Research Perspectives - Issue 1 by ETSU College of Clinical and Rehabilitative Health Sciences

Research Perspectives Issue 1 2017

Innovate

Educate

Collaborate

Dear Readers,

Research Magazine 2017 College of Clinical and Rehabilitative Health Sciences at East Tennessee State University Dean Dr. Don Samples Associate Dean of Academic Affairs Dr. A. Lynn Williams Associate Dean of Research Dr. W. Andrew Clark Writing Kristen Swing Design Annie Buckles Photography Charlie Warden Ron Campbell 156 S. Dossett Drive Johnson City, TN 37614 423-439-7454 carhs@etsu.edu www.etsu.edu/crhs

Welcome to the inaugural issue of the College of Clinical and Rehabilitative Health Sciences Research Magazine. The intent of this document is to provide alumni, students, friends of the college and interested parties an idea of the type and diversity of research being conducted in the college. Our college has a diverse faculty spanning three departments; Audiology and Speech-Language Pathology, Physical Therapy and Allied Health Sciences. The disciplines contained in these departments provide critical care for the patient and are an integral asset to the physician and the medical care team. This issue of the magazine will focus on three main research themes; Innovate, Educate and Collaborate, and an example from each of the three departments will be provided for each theme. We chose these three themes because they represent different aspects of the research mission within our college. Innovation is what many of us envision when we think about research and innovation can be diverse, ranging from the identification of a new mechanism of action to the development of a new teaching technique. The faculty profiled in this magazine, illustrate the diverse types of innovative research projects being conducted in our college. One of the primary missions in the college is to educate our students and we try to provide any student with a research experience as part of their education if they are so interested. Three students and the faculty involved in their research experience are included in this issue of the magazine. Contributing to the body of research evidence supporting our disciplines is an important part of the college experience. Finally, in many circumstances a collaborative research team allows researchers to avoid “tunnel vision” based on biases inherent in single discipline teams. Collaboration can be between disciplines in the college, between colleges at ETSU or involving outside entities that augment the scope of the project by blending facilities and intellectual capabilities while optimizing the research budget. While researchers are required to “share the spotlight” with others, the speed, manpower, scope of the project and research output from these teams are impressive. I am proud to play a role with the research mission of the College of Clinical and Rehabilitative Health Sciences and hope that this issue of the Research Magazine provides you some insight into the exciting research being conducted in our college. Should you desire to help support research within our college we would welcome your input and support. W. Andrew Clark, PhD, RD

Issue 1 2017

Contents 3

Innovations in Physical Therapy

Innovations in Speech-Language Pathology

Educate: Research in Audiology

Educate: Research in Allied Health

Educate: Research in Physical Therapy

Collaborations in Allied Health

Collaborations in Speech-Language Pathology

Collaborations in Allied Health

Research Across Departments

Dr. Craig Wassinger

Dr. Courtney Hall

Dr. Chayadevie Nanjundeswaran Kadie Sharrett

Marshall Wagner

Dr. Trish King and Jordan Johnson

Dr. Arsham Alamian, Dr. JoAnn Marrs, Dr. W. Andrew Clark, Dr. Jonathan Peterson Dr. Brenda Louw, Dr. Michelle Lee

Dr. Michelle Johnson, Victoria Zaleski

East Tennessee State University is an AA/EEO employer and does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities. ETSU-071-16 .05M

Thank you for your support to the research and development at East Tennessee State Universityâ&#x20AC;&#x2122;s College of Clinical and Rehabilitative Health Sciences.

To collaborate in research with the ETSU College of Clinical and Rehabilitative Health Sciences, please contact W. Andrew Clark: clarkw@etsu.edu.

