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Exercise is critical for effective disease management of Parkinson’s disease (PD); however, people with PD are less active than their age-matched peers. The social cognitive theory of behavior provides a framework to examine this problem and to generate potential targets of intervention. In this project, I investigate the effect of, personal, social/environmental, and behavioral determinants on exercise and physical activity in people with PD. To investigate the personal and behavioral determinants, we focused upon motivation related to physical activity. We used a neuroeconomic paradigm requiring participants to decide to accept or reject physical effort in the face of varying levels of effort and reward (effort-based decision-making). We sought to determine if effort-based decision-making specifically related to exercise was different in people with PD compared to controls (study 1). In addition, we set out to determine if components of motivation, in the form of apathy and the anticipation of pleasure, predicted decision-making for physical effort in people with PD, when controlling for the physical measures of age, physical capacity and disease severity. We used hierarchical logistic regression models to test the effect of effort, reward and trial (time) at the individual level as well as sex and the presence of PD at the group level in 32 people with PD and 23 age-matched controls. Additional exploratory analyses tested the mediating effect of age, disease severity, physical capacity as well as apathy and the anticipation of pleasure at the group level. We found that people with PD who were receiving dopamine replacement therapy, were physically active, and were non-depressed responded similarly to effort and reward valuations compared to those without PD. However, apathy and the anticipation of pleasure, after controlling for the contribution of age, disease severity and physical capacity, were significant predictors of decisions for both the discrete motor and exercise tasks in people with PD only. The apathy and the anticipation of pleasure may be unique predictors of decisions to engage in exercise in people with PD. To investigate social/environmental and behavioral effects, we developed a PD specific peer coach training program and a remote peer-mentored walking program using mobile health (mHealth) technology with the goal of increasing physical activity in 5 peer dyads with PD (study 2). We set out to examine the feasibility, safety, and acceptability of the programs along with preliminary evidence of individual level changes in walking activity in the peer coach and peer mentee and changes in self-efficacy and disability in the peer mentees. We found that remote peer coaching using mHealth was feasible, safe, and acceptable for persons with PD. Increases in average steps/day, exceeding the clinically important difference, occurred in 4/5 mentees. Peer coaching using mHealth technology may be a viable method to increase physical activity in individuals with PD. Taken together these two studies highlight the importance of addressing the relation between personal, behavioral and social/environmental determinants on exercise and physical activity behavior in people with PD. Motivation for exercise in people with PD was enhanced with peer coaching and when general apathy was low and anticipation of pleasure was high. People with PD who were active and were being treated with dopamine replacement therapy were responsive to rewards and were accepting of physical effort. Prescription of exercise that is associated with pleasure as well as rewards may be readily accepted by people with PD. This prescription can be supported with peer coaching to enhance physical activity outside of the formal healthcare environment. Together these factors may lead to improved management of PD by addressing the effect of motivation on physical activity. / 2021-09-28T00:00:00Z

Ehlers-Danlos syndrome (EDS) is a group of rare conditions caused by genetic defects to the extracellular matrix. These defects affect skin, joints, vasculature, and internal organs. In the EDS group, 80%–90% of the conditions are categorized as hypermobile type. Hypermobile Ehlers-Danlos syndrome (hEDS) is thought to be the most common hereditary connective tissue disorder. This disorder distinguishes itself from other types of EDS through the presentation of generalized joint hypermobility (GJH) and related musculoskeletal issues. Patients with hEDS experience a combination of sleep, immune, psychological, dermatological, and neurological dysfunctions. Premature wear on major joints is common, and when conservative treatments are ineffective, many patients rely on surgical options to treat chronic pain. Approximately 71% of patients with EDS report undergoing at least one surgical procedure; however, pain outcomes after surgery are largely unknown (Rombaut et al., 2011). This fact is surprising given the burden and consequences of living with this rare disease. From a review of the literature on hEDS, it is evident that there are still many unknowns regarding the pathology and patterns of this rare condition. The current project aimed to identify the impact of sex differences and presentation for surgery on the frequency of comorbidities experienced by patients with hEDS. Through a retrospective chart review, the understanding of demographic patterns and the extensive involvement of body systems as related to hEDS were explored. Medical records for 100 hEDS patients who had been treated at Boston Children’s Hospital (Boston, Massachusetts) were reviewed. From the data extracted, it was found that when comparing frequencies of medical comorbidities experienced in individuals diagnosed with hEDS, those patients who underwent surgery reported significantly more comorbidities than those who did not have surgery. In addition, 70% of individuals who presented for surgery fell within the categories of orthopedic, gastrointestinal, or laparoscopic/endometriosis-related surgical procedures. The results of this study may be instructive in the management and care of hEDS patients undergoing surgery.

