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 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.Item Understanding the Role of Cues in Predicting Physical Activity Behavior(2023-06) Jochim, Alexander; Kaushal, Navin; Munk, Niki; Wierenga, KellyCues have been theorized to promote health behaviors but currently our understanding of the effectiveness of cues is inconclusive. The purpose of this systematic review was to assess the effectiveness of cue interventions in promoting physical activity (PA). Six databases were searched which captured 3,996 articles. After comparison with the eligibility criteria, 19 articles were included in the review. Data extraction revealed that while cues were effective in increasing PA behavior, less than half of the studies (n = 8) were supported by theory-based methodologies. We concluded that cue-based interventions are effective for promoting PA behavior, but future research must develop valid measures of cues and incorporate theory into their study designs. The purpose of the thesis study aimed to address this gap by testing if cue consistency would help explain PA habit and behavior through the Dual Process approach. We conducted an observational study with two measurement periods. We recruited 196 participants via an online volunteer registry. Participants completed measures of exercise behavior, intention, habit, perceived behavioral control (PBC), affective attitudes, and cue consistency at baseline and one month later. We ran a Hierarchical Multiple Regression analysis to determine whether a) habit, intention, PBC, affective attitudes, and cue consistency predicted moderate-vigorous physical activity (MVPA) and b) whether PBC, affective attitudes, and cue consistency predicted habit. Our results showed that MVPA was significantly predicted by habit (β = 0.23, p < 0.01), intention (β = 0.16, p < 0.05), PBC (β = 0.23, p < 0.01), affective attitudes (β = 0.20, p < 0.05), and cue consistency (β = -0.20, p < 0.05). Habit was predicted by affective attitudes (β = 0.48, p < 0.001) and cue consistency (β = 0.32, p < 0.001), but PBC (β = 0.10, p = 0.11) was not significant. We found a stronger relationship between cue consistency and habit than previous studies that evaluated cues individually, supporting the cue consistency construct. Our results suggest that cue consistency should be incorporated in the Dual Process approach as a determinant of habit. Future research should look to replicate our findings through cue-based interventions grounded in theory.Item Mid-upper arm circumference and nutritional risk in macrocephalic pediatric patients(2022-06) Wadelton, Christina Ann; O'Palka, Jacquelynn M.; Christensen, Celanie; Blackburn, Sara A.Objective: Nutritional assessment and diagnosis of malnutrition in pediatric patients is dependent on anthropometric measurements. In macrocephalic children, current anthropometric measures may fail to correctly diagnose malnutrition. The purpose of this study is to determine if the measurement of mid-upper arm circumference (MUAC) in pediatric patients with macrocephaly better identifies children at nutritional risk as compared to weight-for-length (WFL) or body mass index (BMI). Methods: A cross-sectional pilot study of children aged 6-36 months with a head circumference 2 SD above the mean was performed. Visual assessment was used as the clinical “gold standard” for presence of malnutrition. MUAC was compared to the WFL or BMI for each child to determine which anthropometric measurement better identified presence of malnutrition. Statistics: Two-way contingency tables were used to summarize the relationships between each pair of assessments of whether a child is malnourished. Agreement between the methods was evaluated using kappa statistics and percent agreement. Analyses were performed using SAS version 9.4 ™ statistical software. Results: Twenty patients were included who met study criteria. The mean head circumference z-score was 2.6. The mean BMI/WFL z-score was 0.9, which would qualify the child as “nourished.” Of the 20 children included in the study, 20% (n=4) appeared visually malnourished on physical exam. BMI/WFL confirmed diagnosis of malnutrition in 75% (n=3) of children. MUAC confirmed diagnosis of malnutrition in 75% (n=3) of children. Diagnosis of malnutrition using BMI/WFL as compared to visual assessment had a non-significant p-value of 0.317. Diagnosis of malnutrition using MUAC as compared to visual assessment had a non-significant p-value of 0.317. With a p-value of >0.5, there is no statistically significant difference