Theses and Dissertations

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Vocational rehabilitation assistive technology, access, supported employment, and employment outcomes for transition-aged young adults with cognitive disabilities
(Colorado State University. Libraries, 2024) Alshamrani, Khalid, author; Graham, James, advisor; Roll, Marla, advisor; Jennings, Louise, committee member; Sharp, Julia, committee member
Objective: The purpose of this dissertation was to conduct three research studies aimed at understanding the barriers and facilitators to equitable access to vocational rehabilitation (VR) assistive technology (AT), its utilization in supported employment (SE), and the resulting competitive integrated employment (CIE) outcomes of transition-aged young adults (TAYA) with cognitive disabilities. Introduction: TAYA with disabilities face significantly higher rates of unemployment and underemployment than their peers without disabilities. For TAYA with cognitive disabilities, these disparities are even more pronounced, making them one of the most excluded groups from the labor force. Despite cognitive disabilities being the largest disability group served by state VR programs, this population continues to face poor employment outcomes upon exiting these programs. Although there is growing evidence of AT's potential to improve employment outcomes, AT support remains underutilized for TAYA with cognitive disabilities, with notable disparities in its utilization. Methods: Study One employed a retrospective cross-sectional study using Rehabilitation Services Administration Case Service Report (RSA-911) data from 2017 to 2019, a period before the COVID-19 pandemic impacted state VR service operations. Multivariable logistic regression analysis was conducted to examine the main and interaction effects of various sociodemographic variables commonly considered in disparities research on the likelihood of receiving AT services among TAYA with disabilities participating in state VR programs. This study provides a baseline understanding of disparities and access to AT services among TAYA with disabilities served by state VR programs in a pre-pandemic context. Study Two was a qualitative study. We conducted focus groups to gather insights from four key stakeholder groups—VR policymakers and funders, VR service providers, employers, and TAYA with cognitive disabilities and their families. The focus was on exploring their perspectives and experiences related to the transition to virtual support and how TAYA with cognitive disabilities accessed and utilized AT devices and services for facilitating their CIE during and following the COVID-19 pandemic. All focus group sessions were held virtually and video recorded and analyzed using thematic analysis. Study Three was another retrospective cross-sectional study using RSA-911 data from July 2017 to June 2022. We investigated how the receipt of AT and/or SE services was independently associated with obtaining CIE at program exit, and how the probabilities of achieving CIE varied across the pre-COVID, during COVID, and post-COVID periods among TAYA with cognitive disabilities served by state VR programs. Multivariable logistic regression analysis was used to calculate odds ratios for the likelihood of obtaining CIE at program exit among TAYA with cognitive disabilities who received the two VR services (AT, SE). To assess whether the relationships between these two VR services and CIE outcomes varied over time, interaction terms between the COVID-19 pandemic periods variable (pre-, during, and post-pandemic) and the two VR services of interest were included in the model. Results: Study One revealed that less than 3% of TAYA with disabilities received AT services. The following client characteristics were associated with a lower likelihood of receiving AT services for TAYA with disabilities: unemployed, minority, significant disability, older in age, TAYA with mental and cognitive disabilities, and not enrolled in PSE. Study Two identified key findings from focus group sessions, highlighting positive overall experiences with using mainstream mobile devices and applications. Areas for improvement beyond the pandemic include enhancing AT access through state Medicaid waivers, providing VR providers with training opportunities to deliver effective AT support to TAYA with cognitive disabilities seeking CIE who need and could benefit from such support, and ensuring the technology employed and used is accessible and usable by this population. In Study Three, more than half (55.9%) of TAYA with cognitive disabilities in the study sample did not achieve CIE at program exit. Only 1.4% received AT services and 10.7% received SE services. Overall, the receipt of AT and SE showed positive and significant associations with achieving CIE at program exit compared to those who did not receive these services. In addition, there were higher probabilities of achieving CIE outcomes during and post-COVID compared to the pre-COVID period. Conclusion: The findings from this dissertation highlight the underutilization of AT support among TAYA with disabilities served by state VR programs, particularly in addressing their job-seeking needs and transitions from education to CIE. The shift to virtual support, accelerated by the COVID-19 pandemic, increased access to mainstream mobile devices and applications for TAYA job seekers with cognitive disabilities. Before the COVID-19 pandemic, AT support access was primarily focused on supporting TAYA with cognitive disabilities who were participating in academic programs or being employed for job retention, with limited AT support for job seekers. During the pandemic, however, TAYA job seekers with cognitive disabilities had access to mainstream mobile devices and applications within the VR system. Such access allowed this population to acquire skills in using mobile devices and applications for pursuing their CIE opportunities, access job training resources, continue receiving virtual supports, and engage in virtual job interviews with potential employers. The intersection of AT and SE offers an opportunity to enhance CIE outcomes for TAYA with cognitive disabilities. The probability of achieving CIE was higher among this population receiving SE and AT support during and post-COVID than pre-COVID. This underscores the need for continued efforts to improve targeted transition policies and practices, enhance the services and supports for TAYA with cognitive disabilities, and provide AT training opportunities to VR personnel who serve this population. Increasing AT training in rehabilitation educational programs and in-service training could enhance VR AT service utilization. Further research is needed to generate evidence supporting AT use in vocational settings and to develop guidelines for its incorporation into employment transition processes. Such efforts are essential to ensuring that TAYA with cognitive disabilities have equitable opportunities and the support they need for employment success.