Innovate Innovations InnovationsininPhysical PhysicalTherapy Therapy

Wassinger among first in nation to be certified as therapeutic pain specialist. In 2016, Dr. Craig Wassinger, an associate professor in the Department of Physical Therapy, completed an eight-month training program to receive the new national certification from the International Spine & Pain Institute and Evidence in Motion. He was one of 20 students in the inaugural cohort. Wassinger, a physical therapist who has been conducting pain-related research since 2008, said he started to see a lot of patients with chronic pain and realized he needed to do something different to better serve those individuals. “If we could make the pain go away altogether, of course, that’d be great,” Wassinger said. “But no one has that silver bullet and you can chase that forever.” Instead, Wassinger said it is about changing a patient’s mindset as it relates to pain. “Once you’ve had pain for a long time, pain actually becomes the disease. The original injury is as healed as it is going to be and the pain becomes the problem,” Wassinger said. “A lot is helping them to understand what is going on with their pain. The problem is the way their nerves are acting.” By reframing an injury, Wassinger said the patient often becomes less fearful of the pain he or she experiences and is willing to push harder in physical therapy because of the understanding that the pain is a part of the process and not furthering the injury. “Once they have that shift in framework, they can be more active,” he said. “Then hopefully that pain can go away.” Wassinger believes therapeutic pain services could complement the use of prescription drugs to improve a patient’s pain level, and, in some cases, may be a total substitute for pain medication. “There is a huge prescription drug abuse problem in the United States and this is an alternative that is hugely needed and could help prevent opioid addiction,” he said. It’s not just Wassinger’s patients who are benefitting from his certification as a therapeutic pain specialist, either. Students coming through ETSU’s physical therapy program are also coming out ahead as Wassinger helps lead curriculum direction as it relates to pain content. 3

Dr. Craig Wassinger encourages his students to recognize the difference between “interest” and “investment.” While a person is interested in plenty of things, he emphasizes the importance of actually investing in “opportunities that might give you the opportunity to grow.” ETSU’s Department of Physical Therapy Pain Specialist, Dr. Craig Wassinger

Innovate Innovations in Physical Therapy

Dr. Courtney Hall, an associate professor in the Department of Physical Therapy, helped draft the first-ever clinical guidelines relating to vestibular rehabilitation in physical therapy. Hall specializes in vestibular rehabilitation, a form of therapy intended to alleviate primary and secondary problems caused by vestibular (inner ear balance) disorders. Vestibular rehabilitation primarily aims to reduce dizziness, vertigo and falls from imbalance. “There are guidelines for a variety of musculoskeletal conditions such as back pain, but there have not been any established for vestibular rehabilitation,” Hall said. “About four years ago, I reached out to a colleague and said we needed to develop these clinical practice guidelines.” Hall, along with a colleague from the University of Pittsburgh and a professor emerita from Emory University, have been working on those guidelines ever since.

Innovate continued... The guidelines are sanctioned by the American “It has been a process,” Hall noted. “We consulted Physical Therapy Association and last spring with a committee of physical therapists, they were published in the Journal of audiologists, neurologists, ENTs and Neurologic Physical Therapy. patient advocates on this because we needed to have input from “These guidelines are really to multiple disciplines.” The clinical practice benefit both the patients and the clinicians,” Hall said. “Patients The process also involved guidelines include 10 can read about vestibular rehabilsystematic literature research, recommendations, or itation and understand what a determining what the best “action statements,” physical therapist does to treat practices are based on evidence dizziness. And it is a resource for from the field over the last related to the treatment clinicians in that it sets the stage several years. of patients with vestibular for what the standard of care is The clinical practice guidelines disorders. based on what the research and include 10 recommendations, or evidence show. Hopefully, it will “action statements,” related to the reduce unwarranted variations in care.” treatment of patients with vestibular The guidelines are required to be updated every disorders. “We also identify knowledge gaps – five years to keep up with the current evidence. those areas where the research and evidence are still missing,” Hall said. “Hopefully, researchers will start to fill in those gaps.”

