention Development(2023-08) Nemati, Raheleh; Munk, Niki; Kaushal, Navin; Keith, NiCole; Naugle, KellySelf-administered massage is a form of self-management that has been shown to alleviate symptoms among individuals with knee osteoarthritis. However, existing interventions have yielded inconsistent results in terms of promoting the practice of self-administered massage, highlighting a critical gap in the application of a theoretical or conceptual model. The current study utilized an expanded health belief model that integrates constructs from the theory of planned behavior aimed to identify the behavioral determinants associated with the practice of self-administered knee massage. An observational study was designed to address the objectives using an online survey. A total of 268 participants with knee osteoarthritis completed the survey. Data regarding the clinical characteristics of participants, including the year of diagnosis, chronicity of pain, affected knee(s), and the intensity of pain in terms of current, average, and worst levels, were collected. Structural equation modeling was used to test the predictive validity of the proposed model. The model revealed self-administered massage behavior to be predicted by intention (β = .21, p < .014). Intention was predicted by cues (β = .29, p <.001), task self-efficacy (β = .29, p <.001), affective attitudes (β = .14, p =.011), perceived severity (β = .27, p <.001), and perceived facilitators (β = .22, p <.001), but not response self-efficacy, instrumental attitudes, or barriers. Intention mediated the effects between cues (β = .06, 95% CI .025, .129) and perceived severity (β = .06, 95% CI .014, .127) and behavior. Model determinants were found to mediate between age and behavior (β = -.16, 95% CI -.224, -.093). Interventions aimed at promoting self-administered massage should focus on enhancing individuals' perception of the severity of their knee OA progression and their confidence in performing the massage by teaching them the common massage techniques.