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Advancing the transition to employment for young adults with intellectual disabilities through assessment, self-report, and learning from lived experience
(Colorado State University. Libraries, 2024) Parsons, Cristina C., author; Persch, Andrew C., advisor; Schmid, Arlene A., advisor; Graham, James, committee member; Hickey, Matt, committee member; Cleary, Dennis, committee member
This dissertation seeks to advance the transition to employment for young adults with intellectual disabilities through three distinct approaches. First, we explore the construct of self-determination specifically as it pertains to the employment of young adults with intellectual disabilities. Second, we intentionally refine an assessment of "vocational fit" for self-report by young adults with intellectual disabilities. Third, we examine how young adults with intellectual disabilities and their families experience barriers to engagement in self-advocacy in navigating complex systems intended to assist with the transition to work. In Study 1, we found evidence to support the idea that the context of employment plays a bigger role in the construct of self-determination than is explicated in current self-determination theories. We learned in Study 2 that young adults with intellectual disabilities can interpret and respond appropriately to a self-report version of a vocational fit assessment. In Study 3, findings taught us that the complexities of support systems intended to assist young adults with intellectual disabilities in reaching their employment goals drastically affects their and their families' ability to advocate for their rights and needs. Taken together, these studies present a multi-faceted approach to improved assessment, inclusion, and access necessary for the successful transition to employment for young adults with intellectual disabilities.
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An exploratory cross- case study of parent and teacher perspectives on children's kindergarten experiences following play-based early childhood education
(Colorado State University. Libraries, 2024) Fyffe, Lisa Ann, author; Davies, Patricia, advisor; Schmid, Arlene, advisor; Quynn, Kristina, committee member; Jennings, Louise, committee member
Play has been the foundational pedagogical approach to early childhood education dating back to the days of Plato (428-347 B.C.E..) and Socrates (469-399 B.C.E.). Yet recent changes in public policy emphasizing academic content mastery at kindergarten entry threaten the tradition of play as the dominant means of learning for young children enrolled in early childhood education centers. Early childhood professionals argue that pedagogy emphasizing approaches to learning, social relationships, and self-management are essential in preschool, and prepare children for subsequent academic instruction. Parents, fearful that their child will not be ready for kindergarten if they are not exposed to academics early on, place pressure on privately funded early childhood centers to provide academic rigor under the guise of school readiness. The desire for children to develop learning readiness through playing stands in contrast to educational reforms priorities of standardized instruction and measurable academic results to support efficacy in early childhood education programs. Early childhood educators, in response to public policy and parental expectations, may design their preschool curriculum with an academic emphasis, thus disrupting the tradition of play as the dominant means of learning for young children. For play to retain its' importance in early childhood education, research will need to demonstrate how play prepares children for kindergarten. This dissertation explores how children fared in kindergarten following play-based early childhood education at a Reggio-Emilia-inspired preschool. The Reggio Emilia-inspired philosophy of early childhood education emphasizes artistic expression, child-led exploration, engaging environments and collaborative relationships to promote children's curiosity and joyfulness with learning (McNally & Slutsky, 2018). Play-based learning is a pedagogical approach to early childhood education grounded in guided play, where the adult curates a learning context towards an educational goal and the child maintains agency and some degree of freedom to explore and discover while learning (Zosh et al., 2018). Cross-case analysis was used to gain a deep understanding of the experiences of four children navigating kindergarten during the Covid-19-affected 2020-2021 school year. Data included: a series of three 1-hour interviews with four mothers and three kindergarten teachers at the onset, midpoint and conclusion of the school year, field visits during remote learning, and artifact collection including work samples and progress reports. The most substantial findings from this longitudinal study center on three main constructs: school readiness, everyday adaptability, and kindergarten performance, which are each addressed in the three manuscripts included in the dissertation. Finally, I situate my dissertation within the Occupation and Rehabilitative Science framework and conclude my dissertation by describing the implications of this dissertation of occupational therapy practice and future scholarship.
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Personal and contextual influences on Saudi parents' willingness and tolerance for children's risky play
(Colorado State University. Libraries, 2024) Alarawi, Rana M., author; Bundy, Anita, advisor; Lane, Shelly, committee member; Hepburn, Susan, committee member; Hickey, Matthew, committee member
Objective: The purpose of this dissertation was to examine personal and environmental factors that influence Saudi parents' willingness to promote, and tolerance of, risk taking in children's play. In this dissertation, I tested a conceptual model that explains the transactions among multiple constructs: factors affecting parental risk willingness, coping efficacy, perceptions of child, and risk tolerance. I also introduced a new tool, the Factors Affecting Tolerance for Risk in Play Scale (FAC-TRiPS) to assess personal, social and cultural factors affecting parental tolerance for risk in play. Lastly, I examined variations between Saudi mothers and fathers in relation to their willingness to allow and tolerate risk in play. Importance: Risky play is defined as "thrilling and exciting forms of physical play that involve uncertainty and a risk of physical injury" (Sandseter, 2010, p.22). Benefits of children's participation in "risky play" are broadly recognized (Barker et al., 2014; Brussoni, Olsen, et al., 2012; Gray et al., 2015; Sandseter, 2007; Sandseter & Kennair, 2011). However, most related research originates in Western countries; none focuses on outdoor play in Eastern countries, including Saudi Arabia. Further, while the literature identifies varying perspectives on risky play among parents, there is limited understanding of parental, social, and cultural contexts shaping and influencing Saudi parents' tolerance of risk in play. Participants: The sample included 90 Saudi parents with children ages 7 to 10 years who were able to read and speak English. Parents of this age group are expected to accept risky play. Method: This cross-sectional, quantitative dissertation encompassed three studies. In the first study, I used moderation analysis to test a conceptual model examining the relationship among factors contributing to parents' willingness to allow risky play and their risk tolerance. I also investigated the moderating effects of parental coping self-efficacy and parents' perceptions of their children's coping ability on the relationships among factors contributing to parents' willingness to allow risky play and their risk tolerance. In the second study, I utilized Rasch analysis to explore evidence for construct validity and internal reliability of data gathered with the FAC-TRiPS. In the third study, I examined gender variations in Saudi parents' willingness to promote, and tolerance for, risk taking in children's play by answering two research questions: (1) Do Saudi mothers and fathers differ systematically on FAC-TRiPS items? and (2) How does the inclusion of gender influence the relationship among factors affecting parental perceptions of tolerance for children's risky play? Results: Findings of the first study showed that play factors contributing to parents' willingness to allow risk (e.g., fear of injury and fear of negative judgment) were negatively correlated with risk tolerance. Additionally, parents' coping self-efficacy significantly moderated the relationships among play factors contributing to parents' willingness to