between BMI/WFL and MUAC in diagnosis of malnutrition. Conclusion: MUAC did not perform better than BMI/WFL at identifying malnutrition in pediatric macrocephalic patients.Item Describing Emerging Adulthood in Individuals with Intellectual Disability Using Photo-Elicitation Methodology(2022-05) Gano, Laura Ann; Munk, Niki; Berlin, Kathy; Kaushal, Navin; Stanton-Nichols, KathleenFor adults with intellectual disability life as an adult is more constrained, with fewer opportunities; the literature indicates that intellectual disability negatively impacts people across multiple life domains. Despite this adverse influence, it is largely unknown how those with intellectual disability describe their experiences with adulthood. The current study utilizes photo-elicitation interviewing methodology in an attempt to rectify this deficit. Photo-elicitation research methodology uses images, rather than text, to construct queries and prompt responses. This approach is generally undertaken in disability studies to accommodate participants’ verbal and cognitive challenges, to make abstract concepts concrete, to provide opportunity for meaningful participation, and to empower subjects within the research environment. In this study, photo-elicitation interviewing was employed with a sample of 11 young adults with intellectual disability to discover how adulthood might differ in comparison with typical peers. Participants shared their perceptions of adulthood and experiences related to family, learning/education; community/volunteering/spiritual or faith community/employment/vocation; housing/neighborhood; friends/supportive relationships/personal connections; hobbies/fun; personal health. Results replicate participants’ endorsement of the same broad criteria for adulthood attainment as typified by normative peers in the emerging adulthood literature: acceptance of responsibility for oneself; independent decision-making; financial independence. Salient emergent findings specific to the study population indicated that adulthood differs in comparison with typical peers in relation to (1), advocacy efforts to increase awareness and value of the disability experience; (2), the effect of the COVID-19 pandemic; (3), the need for continued access to support services. Access to services can only be achieved through increasing awareness of this need, recognizing the importance of this need, and prioritizing policy change to meet this need. Participants in this study have indicated that they are more than up to the task of increasing awareness through advocacy, yet it falls to social institutions such as education and government to recognize this need for ongoing support and to prioritize this need by implementing service provision policy change.Item The Impact of a Growth Measurement Training Program on the Use of Length Boards in a Newborn Intensive Care Unit(2021-07) Thornton, Jessica Lynn; Blackburn, Sara; Denne, Scott; O'Palka, JacquelynnObjective: Nutritional assessment of infants in the Newborn Intensive Care Unit (NICU) depends on the performance of accurate, serial anthropometric measurements. In this Level IV NICU, nurses used tape measures more often than length boards making the length measurements inaccurate. The purpose of this study is to determine if an in-person, hands-on length board training program versus a self-instruction poster education, increases the use of length boards to measure length in NICU infants. Methods: Two nursing in-service education training sessions on how to correctly use a length board were held with the NICU staff over two separate two (2-week) periods. One session consisted of a self-direct education training method. The second education method was an in-person interactive learning experience with hands on practice. At the end of each education session, the participants completed the same four-question post-test. One month later, data was collected for one month following each of the training periods on the tool used to obtain linear measurements on infants in the NICU. Statistics: A 2x2 contingency table was constructed using the two qualitative variables of length board uses after the poster education versus length board uses after the live in-service education. Analysis was performed using SAS 9.4 ™ statistical software. Chi squared equals 93.980 with 1 degree of freedom. P-value <0.0001. Results: The month following the self-directed poster education, two hundred ninety-one (291) or 92% measurements were obtained using a tape measure and 19 (7%) obtained using a length board. The month following the