This study sought to understand activity choices of older adults when they were depressed and in the early stages of recovery. Qualitative analysis was used to identify themes of activities continued, stopped, resumed, and newly begun. Participants (n=27) were recruited from a randomized clinical trial (R37 MH43832) and were community dwelling, predominantly female, with a mean age of 73.3 years. One interview was conducted with each participant in recovery for at least 3 but no longer than 7 months, using a semi-structured interview. When depressed, participants continued some activities and stopped others. Activities were continued when they were part of an established habit or commitment, gratifying, a means of distraction or escape, and/or an attempt to hide depression from others. Participants continued activities when they were nudged by another person and/or felt a sense of pushing oneself to maintain normalcy. Participants stopped some activities when they were no longer meaningful and/ or were too physically painful to complete. Some activities were stopped when participants had insufficient physical/cognitive energy or did not wish to expend their limited reserve, avoided negativity, and/or constricted their social space. In recovery, the majority of activities in which participants engaged when they were depressed were continued spontaneously. Some, however, were stopped when no longer meaningful or necessary, and/or when participants activity level increased substantially, limiting available time. Participants resumed most activities when activities were again meaningful, physical and/or cognitive energy returned, pain complaints diminished, health promotion was desired, and/or when participants were able to confront negative situations, and/or enlarge their social space. Some activities, however, were not resumed when participants actively weighed activity options and chose to divert time and energy to higher priorities. Some participants engaged in new activities not done prior to or during depression when positive self-change opened up opportunities for engagement or participants undertook efforts to reorganize their lives. In conclusion, adaptive strategies were brought into play at various time points as participants selected activities to continue, stop, resume, and newly begin as they strove to survive the depressive episode and, then, re-enter and participate in their former lives in recovery.

This research study examines Personal Health Records (PHRs), focusing on the issues of data contents from the end users perspectives. The study evaluates the understandability of the Continuity of Care Record (CCR) standard terminology currently used in PHR system and explores users preferences and needs for data contents. PHRs are becoming an increasingly important and popular means of enabling individuals to have more direct and stronger ownership and management of their health information. One of the potential barriers to the PHRs adoption is the usability of the system, particularly the fact that PHR data contents contain difficult terminology and does not meet the users needs and preferences. A review of currently available PHR systems shows that vendors are trying to design a comprehensive PHRs primarily based on data contents from the health providers perspectives, especially the CCR standard. However, this comprehensive data set may be neither suitable nor appealing to most individuals with a busy schedule. Therefore, this research aims at identifying the needs and preferences of the primary users of PHRs with the ultimate goal of designing a user-friendly PHR system that caters to the specific and individual needs of a healthy young adult population.   A mixed-method of qualitative and quantitative research in the form of an exploratory-descriptive study was conducted to examine the individuals needs in terms of PHR contents and terminology. Data was collected through an in-depth, semi-structured interview. Furthermore, a qualitative review study was conducted to identify each data element in the currently available free and for-purchase PHR systems and compare those with the CCR. The PHR included in this study were randomly chosen from the list of PHR tools and services available at www.myphr.com. The results of this research provide insight for PHR developers, enabling them to better design and tailor PHR technology in order to fulfill the needs and desires of each specific individual group and subgroup. A PHR system tailored to the users individualized needs will serve to make the user feel more comfortable using and maintaining it, and then could lead to wider adoption of PHR within the population.

Manual wheelchair users are at high risk of developing upper limb pain and injury. While much has been published identifying the prevalence of upper limb pain, very little has been published on its treatment and prevention. Consequently, a propulsion training system was developed based on biomechanical, ergonomic, and motor learning theory principles. Three groups were compared: a control group (CG) that received no training, an instruction only group (IO) that reviewed a multi media instructional presentation (MMP), and a feedback group (FB) that reviewed the MMP and received additional real time feedback (RTF). The purpose of this study was to 1) Develop propulsion-training programs that minimized injurious biomechanics; 2) Test if the training programs can cause lasting changes; 3) Investigate if resultant forces and moments at the shoulder can be reduced and 4) To determine if one treatment (MMP) was superior to the other (RTF) in achieving these goals. First, the RTF systems design was completed and tested on a pilot subject (chapter 2). Next the training systems were tested over ground (chapter 3) and on a dynamometer where shoulder forces were modeled (chapter 4) (N=27). Results showed baseline pain measures to be extremely low and did not increase significantly. In addition, the effects of training were not influenced by surface type or speed condition (presence or absence of a target speed). In chapter 2, the FB group who received RTF and MMP displayed larger increases in contact angle(CA)(angle along the arc of the hand rim) and greater decreases in rate of rise of peak resultant force (rorFr) than the IO group who received the MMP alone. 5 While both training groups decreased stroke frequency (SF), the IO group displayed a larger reduction than the FB group. Furthermore, both treatment groups showed a short term increase in peak resultant force (maxFr) however their long term values were not significantly greater than baseline and their shoulder forces did not increase significantly. Finally, the CG showed a long term increase in maxFr at the hand rim (p<.05), however their shoulder forces did not increase.