allow risk and their tolerance for encouraging children to engage in risk taking. That is, parents with high self-efficacy were more inclined to perceive less stress in such situations and were more apt to allow their children to engage in risky play. However, parental perceptions of their children's coping ability did not have a moderating effect on the interaction between factors contributing to parents' willingness to allow risky play, and their tolerance for, risky play. In the second study, preliminary analysis suggested that the FAC-TRiPS yielded valid and reliable data measuring factors influencing parents' risk tolerance. Because the instrument in its early stages of development, further research with a larger sample is needed to refine items and enhance the instrument's functionality and precision. In the third study, although parent gender did not significantly predict risk tolerance, Saudi mothers and fathers exhibited systematic differences on three FAC-TRiPS items. Mothers reported more fears surrounding potential negative judgment and repercussions from an authority while fathers were more influenced of Media reports. Within the context of other factors, gender appeared to play a complex and indirect role in determining parents' risk tolerance. Conclusion: This research serves as a useful foundation for understanding the impact of context on parents' willingness to promote children's participation in risky play. Key themes across the three studies indicate that risk tolerance is likely influenced by a multitude of factors including personal, psychological, and cultural factors. This research represents the first to study a sample from Saudi Arabia, contributing an Eastern perspective to the existing body of research on risky play. Nevertheless, its findings invite further exploration into gender, societal, and cultural influences on how parents perceive and approach their children's participation in risky play environments. Additionally, further validation of the FAC-TRiPS and the Risk Tolerance model is needed. Findings of this research lend further support to the critical role of environmental facilitators and barriers on functioning as well as raise a need for creating a culture in which the duty of care is balanced with the dignity of risk in order to enable children of all abilities to participate in playful and age-appropriate risk-taking opportunities.
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Acute care rehabilitation utilization, access, and outcomes among hospitalized adults with traumatic brain injury
(Colorado State University. Libraries, 2024) Bukhari, Rayyan A., author; Graham, James, advisor; Weaver, Jen, committee member; Davalos, Deana, committee member; Sharp, Julia, committee member
Objective: The purpose of this dissertation was to conduct three research studies aimed at gaining a comprehensive understanding of the barriers and facilitators to equitable access to and timing of rehabilitation services, community discharge, and unplanned 90-day post-discharge hospital readmission among individuals hospitalized with Traumatic brain injury (TBI). Introduction: There are approximately 2.5 million TBI-related emergency department visits, 288,000 TBI-related hospitalizations, and 61,000 TBI-related deaths reported each year (Centers for Disease Control and Prevention, 2019). TBI is associated with high rates of disability, including limitations in performing basic activities of daily living (ADLs), such as self-care, and/or in performing physical tasks, such as mobility (Klima et al., 2019; Jessica Lo et al., 2021; Whiteneck et al., 2016). Individuals who are hospitalized with TBI should receive equitable access to multidisciplinary care, including rehabilitation services (occupational therapy [OT], and physical therapy [PT]) to address potential self-care issues, physical limitations, and cognitive deficits (National Academies of Sciences & Medicine, 2022). Early onset of acute care rehabilitation services can have positive long-term benefits for patients, including improved function, increased mobility, and enhanced quality of life (Andelic et al., 2012; Bernhardt et al., 2017; C. Y. Wang et al., 2021). A primary focus of acute care rehabilitation services is to improve patients' functional performance (Ejlersen Wæhrens & Fisher, 2007). Following acute care stays, community discharge is generally viewed as quality care indicator in acute care settings (Department of Health and Human Services [HHS], 2019). Readmission is a common concern for those who have chronic illnesses or injuries, and it is associated with higher healthcare expenses and lower quality of care (Jencks et al., 2009). Readmission rates after TBI contribute considerably to these costs, making lowering readmission rates a universal goal (Canner et al., 2016). Despite research advances and policy changes, barriers and challenges remain facing individuals with TBI (National Academies of Sciences & Medicine, 2022). Not all individuals with TBI have early access to rehabilitation services, are discharged to the community, or can avoid hospital readmission. Although several studies have addressed these issues in general population, variability in community and personal level factors among individuals with TBI need to be addressed (Office of Disease Prevention and Health Promotion & Services., 2020). Therefore, these dissertation studies are aimed at providing empirical support, further understanding, and increasing our knowledge around factors that influence individuals with TBI acute care rehabilitation services utilization and outcomes. Method: This dissertation is comprised of three studies. In Study One, we investigated how Social Determinants of Health (SDoH) impact access to and timing of rehabilitation services. Multivariable logistic and Cox regression analyses (i.e., time-to-event analyses) were used to calculate odds ratios for the likelihood of receiving OT and PT services, and hazard ratios for the duration to initiation of services among those who received these services. In Study Two, we explored whether the relationship between acute care OT/PT utilization and community discharge is moderated by functional or physical performance at discharge. Multivariable moderation logistic regression models were used to calculate odds ratios for the likelihood of community discharge among those who utilized OT/PT services. In both OT and PT models, we computed the main effect of OT/PT utilization on community discharge, the main effect of functional/physical (ADL/Mobility) performance scores at discharge on community discharge, and the moderating effect of ADL/mobility scores on the relationship between OT/PT utilization and community discharge. In Study Three, we examined the association between discharge functional status and unplanned hospital readmission. Logistic regression was performed to calculate odds ratios for the likelihood of unplanned 90-day hospital readmission among those who received rehabilitation services during their acute care stay. Results: In Study One, all community-level SDoH such as education attainment, income, and rurality did not show significant associations with access to or timing of acute rehabilitation services (p-values= 0.09 – 0.95). In Study Two, both ADL/mobility performance scores at discharge significantly moderated the relationship between OT/PT utilization and community discharge (ORs= 0.99, 95% CIs [0.98, 1.00]). In Study Three, neither discharge functional nor mobility scores were associated with readmission (p-values= 0.14 – 0.17). Among the three dissertation studies, several covariates such as age, presence of a significant other, race/ethnicity, health insurance type, TBI severity, length of stay, and comorbidity burden showed significant associations with access to or timing of acute rehabilitation services, community discharge, and readmission status (p-values= 0.04 – <0.001). Conclusion: Further investigations are needed to 1) ascertain whether our community-level SDoH variables, based on the first three digits of zip codes, adequately capture individual experiences and their impact on healthcare, or if community-level education, income, and rurality genuinely do not affect access to and timing of therapy services for hospitalized patients with TBI; 2) determine whether the consideration of ADL/mobility scores at discharge alone limits our understanding of the relationship, failing to encompass other patient-level factors that could either facilitate or impede a safe community discharge; and 3) determine whether discharge functional and mobility scores were too restrictive in capturing the full benefits of acute care rehabilitation services in reducing the risk of unplanned 90-day readmission risk in hospitalized patients with TBI.