interactive, in-service training, one hundred forty-eight (148) or 57% measurements were obtained using a tape measure and 105 (41%) with a length board. Thirty five percent (35%) more length measurements were obtained using a length board after the line in-service training (P-value <0.0001). Conclusion: Nurses in a Level IV Newborn Intensive Care Unit utilized length boards significantly more after a live in-service education than after a self-directed education.Item The Impact of Online Nutrition Education on WIC Client Retention and Redemption of the Cash Value Benefit of Fruit and Vegetables(2021-06) Gray, Sara Michelle; O'Palka, Jacquelynn; Blackburn, Sara A.; Magee, PaulaAll participants of the Indiana Special Supplemental Nutrition Program for Women Infant and Children (WIC) receive supplemental foods, nutrition education, and health care referrals. The Indiana WIC program established an online nutrition education program to help eliminate barriers to participants who are unable to be physically present for their second nutrition education appointments. The aim of this study was to compare the participation of WIC participants enrolled in standard in-person appointments with WIC participants enrolled in the Online Nutrition Education (ONE) pilot program by assessing the completion of the ONE lessons and the cash value benefit usage at 3 months after participants’ acceptance into the WIC program. A quasi-experiment was performed using a time series comparison of WIC participant attendance at their in-person nutrition education appointment to participants completion of an online nutrition education lesson. A second comparison of the two groups observed the participants redemption of their cash value benefit on fruits and vegetables (CVB). The increase in participation from 2019 to 2020 was statistically significant (P=0.035). Analysis showed that there was a significant difference (P ≤ 0.001) between the 2019 and 2020 CVB mean redemption rates. This study provides evidence that WIC participants are more likely to maintain their participation when offered the addition of an online nutrition education appointment type.Item Comparison of Intravenous Lipid Emulsions in Parenteral Nutrition: A Pilot Study(2021-02) McGuigan, Alexis K.; O'Palka, Jacquelynn; Blackburn, Sara; Laughlin, Michelle; Carter, AmyBackground: SMOF lipid™ infusion containing soybean oil, medium-chain triglycerides, olive oil, and fish oil has been approved and recommended for use in adults receiving parenteral nutrition (PN). Research shows that SMOF lipid infusion is safe for use in post-operative and critically ill patients. Improved patient outcomes are linked to SMOF lipid use over traditional soybean oil lipid emulsions. Objective: The purpose of this study was to determine the effect of SMOF lipid infusion on incidence of infection, ICU length of stay, hospital length of stay, and mortality in adult trauma patients as compared to parenteral nutrition utilizing 100% soybean oil emulsion or a lipid-free, dextrose and amino acid administration. Methods and Analysis: A retrospective chart review was conducted for adult trauma patients admitted to Eskenazi Health’s surgical intensive care unit (SICU) that received PN from May 2017 to May 2020. Data were collected from the electronic health record and trauma registry. Results: Twenty-nine patients were included who met study criteria: 17 patients in the traditional lipid cohort and 12 in the SMOF lipid cohort. The length of PN therapy was comparable between the traditional and SMOF ILE groups, 13.9 days (± 11.5) and 13.3 days (± 14.3) respectively. All 12 patients in the SMOF lipid cohort received intravenous lipid emulsion (ILE) compared to 42% (n=7) of traditional lipid group patients (p=0.001). SMOF treatment group were provided 100% of estimated energy needs via PN compared to an average of 94% (± 9.7) of estimated energy needs in the traditional lipid treatment group (p=0.036). Incidence of infection during initial hospitalization was significantly lower in the SMOF treatment group (n=3, 25%) compared to the traditional lipid treatment group (n=13, 76%). Mortality was decreased in the SMOF treatment group (0%) when contrasted to the Intralipid treatment group (23.5%), p=0.04. Conclusion: Patients receiving SMOF lipid emulsion within PN therapy had better clinical outcomes compared to those receiving Intralipid soybean-lipid emulsion or a dextrose and amino acid administration.Item The Effect of Anterior Cruciate Ligament Reconstruction on Leg-Spring Stiffness During Hopping(2020-12) Wolfe, David