Oral health is essential to understand as every individual has suffered from some oral disease. Oral diseases can affect any individual at any age, whether their conditions are preventative, severe, or irreversible. Therefore, understanding the impact of oral health is crucial due to the widespread prevalence of dental caries and periodontal diseases, which are significant public health concerns globally. These conditions affect oral well-being and have systemic implications, contributing to health disparities. Health behaviors significantly impact oral health, particularly tooth brushing and interdental cleansing. Increasing tooth brushing frequency to twice daily with fluoridated toothpaste decreases caries incidence by 50%. Regular tooth brushing, twice or more daily, correlates with a favorable oral microbiome and reduces dental plaque. In contrast, irregular brushing increases the risk of dental caries and disrupts oral microbiome composition. Frequent tooth brushing and flossing are associated with reduced risks of cardiovascular disease, gingiva bleeding, and inflammatory markers such as C reactive protein and fibrinogen. Individuals brushing twice daily have a lower risk of gingiva bleeding than those brushing once or less daily. Poor tooth brushing habits increase the risk of cardiovascular diseases by 70% and have an increased number of inflammatory markers. Furthermore, increased tooth brushing frequency correlates with lower risks of oral diseases, malignancies, diabetes mellitus, and dyslipidemia. This is due to the systemic-oral connection stating that oral diseases can affect an individual's health. Conversely, systemic health can affect the oral health of an individual. This is extensively seen in the relationship between periodontal disease and cardiovascular diseases, as both have a direct connection with one another. Promoting foundational oral hygiene practices like tooth brushing and flossing is essential for preventing and potentially reversing these issues. However, successful integration requires a nuanced understanding of habit formation. Recognizing the psychological components involved, such as motivation, routine establishment, consistency, and effort, is essential. Research indicates that habits are formed through cues, routines, and rewards, forming the habit loop, which is essential in developing habits. Individuals can effectively build and sustain oral health habits by comprehending these elements. Integrating toothbrushing and flossing into daily routines becomes more achievable when guided with evidence-based habit formation strategies such as understanding the shift and transition between goal-directed and habitual behaviors. Behaviors are categorized as goal-directed or habitual, depending on the conscious decision-making and planning level involved. Goal-directed behavior requires high-level decision-making and planning, while habitual behavior is automatic and unconscious. Two strategies, model-based and model-free, are intertwined with habit formation, with the former involving goal setting, evaluation of outcomes, and cognitive processes, and the latter focusing solely on rewards. The habit loop, involving cue, routine, and reward, is crucial in habit formation. Repetition and consistency are vital to instilling habits and transitioning behaviors from intentional to reflexive and automatic. The basal ganglia, particularly the dorsal striatum, plays a central role in habit formation, shifting from goal-directed to habitual behavior over time. The dorsomedial region is essential in decision-making and learning, while the dorsolateral region is associated with automatic and habitual behavior. The transition between goal-directed and habitual behavior is seen in the caudate nucleus and the putamen, increasing neuronal activity when a behavior is being performed. Furthermore, it is essential to learn the differences in health habits between children and adults as both involve different factors and require different approaches to maintaining positive oral health and establishing habits. The process of habit formation differs between children and adults due to developmental stages and cognitive abilities, emphasizing the role of parents in instilling positive oral health habits in children and the need for adults to evaluate and adopt positive habits throughout their lives. Parental guidance requires motivation, praise, and self-regulatory skills to adapt to changes and difficulties that may arise while trying to establish routines in children. Establishing education on oral health and habit theory empowers individuals to take proactive steps in maintaining optimal health, addressing health challenges associated with oral health conditions, and promoting overall well-being.

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