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Advancing clarity: exploring professional thinking skills in occupational therapy
(Colorado State University. Libraries, 2023) Burke, Hannah K., author; Lane, Shelly J., advisor; Bundy, Anita C., committee member; Sample, Pat L., committee member; Hepburn, Susan, committee member; Spielmann, Virginia, committee member
Background: Reasoning, reflection and evidence-based practice are three interrelated and essential skills for occupational therapy practice. As threshold concepts in the field, they contribute to development of a sense of professional identity. However, these skills are inconsistently defined and differentiated from one another, leading to difficulties in related communication, education, and research. In this dissertation I sought to advance the profession's understanding of consensus conceptualizations of these essential professional thinking skills and how they are taught. Methods: This dissertation comprises five articles reporting results of two broad studies. In the first study, a scoping review, I explored peer-reviewed occupational therapy literature that included a definition of a term related to reasoning and/or reflection. Along with my research team, I extracted data from each paper on definitions of relevant terms, relationships amongst relevant terms, references used to define relevant terms, and descriptive information about each article. In the second study, I used Delphi methodology to explore nine occupational therapy educators' consensus definitions of, conceptualizations of relationships between, and educational strategies for teaching clinical reasoning, professional reasoning, reflective practice, and evidence-based practice. I then conceptually integrated results of both studies to compare findings between the literature and educators. Findings: Both studies indicate that there is some agreement about main characteristics of each of these skills. They also both suggest that clinical/professional reasoning, reflective practice, and evidence-based practice are related to each other in complex, non-linear ways that warrant further exploration. Findings from the Delphi study additionally indicate that there are key educational strategies that may support development of multiple of these professional thinking skills. Conclusion: This dissertation adds to the body of literature clarifying conceptualizations of necessary professional thinking skills in occupational therapy. Continued explicit consideration of conceptualizations of reasoning, reflection, and evidence-based practice within occupational therapy literature and education will advance communication, measurement, and, ideally, uptake of these skills into practice to support an integrated sense of professional identity.
Open Access
Acquiring stakeholder input on the clinical usefulness of measuring outcomes of therapeutic horseback riding
(Colorado State University. Libraries, 2023) Brenneman, Moriah, author; Peters, Caiti, advisor; Schmid, Arlene, advisor; Stallones, Lorann, committee member
Therapeutic riding (TR) is a recreational activity which provides mounted and ground-based horsemanship opportunities adapted to the abilities of the participants Click or tap here to enter text.. TR provides physical and psychological benefits to participants with diverse disabilities, including physical, developmental, cognitive, and age-related disabilities, promoting higher quality of life (QoL); however, certified therapeutic riding instructors (CTRIs) and centers are limited in their capacity to implement outcome assessments and report the benefits of their community-based TR programs to a broad audience due to credentialing requirements, time restraints, and limited financial resources. Therefore, the purpose of this study was to identify whether and how TR professionals are currently measuring participant outcomes; benefits and barriers to implementing standardized assessments in TR; and characteristics which would make TR assessments clinically useful in the community TR environment. To address this purpose, we conducted a computer-based survey among TR stakeholders. We identified that while TR professionals measure outcomes among their participants, they typically do not use standardized assessments. Benefits of implementing standardized assessments included bolstering the TR profession, acquiring funding, and communicating about TR services with a broad audience. Barriers to implementing standardized assessments included time, systemic, and expertise constraints. Respondents reported that standardized assessments should be relevant to all age groups and populations who receive TR services. Finally, our respondents reported that for standardized assessments to be clinically useful, they would need to be low-cost (free or $1 – 2 per use), require less than 20 minutes, and available in either paper or computer format. This study revealed that standardized assessments may be a strong support to the TR profession; however, assessments must meet the needs of TR providers in the community.