Individuals with spinal cord injuries who use a wheelchair for full time mobility are at high risk for developing upper limb pain and dysfunction, which can negatively impact functional mobility and quality of life. Due to the detrimental effects, the Consortium for Spinal Cord Medicine and the Paralyzed Veterans of America developed a clinical practice guideline (CPG) to educate clinicians on upper limb preservation methods. Past research has found that passive implementation of a CPG does not change clinical practice and a structured program is needed for effective education. In this dissertation, we have developed a strict protocol to implement the CPG and performed a randomized clinical trial to determine if new wheelchair users who were strictly educated on the CPG have better functional mobility skills, wheelchair characteristics and lower pain. During the course of the study, we found no objective method to evaluate the quality of a transfer. Therefore, an original outcome measure was developed. We evaluated the tool and found that it is safe, can be completed in a short amount of time and has a wide range of reliability and validity. Refinements are necessary, but the tool fills a substantial void in the area of transfer evaluation. The newly created outcome measure was used to evaluate the transfer skills of participants in the randomized trial. A trend in the data found that participants who were strictly educated on the CPG performed better transfers at six months post discharge. The same group of participants was evaluated on wheelchair set up, selection and manual wheelchair propulsion skills. No differences were found between groups based on wheelchair set up and selection; however those strictly educated on the CPG propelled with significantly lower normalized peak resultant forces at six months post discharge. Finally, results found that individuals who were strictly educated on the CPG reported higher pain during movement activities at six months post discharge, although this may be due to increased awareness. The new outcome measure and structured education program are important tools to improve care provided during acute rehabilitation for full time wheelchair users with spinal cord injuries.

Background/ Purpose: A priority in healthcare for older adults is to detect declines in mobility and balance before falls occur with potential consequences of morbidity, disability, even mortality. Self-report and performance measures have varying degrees of respondent and administrative burden. We investigated the role of a single global self-rating in the detection of mobility decline. Change by repeated self-rated mobility state was compared to transition rating of self-perceived change over six months. Additionally, repeated state and transition reported change were compared with performance change. We anticipated discordance, and explored the support for potential theories to explain discordance. Methods: Using a prospective, exploratory, observational cohort study with mixed-methods analysis, we focused on the natural history of age-related mobility change. Community-dwelling older adults provided state and transition global ratings of mobility and balance over six months, and completed questionnaires and performance tests of physical function. A subset of the older adults participated in semi-structured interviews to identify themes for domain definitions of mobility and balance, and the timeframe and frames of reference used for state ratings. Analyses included correlations for agreement between measures, and comparisons of means to investigate groups established based on discordance. Results: Participants, n=104, had data at two consecutive time points, and 33 participated in interviews. Domain definitions and state timeframes varied. Two main frames of reference were identified. The serial state and transition based rating of change were discordant, as were self-rated and performance change. Nearly 75 percent of those with gait speed decline of at least 0.10 m/s reported worsening by transition, and about 25 percent selected a lower state rating. Conclusions: Transition ratings appear more sensitive than serial state ratings for detection of decline in gait speed, while decline by serial state rating may be more specific to larger performance changes. Self-ratings appear to communicate valuable information about mobility and balance not available from other measures, and we recommend an expanded use of open-ended questions in research and clinical practice.