K.; Bahamonde, Rafael; Streepey, Jefferson; Riley, Zachary; Naugle, Kelly; Beekley, MatthewLeg-Spring Stiffness (LSS) is the measure of the musculoskeletal, neuromuscular, and biomechanical functions of the human body, and an appropriate evaluation metric for changes brought on by Anterior Cruciate Ligament Reconstruction (ACLr). ACLr can lead to flexion and extension loss, resulting in increased stiffness of the musculotendinous units of the ACLr leg and thus changes in LSS. LSS can be measured using Kleg, but little is known about the validity and reliability of the different methods of LSS and Kleg calculations. The purpose of this study was to determine if ACLr leads to a change in LSS (as measured by Kleg) during hopping, and to compare results of the Spring-Mass calculation and knee Joint Torsional stiffness methods in the computation of the overall Kleg. Video data synchronize with GRF were used to compute the kinematic and kinetic variables. Mann-Whitney U tests were used to determine significant differences between the control and experimental group for the Spring-Mass method of calculation (p = 0.004), Joint Torsional method (p =0.44), Kknee (p = 0.29), and Kankle (p = 0.17). Cohen’s effect calculations showed small to medium effects for the KKnee, (d = 0.383) but moderate effect size for the KAnkle, (d = 0.541). Wilcoxon Signed Rank comparison for all the legs and (N=42) between computational methods were significant differences between computational methods (Z = 5.65, p = 0.000), and with a large effect size (Cohen’s d = 3.14). Similar results were found when comparing only the ACLr leg values (p = 0.005, Cohen’s d = 4.88). The comparison between ACL Leg vs Non-ACL leg for experimental group subjects was not significant in either calculation method (Spring-Mass p = 0.20, Z = -1.27; torque calculation p = 0.96, Z = -0.05). The spring-mass method was more stable and able to detect differences between the control and ACLr group. The lack of statistical differences in the joint torsion calculation method, as well as in comparing the unaffected leg to the ACLr leg in the experimental group, suggests that LSS may not be a precise enough measurement to determine the effects of an ACLr.Item Virtual Reality: Its Effects on Physical Activity Intensity and Pain Sensitivity(2020-12) Evans, Eric Joseph; Naugle, Kelly; Arnold, Brent; Kaleth, Anthony; Naugle, KeithThe ability of virtual reality (VR) active games to elicit moderate-to-vigorous physical activity (MVPA) has yet to be fully understood. Also, whether VR combined with physical activity could have a greater pain reducing effect compared to non-active VR distraction remains unknown. The purpose of this study was to evaluate the effects of commercial VR active games on physical activity intensity levels, enjoyment, and pain sensitivity in young health adults. Thirty-six (18 males, 18 females) participants completed four study sessions, with each devoted to playing one VR game for fifteen minutes. The games included Beat Saber, Holopoint, Hot Squat, and Relax Walk VR. Levels of physical activity reached during VR gameplay were measured with percentage of heart rate reserve (%HRR), ratings of perceived exertion (RPE), and accelerometry. Enjoyment was measured with a visual analog scale and the Physical Activity Enjoyment Scale following each gaming session. Pressure pain thresholds (PPT’s) of the dominant forearm and ipsilateral thigh were conducted before and after VR gameplay. The primary outcome measures were analyzed with mixed model ANOVAs. The %HRR and RPE results showed that only Hot Squat consistently elicited moderate intensity activity. Accelerometry data showed that Hot Squat and Holopoint elicited higher whole body and lower body intensity levels than Beat Saber and Relax Walk VR. For enjoyment, Beat Saber and Holopoint were rated higher than Hot Squat and Relax Walk VR. Results for pressure pain thresholds (PPT’s) showed 1) an overall acute hypoalgesic effect on the forearm and thigh following all VR games, and 2) an enhanced hypoalgesic effect (combining MVPA and VR distraction) on the thigh following Hot Squat. Overall, results from this study suggest that active VR games can elicit varying degrees of physical activity intensity levels in young healthy adults, with Hot Squat eliciting moderate intensity activity. Thus, active VR games could be an alternative and enjoyable mode of obtaining physical activity. This study also showed that active VR games can elicit an acute hypoalgesic effect, with the effect potentially exacerbated with greater movement during gameplay.