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Occupational therapists' perspectives on their unique role in pelvic health
(Colorado State University. Libraries, 2023) Fyhrie, Jennifer, author; Schmid, Arlene A., advisor; Weaver, Jennifer, committee member; Fruhauf, Christine A., committee member
Introduction: Pelvic floor dysfunction (PFD) may present as urinary/fecal incontinence, pelvic organ prolapse, and/or pelvic pain. These symptoms have been shown to cause disruption to individuals' activities of daily living and decrease quality of life. Conservative estimates indicate 28 million women are affected by PFD worldwide. The core of occupational therapy (OT) is to mitigate barriers to engagement in occupations of one's choosing, yet there is a gap in the literature detailing occupational therapy practitioners' (OTP) perspectives on their unique contributions in pelvic health. Methods: This exploratory descriptive study utilized an online survey to purposively recruit OTPs and screen individuals for an interview. Inclusion criteria required that participants a) be a licensed or retired OTP, b) have at least one year experience as an OTP, and c) have any professional experience in pelvic health. One-on-one semi-structured interviews occurred on a virtual platform, were audio-recorded, and transcribed. Using Dedoose software, thematic inductive analysis was conducted. Results: Thirty-one individuals completed the survey, 21 were eligible to participate, and 13 participated in an interview. It was found that OTPs believe they offer a unique contribution to the pelvic health field. Three primary qualitative themes were generated that elaborate on this belief: OTPs apply a psychosocial lens, the OT approach is comprehensive, and OTPs use occupation-focused interventions when working with people with PFD (e.g., consider the influence of client mental health as client preferences, culture, and lifestyle). Conclusion: This study identified the perceptions of OTPs regarding their unique approach to working with clients in pelvic health. Data suggests that OTPs complement the biomechanical focus of other pelvic health providers by recognizing the role of mental health and intervening to down-regulate the nervous system.
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Investigating the neural mechanisms of rhythmic entrainment and auditory priming using EEG
(Colorado State University. Libraries, 2023) Mingils, Susan, author; Davies, Patricia, advisor; Stephens, Jaclyn, advisor; Atler, Karen, committee member; LaGasse, Blythe, committee member
A body of literature on rhythmic entrainment, the synchronization of behaviors to rhythmic stimuli in the environment, shows auditory rhythmic cuing can improve motor performance in neurotypical and clinical populations. This is thought to be driven by underlying communication, i.e., functional connectivity, between auditory and motor brain regions. Surprisingly, some clinical research shows rhythmic entrainment interventions, designed to enhance motor performance, may improve cognitive performance as well. However, it is unclear if improved cognitive performance during rhythmic entrainment reflects changes in functional connectivity. Evidence from cognitive neuroscience suggests rhythmic auditory stimuli may direct attentional resources through the synchronization of certain neural oscillations with the rhythmic pulse. Neural oscillations are repetitive patterns of brain activity which can be measured noninvasively at the scalp using electroencephalography (EEG). Measuring how neural oscillations from spatially distinct brain regions synchronize with each other reflects changes functional connectivity. Before functional connectivity during rhythmic entrainment can be studied, research is first needed to establish connectivity patterns when processing auditory rhythmic stimuli (auditory condition) and during self-paced rhythmic motor performance (motor condition), which was the goal of Study 1. Overall, the results of Study 1 provide evidence that the auditory condition may promote more efficient functional connectivity with increased activation in localized brain regions, while the motor condition may utilize long-range low-frequency neural oscillations to suppress activity in task-irrelevant brain regions to sustain attention. A recent EEG study by our lab compared the neural oscillations of participants who listened to auditory rhythmic stimuli presented for a little over five minutes (auditory-first group) to participants who completed a self-paced rhythmic motor task for about minutes (motor-first group) prior to tapping along to auditory rhythmic cues (rhythmic entrainment condition). One important finding was a greater "priming effect" in the auditory-first group, who showed reduced neural resources needed during rhythmic entrainment compared to the motor-first group. Thus, auditory priming, compared to motor priming, may result in a more efficient use of neural resources during rhythmic entrainment. However, the optimal duration of auditory priming to promote efficient brain and behavior function is unknown. Therefore, the goal of Study 2 was to determine how different durations of auditory priming affect brain efficiency in neurotypical individuals, as measured using EEG. Overall, the results of Study 2 found that a duration of about two minutes may be optimal for auditory processing of rhythmic stimuli. However, more research is needed to confirm if auditory priming reduces neural resources needed during rhythmic entrainment compared to no priming and if auditory priming improves motor performance. Rhythmic entrainment and auditory priming are both important principles of rhythm-based interventions used in rehabilitation. A better understanding of their neural mechanisms in neurotypical individuals provides a necessary foundation for future research examining these processes in clinical populations and as a component of clinical interventions.
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Promoting adherence to cognitive-behavioral therapy for insomnia in the medically complex case
(Colorado State University. Libraries, 2023) Lovell, Emily R., author; Eakman, Aaron, advisor; Weaver, Jennifer, committee member; Broussard, Josiane, committee member
Objective. The purpose of this study is to explore how a medically complex case responded to cognitive-behavioral therapy for insomnia (CBT-I) in a community-based setting based on adherence to treatment recommendations. Method. A mixed-methods retrospective case study design was used to explore answers to two research questions: 1) How effective is CBT-I for an individual with insomnia comorbid with bipolar disorder? 2) How is CBT-I tailored for an individual with insomnia comorbid with bipolar disorder in a real-world setting? 3) How do we assess adherence to CBT-I delivered by an occupational therapist? Data sources included sleep diaries, service logs, pre-/post-treatment assessments, and interviews with the client and therapist. Results. Improvements in sleep latency, wake after sleep onset, early morning awakening, total sleep time, and sleep efficiency were observed. The most noteworthy improvements were a gain of almost two hours of total sleep time and a post-treatment SE of 95%. Likewise, scores on the Insomnia Severity Index, Epworth Sleepiness Scale, Sleep Disorders Symptoms Checklist-25, Dysfunctional Beliefs and Attitudes about Sleep scale, Sleep Hygiene Index, Quick Inventory of Depressive Symptomatology, and Patient Health Questionnaire-9 all improved to the extent that the client no longer met criteria for chronic insomnia. Overall adherence to the behavior components of CBT-I was very high. High motivation and scheduling and engaging in activities emerged as factors that promote adherence from the interview conducted with the client. A therapeutic relationship emerged as a factor that promotes adherence from the interview conducted with the therapist. Conclusion. CBT-I can be safely delivered by occupational therapists to individuals with bipolar disorder. Large improvements in sleep were observed and the client had high adherence to treatment protocols.