People with spinal cord injury (SCI) are at risk of pressure ulcer development due to impaired mobility, sensation or changes in tissue properties. Increased skin temperature is one of the least explored risk factors for pressure ulcers. Since people with SCI also encounter thermoregulation deficits, investigation of the effectiveness of local skin cooling in this population is particularly important. Three groups of subjects were recruited: 1) 14 subjects with SCI at T6 and above, 2) 8 subjects with SCI below T6, and 3) 14 healthy controls. Reactive hyperemic response was the main study outcome and was measured after three different combinations of stimuli: 1) pressure only, 2) pressure with fast cooling (-4°C/min) and 3) pressure with slow cooling (-0.33°C/min). Spectral density of the skin blood flow (SBF) was used to investigate the underlying microcirculatory control mechanisms. Five of the subjects did not have reactive hyperemia in all test sessions and were excluded from statistical analysis. In the control group, the normalized peak SBF and perfusion area were close to significantly greater in pressure only as compared to fast cooling (p=0.023 and p=0.023, respectively) and slow cooling (p=0.033 and p=0.016, respectively). Although this phenomenon was not significant when analyzing subjects with SCI alone, significant changes were observed in the signal attributed to the metabolic control mechanism and were observed in this population with pressure only (p=0.019) and pressure with slow cooling (p=0.041). Since the reactive hyperemic response is mediated by different control mechanisms, the less obvious changes in reactive hyperemia in people with SCI may be due to alterations in microcirculation after injury. Results from this study suggest that local skin cooling is beneficial to ischemic tissue by decreasing the metabolic demand, and this is generally consistent with previous animal studies and our pilot study. Findings from this study also suggest that investigating time domain parameters and time-dependent spectral analysis of the SBF signal is helpful in understanding circulatory control in people with different levels of neurological deficits. This study contributes toward justification for the development of support surfaces with microclimate controls to enhance tissue integrity.

Purpose: Explore the association between movement pattern variables and physical function (PF), compare movement pattern changes between standard and agility/perturbation training and explore the association of movement pattern changes with PF changes after an exercise program. Methods: Baseline evaluation was performed to collect subject characteristics, self-reported and performance-based PF followed by motion analysis and electromyography tests performed during gait and step down tasks. Subjects randomized into standard or agility/perturbation groups underwent 12 training-sessions. Post-treatment evaluation was performed at 2 months. Analyses: All analyses were performed for gait and step down task separately. At baseline stepwise multiple regression analyses were performed to explore the association of lower extremity kinematics and co-contraction with the Western Ontario and McMaster Universities Osteoarthritis Index -PF subscale (WOMAC-PF) and the Get up and Go test (GUG) separately. At post-treatment, comparisons of the changes in lower extremity kinematics and changes in co-contraction patterns between subjects who received standard versus agility/perturbation training were performed. Following, stepwise multiple regression analyses were performed to explore the association of changes in lower extremity kinematics and changes in co-contraction with changes in WOMAC-PF and changes in GUG. Results: At baseline results indicated that increased co-contraction during gait and step down were associated with poorer PF. The increased co-contraction of lateral muscle couples during gait was probably an attempt to control knee loading. The increased co-contraction of lateral and medial muscle couples during the step down was likely an attempt to avoid pain and instability as well as control loading at the knee. At post-treatment there was no difference in movement patterns changes between the two exercise groups. Increased co-contraction during gait was associated with improvement in GUG whereas during step down increased co-contraction was associated with worsening in WOMAC-PF. At both time points the observed associations of co-contraction with PF were likely a response to the unique constraints imposed by gait and the step down. We believe in order to improve patterns of movement and thereby improve PF in this population, rehabilitation programs may need to focus on specific practice of tasks which are difficult to people with knee osteoarthritis.

Participation in physical activity is an evidence-based strategy for improving health in older adults. However, less than 30% of older adults engage in any form of regular physical activity. Despite the development of best practice recommendations, the impact of physical activity programs on older adult participation and the performance of activities of daily living (ADL) is not well understood. This dissertation examined best practice programs in relation to ADL performance through a literature review and an intervention study. Our systematic review identified 15 studies on multi-component, group, exercise interventions for community-dwelling older adults. Studies varied greatly in terms of setting, sample size, mode of exercise, length of intervention, and outcomes, and only four studies included all the recommendations of best practice. ADL performance was the least frequently included outcome, supporting the need for additional research. Our pretest, posttest, and post-posttest cohort study evaluated the effects of a 10 week, multi-component, best practice, exercise program on physical activity, ADL performance, physical performance, and depression in community-dwelling, older adults from low-income households (N = 15). Comparison of pretest and posttest scores using a one-tailed paired samples t-test resulted in improvement (p < .05) for 2 of 3 ADL domains on the Activity Measure-Post Acute Care (AM-PAC) and on all 6 physical performance measures of the Senior Fitness Test (SFT), with medium to large effect sizes for all measures. The Geriatric Depression Scale (GDS) yielded no significant change. Physical activity was evaluated at pretest, at 4 weeks posttest, and at 8 weeks post-posttest using the Yale Physical Activity Scale (YPAS). Repeated measures ANOVA revealed significant main effects for 3 of 8 measures - Total Activity Hours, Total Energy Expenditure, and the Leisurely Walking Index. Post-hoc analysis using the Bonferroni adjustment was significant only for the Leisurely Walking Index from pretest to posttest. Retention rate was 78.9%, and the adherence rate for group sessions was 89.7%. These results suggest that implementation of a multi-component, best practice exercise and physical activity program with sedentary, community-dwelling older adults may be well tolerated and may positively impact physical activity, ADL performance, and physical performance.