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Occupational therapists' perspectives and role with illness-induced trauma from medical conditions
(Colorado State University. Libraries, 2023) Beyers, Camryn, author; Schmid, Arlene A., advisor; Weaver, Jennifer A., committee member; Currin-McCulloch, Jen, committee member
Illness-induced trauma might cause a disruption in an individual's occupational performance. This study examined occupational therapy practitioner's perspectives and role in addressing illness-induced trauma in practice. In this explanatory sequential mixed methods design, twenty-four occupational therapists completed an online survey and ten occupational therapists participated in a semi-structured 1:1 interview. Survey questions asked about their knowledge of illness-induced trauma. Interview questions asked therapists about how they incorporate illness-induced trauma knowledge and trauma-informed care into their practice. Quantitative results showed that the majority of occupational therapists did not receive formal trauma-informed care training, 96% agreed that psychological trauma has a significant impact on rehabilitation outcomes, and 8% agreed that current guidelines for trauma-informed care adequately consider the needs of clients with illness-induced trauma. Qualitative results indicated three major themes: occupational therapy approaches, illness-induced trauma's effect on rehabilitation, and barriers to providing trauma-informed care. Findings suggest that occupational therapy practitioners have a unique perspective on addressing illness-induced trauma and their ability to practice trauma-informed care could support a client's ability to process and heal after a traumatic medical event.
Open Access
Occupational therapists: the quarterbacks of pelvic healthcare
(Colorado State University. Libraries, 2023) Le Fevre, Eleanor, author; Schmid, Arlene, advisor; Weaver, Jen, committee member; Fruhauf, Christine, committee member
Background: The ability to effectively manage chronic issues has a large impact on a person's quality of life. Pelvic floor dysfunction (PFD) is a chronic and debilitating disorder which affects millions of people worldwide. PFD is often placed lower in the hierarchy of treatable medical conditions yet has a substantial impact on a person's functional capability. Pelvic health occupational therapists (PHOT)s are emerging practitioners in PFD management. PHOTs provide a client-centred, holistic approach to care. To date PHOT is not well described in the literature or well known in the practice of pelvic healthcare. Aim: To investigate the perceptions of PHOTs, their value in the management of PFD, and how this value is communicated to other healthcare providers (OHCP)s. Methods: This qualitative research study included a demographic survey and one-to-one interviews with PHOTs and lead researchers. Thirteen PHOTs were interviewed by a lead researcher and provided data on their perceptions and interactions with OHCPs. Data collection was completed over a five-month period from July 2022-December 2022. Data collection ended once saturation in responses was reached. Data were analyzed by lead researchers using an in vivo coding process, creation of categories and code book. I created themes and sub-themes driven by the data. Results: Two main themes were created from the data with PHOT participants supporting inclusion of OT in pelvic healthcare; (1) pelvic healthcare is an interdisciplinary field; (2) more practitioners are needed in PHOT. Conclusion: PHOTs perceptions and value on interdisciplinary teams are key to increased communication between PHOTs, OHCPs, and the clients they serve. Further research is needed to define the PHOT role and impact as part of an interdisciplinary team.
Open Access
Rasch analysis of the evaluation in Ayres sensory integration (EASI)
(Colorado State University. Libraries, 2022) Grady, Patricia, author; Bundy, Anita, advisor; Lane, Shelly, committee member; Hepburn, Susan, committee member; Sharp, Julia, committee member
Sensory Integration (SI) refers to the neurological process by which a person takes in sensory information, interprets this information, and uses it to inform movement and goal-directed action (Ayres, 1989). For children with a variety of diagnoses, as well as some children who are otherwise typically developing, SI may be impaired or delayed (Bundy & Lane, 2020a). Occupational therapists and other clinicians who treat children with sensory integration (SI) dysfunction face a dearth of appropriate instruments to evaluate SI function. The Evaluation in Ayres Sensory Integration (EASI; Mailloux et al., 2018) is a novel assessment tool that may allow therapists to evaluate SI in a way that is aligned with SI theory. EASI consists of 21 individual tests that measure constructs of SI. The EASI authors have collected normative data for children across the globe. However, this data must be assessed for validity and reliability before it can be used as the basis for normative scoring on the EASI. In this dissertation, I used Rasch analysis to evaluate data with 19 of the 21 tests. The Rasch model is a latent-trait psychometric model that (1) transforms ordinal-level data to interval-level data and (2) allows users to assess evidence for construct validity (unidimensionality and invariance) and internal reliability (Bond, Yan & Heene, 2020). For each of the 19 tests, I evaluated item fit statistics, rating scale fit statistics, person fit statistics, principal components analysis (PCA) of standardized residuals, differential item functioning (DIF) based on sex, person reliability index and strata. The dataset for this study comprised 2653 children from 51 countries; all data were collected by trained EASI examiners. Overall, results revealed promising evidence for construct validity and internal reliability of data collected using 16 of the19 EASI tests evaluated in this dissertation. However, across many tests, I observed lower-than-desired person fit statistics and reliability. Notably, these results were not far from the desired values. I hypothesized that these findings are the result of the overall high ability level of the normative population. EASI is designed to evaluate children with lower-than-average or poor SI function; therefore, these findings are not unexpected nor are they particularly concerning. Three EASI tests (Proprioception: Force, Proprioception: Joint Position, and Balance) required substantial revision as a result of these analyses; each had threats to construct validity that exceeded my expectations. In this dissertation, I provided potential solutions for these three tests; future studies will evaluate the extent to which these solutions resolve concerns. In conclusion, the normative data form an acceptable basis for creating norm-based scores for clinical interpretation. However, larger studies must be conducted with clinical populations to ensure that the tests can differentiate between children with and without SI dysfunction. Further, future studies should investigate the role of culture, language and other factors on the validity of EASI test scores.
Open Access
A qualitative study: the influence of occupational therapy for pelvic floor dysfunction on functioning, disability, and health
(Colorado State University. Libraries, 2022) Pearce, Delaney M., author; Schmid, Arlene A., advisor; Atler, Karen E., committee member; Fruhauf, Christine A., committee member
Introduction: Approximately one quarter of all women in the United States experience symptoms of pelvic floor dysfunction (PFD). Occupational therapy (OT) for PFD is a relatively new area of expertise within the field, resulting in limited research on its efficacy. Objectives: Explore the ways in which OT for PFD influences health using the International Classification of Functioning, Disability, and Health (ICF) as a guide. Method: Four participants completed the study. Eligibility criteria included: >18 years old, biologically female, English speaking, self-reported pelvic floor issue, completed OT intervention for PFD within the last two years. Electronic medical records and Pelvic Floor Distress Inventory Questionnaire-10 (PFDI-20) scores prior to and after completing OT intervention for PFD were reviewed, and semi-structured interviews were conducted. Results: Four themes emerged: 1) improved mental health and physiological function, 2) promotion of the mind-body connection, 3) reintroduction of meaning, and 4) relationships with healthcare professionals and sociocultural influences. Each theme is tied to a component of the ICF. Conclusion: OT for PFD has a positive impact on health per the ICF. This may result in better function and participation in everyday life. More research is needed to investigate the generalizability of these findings.
Open Access
Instrument development of the Vocational Fit Assessment – Self-Report and content validity procedures
(Colorado State University. Libraries, 2022) Thum, Marisa, author; Persch, Andrew, advisor; Atler, Karen, committee member; Sharp, Julia, committee member
People with intellectual and developmental disabilities (PwIDD) are unemployed in the United States at rates much higher than that of the general population. Current job matching practices rely largely on proxy-report of worker abilities, resulting in decreased opportunity for self-determination. As Patient Reported Outcome Measures rise in popularity in other fields as a means of directing patient-centered care, job matching assessments should follow to support client-directed services. The Vocational Fit Assessment (VFA) is an existing tool which compares proxy-reported worker abilities with job demands and creates job matching reports that guide and support job matching decisions. The aims of this thesis were to 1) adapt the existing Vocational Fit Assessment (VFA) into a format that is appropriate for self-report by people with intellectual and developmental disabilities and 2) develop content validity procedures to assess the adapted assessment, the Vocational Fit Assessment – Self-Report.
Open Access
Relationships between the wellness of older adults, health status, participation, and social determinants of health: a cross-sectional analysis using the National Health and Aging Trends Study
(Colorado State University. Libraries, 2022) Parenti, Victoria, author; Graham, James, advisor; Schoessow, Kim, committee member; Miller, Ray, committee member
Objectives: The primary objective of the current study is to explore the independent effects of different types of health and participation variables on subjective well-being among community-dwelling older adults. A secondary objective is to examine the roles that social determinants of health, including environmental, economic, and social factors, may play in mediating those relationships. Data Source: The National Health and Aging Trends Study (NHATS) includes survey data from a large, nationally representative sample of Medicare beneficiaries ages 65 and older. The data capture a snapshot of later-life functioning, including information on health conditions, self-care, well-being, participation, living arrangements, and many more. NHATS data were developed for public use and have been used in more than 400 scientific publications. Participants aged 65 and older were drawn from Round 9 of NHATS conducted in 2019. Methods: Participants were included in the final sample if they resided in the community and completed a sample person interview (no proxy person interviews were included). Main variables being assessed include the 11 items of Well-Being, hospitalizations, general self-rated health, depressive symptoms, and participation in social activities. Proxy variables from the NHATS were selected to represent the individual domains of the social determinants of health, including economic stability, education, healthcare access, social and community context, and neighborhood and built environment. Bivariate and regression analyses were conducted to explore independent relationships and mediation effects. Results: The data indicate that hospitalizations, self-rated health, depressive symptoms, and participation in social activities are independently associated with subjective well-being. Additionally, indicators for economic stability, education, health literacy, and community context were independently associated with well-being among the sample of Medicare beneficiaries. There was one mediating effect of an individual SDOH domain on the relationship between hospitalizations and subjective well-being after conducting the regression analysis. Conclusion: The results from the current study contribute to a growing body of literature examining relationships between several factors and well-being outcomes for community-dwelling older adults. Data from the current study provide substantial insight on how health status, participation, and SDOH indicators can be used in future research to explore these relationships, and identify populations at risk for occupational justice or health inequities. Future research is warranted to validate measures and indicators of SDOH to further explore their relationships with health and well-being outcomes using national data sets.
Open Access
Measuring executive function after yoga for adults with acquired brain injury: a pilot study
(Colorado State University. Libraries, 2022) Grieb, Emily, author; Schmid, Arlene, advisor; Stephens, Jaclyn, committee member; Riggs, Nathaniel, committee member
Background: Acquired brain injury (ABI) may result in cognitive impairments, particularly deficits in executive function (EF), which may impact engagement in everyday activities. Yoga has been shown to improve various health outcomes for individuals with ABI. This study aims to explore the impact of group yoga on EF for individuals with ABI. Methods and Materials: This was a single-arm pilot study that involved eight weeks of therapeutic group yoga led by a registered yoga teacher. Nine participants attended hour-long, in-person yoga classes once a week. Sessions included seated, standing, and floor postures combined with breathwork and meditation. EF was assessed pre- and post-intervention using the Behavior Rating Inventory of Executive Function for Adults (BRIEF-A) self-report form. Results: The behavioral regulation index improved significantly pre to post yoga. No significant improvements were found on the EF scales, metacognition index, or global executive composite. However, measurable improvements (>5%) were found in the following EF scales: Emotional Control, Plan/Organize, and Organization of Materials. Conclusion: Group-based yoga may improve behavioral regulation for adults with chronic ABI, however further research is needed.