Laptop computers are widely used by college students for academic and leisure activities (Cortes, Hollis, Amick, & Katz, 2002). However, there is limited research that identifies risk factors for musculoskeletal discomfort during laptop computer use in this population. This dissertation includes two studies: Study 1: This survey study explores characteristics of laptop computer use and relationships between laptop-related risk factors and discomfort; Study 2: This randomized cross-over study examines the effects of three most common laptop workstation setups on upper body postures, discomfort, and task productivity. Thirty students were recruited from the University of Pittsburgh. The survey was a self-administered questionnaire. Subjects¡¯ posture were videotaped while typing for 10 minutes in six laptop workstation setups (desktop sitting, chair sitting, lying prone, lying supine, floor sitting, and lap sitting), and the three most common workstation setups were analyzed. Body angles were digitized at 10-time points and averaged using ImageJ. Typing style was identified using the Keyboard-Personal Computer Style Instrument. Discomfort was determined using a 10-cm VAS. Task productivity was assessed by typing speed and accuracy. Data were analyzed by ANOVAs and Bonferroni post-hoc comparisons. Subjects were primarily female (83.3%), with a mean age of 26.0¡¾7.3, and white (63.3%). Survey results showed that the most common workstation setups were desktop sitting, followed by lying supine and chair sitting. There were no statistically significant relationships between laptop-related factors (duration and type of workstation setup) and discomfort. Most body angles were significantly different between the three workstation setups: neutral wrists and ulnar deviation, upright trunk, and greater shoulder flexion during desktop sitting; greater neck flexion, wrist extension, and ulnar deviation during chair sitting; less neck flexion and greater wrist flexion and trunk extension during lying supine. For typing style, subjects showed large differences in static postures among the workstation setups. Less discomfort and faster typing speed were observed during desktop sitting, followed by lying supine, and then chair sitting. Overall more neutral postures and less discomfort were observed during desktop sitting, followed by lying supine and chair sitting. These findings highlight the importance of laptop workstation setup choice for preventing potential musculoskeletal problems.

Background: Activities and participation domains are affected in people with vestibular disorders; however, specialized outcome measures for evaluating activities and participation according to the International Classification of Functioning, Disability and Health (ICF) do not exist. Purpose: To develop and validate the Vestibular Activities and Participation (VAP) measure for people with vestibular disorders according to the ICF. Methods: A list of activities and participation candidate items were generated and included in a survey. The survey was then sent to a panel of vestibular experts and agreement was obtained on the items to include in the VAP using the Delphi technique. The psychometric properties of the VAP were established including test-retest reliability; minimum detectable change at 95% confidence level (MDC95), concurrent validity with the World Health Organization Disability Assessment Schedule II (WHODAS II); convergent validity with the Dizziness Handicap Inventory (DHI), and discriminant validity. The test-retest reliability of the VAP total score was estimated using the Intra Class Correlation Coefficient (ICC), model (3,1) and the 95% confidence interval (CI). Agreement per-item was estimated using Cohens kappa statistics. Concurrent and convergent validity were examined using the Spearman correlation coefficient (rho). Discriminant validity was established using a generalized linear model (GLM). Results: Fifty five activities and participation items were generated in which 32 of them had 70% or greater agreement for inclusion in the VAP. The test-retest reliability of the VAP total score was excellent (ICC=.95), (CI=.91-.97). Un-weighted kappa (.41-.80) and weighted kappa (.58-.94) were good to excellent. The VAP had strong correlation (rho=.7, p<.05) with the WHODAS II and moderate to strong correlations (rho=.54-.74) with the DHI subscale and total scores. The MDC95 was .58. After adjustment for age, gender and self-reported imbalance were independent predictors of the transformed VAP total score. Conclusion: The VAP measure was developed to examine the disabling effect of vestibular disorders on peoples activities and participation based on the ICF. The VAP demonstrated excellent reliability and was validated with external instruments.