Open Access
The effect of an intensive, outdoor camp on behavioral regulation and praxis in children
(Colorado State University. Libraries, 2022) Tull, Emily B., author; Lane, Shelly J., advisor; Bundy, Anita C., committee member; Burke, Hannah K., committee member; Butki, Brian, committee member
Background: Behavioral regulation and praxis skills are both crucial to childhood participation and performance in occupation. Behavioral regulation is the ability to employ executive functions in order to regulate, monitor, and adapt behavior to interact within the environment. Praxis is the ability to recognize object and environment affordance, develop an idea for action, plan the action, and then perform it. It is reflected by successful interactions with people and things in the environment. Purpose: This study examined the impact of a 5-day outdoor camp with integrated occupational therapy supports on behavioral regulation and praxis in 36 children with sensory processing, praxis, and behavioral challenges. Methods: Pre-test/post-test retrospective cohort design. Data were drawn from two parent-report questionnaires completed 3 months pre and 3 months post camp: the Behavior Rating Inventory of Executive Function-2 (BRIEF-2) and the Sensory Processing Measure (SPM). Findings: Linear mixed modelling revealed an association between behavioral regulation and praxis throughout the 6-month timespan. Paired samples t-tests showed significant change in praxis, and positive non-significant change in behavioral regulation. Implications: Practitioners should consider contexts and factors contributing to children's praxis and behavioral regulation skills, as well as the interface between the two characteristics. The use of outdoor camps should be considered in occupational therapy intervention for enhancing children's praxis, as well as participation and performance in occupations.
Open Access
The relationship between assistive technology utilization and academic outcomes for post-secondary students with a mental health condition
(Colorado State University. Libraries, 2022) Morgione, Carli, author; Malcolm, Matt, advisor; Roll, Marla, committee member; Haddock, Shelley, committee member
The prevalence of mental health conditions (MHC) in post-secondary students is increasing steadily, affecting as many as 30% of the college student population (Eisenberg et al., 2013). Mental health conditions can affect student's cognitive, social, and emotional functioning including challenges with attention, memory, problem-solving, attendance, and in-class participation, impacting their ability to be successful academically (Brown et al., 2019; Gitlow et al., 2017; Markoulakis & Kirsh, 2013). Previous studies have demonstrated this negative influence, finding presence of a mental health condition in post-secondary students to be related to lower grades (Hysenbegasi et al., 2005; Markoulakis & Kirsh, 2013). Post-secondary institutions need to identify methods to better support these students to promote positive academic and psychosocial outcomes. As part of title II of the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act, assistive technology (AT) and AT support services are legislatively mandated accommodations currently offered to many post-secondary students with disabilities, including students with a disability resulting from a mental health condition. AT was demonstrated to support the cognitive functions impacted by a MHC, such as through note-taking aids, scheduling and reminder technology, and thought organization technologies, to improve students' academic performance and satisfaction (Gitlow, 2021; Malcolm & Roll, 2017a). Limited evidence exists to demonstrate if any relationship exists between students with a mental health condition, utilization of AT services, and academic and psychosocial outcomes. The purpose of this study was to 1) identify predictors of AT service utilization, 2) identify predictors of GPA, and 3) identify predictors of self-advocacy and self-confidence for students with and without a MHC. Results of this study indicate that predictors of higher-grade point average (GPA) included AT service utilization, female gender, increased age, and non-first-generation status. Presence of a MHC was not predictive of AT service utilization, GPA, or ratings of self-advocacy and self-confidence compared to students with disabilities that did not have a mental health condition. Because these findings differ from current literature on the general population of post-secondary students with a MHC, further research is needed to identify if differences in academic and psychosocial outcomes exist for students with disabilities with a MHC compared to students not seeking disability services with a MHC.
Open Access
Systematic review of therapeutic interventions in occupational therapy for children with traumatic brain injury
(Colorado State University. Libraries, 2010) Ferland, Erik Richard, author; Sample, Pat, advisor; Greene, David, committee member; Seger, Carol, committee member
Objective: The aim of this study was to conduct a systematic evidence-based search and review of the published literature pertaining to occupational therapy interventions for children with traumatic brain injuries. Data sources: The databases searched included PsychINFO (EBSCOhost), Academic Search Premier (EBSCOhost), CINAHL (EBSCOhost) and PsycARTICLES (EBSCOhost) as well as the reference lists of articles found. Search terms: Whole words included brain, head. Wild card searches included child*, injur*, p?ediat*, rehab*, interven*, traum*, occupation*, therap*. Inclusion criteria for research articles: The participants must be children and youth with traumatic brain injuries (TBI) sustained from birth -2 1 years old; the intervention must be an associated occupational therapy intervention; the study must include between groups designs, with either quasi-experimental or randomized experimental design, and within subject single subject designs. Data interpretation: The author assessed each article against a rubric that looked at the quality various aspects of the study (e.g. design, methods, and outcome variables). Results: The researcher analyzed six articles with a total of 39 children with TBI. Three articles researched restrain therapy, one researched Lycra-based splints, one researched an antecedent behavioral intervention, and one discussed a problem solving intervention for families of children with TBI. Conclusion: The researchers found positive effects for the CIT interventions, the antecedent behavioral intervention and the family problem-solving intervention. The researchers who looked at the Lycra splinting found mixed results that were inconclusive.