ETSU’s Department of Physical Therapy Vestibular Research, performed by Courtney Hall

Innovate Innovations in Speech-Language Pathology

“Voice defines who you are. It is a unique print, just like your fingerprint. A lot of times, people take it for granted, but if you don’t take care of it, you risk losing that identity.” – Dr. Chayadevie Nanjundeswaran In mid-2016, a top-tier academic journal named an article written by Dr. Chayadevie Nanjundeswaran, a speech-language pathologist and assistant professor, the best speech-language pathology paper published in 2015. In writing the article, Nanjundeswaran created a voice fatigue index (VFI) to help identify individuals with vocal fatigue and characterize their complaints. “Vocal fatigue is experienced so commonly by professional voice users, be it teachers, singers, pastors, really anyone who uses their voice for work,” said Nanjundeswaran, who runs ETSU’s Voice Clinic. “But nobody had defined what it was. The term has just been implicitly used.” As part of her doctoral studies, Nanjundeswaran set out to develop a way to better determine what the typical vocal fatigue patient experiences with the condition. “When you say voice fatigue, everyone says it is tiredness of voice, but there are other symptoms, too,” Nanjundeswaran said. “We as clinicians and researchers understand what it means, but a population that experiences it may not. Laying out the symptoms may help them recognize it.” Nanjundeswaran began her research more than five years ago, creating a questionnaire handed out to 7

patients at the University of Pittsburgh and the Vanderbilt Voice Center. “The results show the VFI can identify individuals with probable vocal fatigue with good reliability, validity, sensitivity and specificity,” Nanjundeswaran said. “The index also helped determine three factors that characterize vocal fatigue: tiredness of voice and voice avoidance; physical discomfort associated with using voice; and improvement of symptoms with rest.” In July 2015, the Journal of Voice published Nanjundeswaran’s article, “Vocal Fatigue Index (VFI): Development and Validation.” Since then, Nanjundeswaran has received requests from researchers around the globe to have her work translated and culturally adapted for use in other countries. It has been translated into at least six languages, including Persian, Turkish, Chinese, German and Brazilian. Nanjundeswaran accepted the Best Paper Award for the article at The Voice Foundation’s 45th annual symposium held in the summer. “I knew the VFI was gaining recognition in the voice world, which was my intent – for people to be able to use it to help patients with voice fatigue,” Nanjundeswaran said. “But I wasn’t expecting this award. Getting recognition for something I worked most of my doctoral education for is very satisfying. I am very humbled.”

Educate Research in Audiology

Research reveals cognitive process is more difficult for those with hearing loss.

adie Sharrett, now a third-year doctoral

student in the audiology program, completed a study in 2016 that evaluates whether people with hearing loss have a harder time than normal listeners at “filling in the blanks” of a conversation. When someone is in an environment with a lot of background noise, like a cocktail party for example, it is not uncommon for that individual to only hear parts of words being spoken during a conversation, Sharrett explained. It is actually the person’s cognitive ability to fill in the gaps that helps him or her fully understand what words have been spoken. “It is about more than the sensory organ of the ear. It is cognitive,” Sharrett said. “So we wanted to see if those with hearing loss are able to fill in those blanks as adequately as normal listeners.” Working with Dr. Richard Wilson, an ETSU alumnus and faculty member, Sharrett spent 10 months studying 24 veterans suffering from similar degrees of hearing loss to determine their cognitive abilities to piece together conversations. “We found there’s a lot more variability in listeners with hearing loss,” she said. “In general, they are not as good at it.” The findings of Sharrett’s study could help better determine appropriate tools and training opportunities to assist individuals in improving their cognitive abilities to understand interrupted speech. “There has been research to show that the more they practice, the better they get at it,” Sharrett said. Sharrett presented her findings at the American Auditory Society’s annual meeting in Scottsdale, Arizona. The study was funded by the James H. Quillen VA Medical Center at Mountain Home through its Research Enhancement Award Program.

Educate Research in Allied Health

arshall Wagner, who graduated in May 2016 with a

degree in nutrition and foods, was named the College of Clinical and Rehabilitative Health Sciences’ outstanding undergraduate student. Now a medical student at Lincoln Memorial University, Wagner spent much of his time at ETSU helping conduct research in the laboratories of CCRHS and College of Public Health faculty members. While working alongside Drs. W. Andrew Clark and Jonathan Peterson, Wagner researched the correlation between circulating CTRP3 proteins in male and female patients who all had a cardiac event, specifically in regards to diabetes and obesity. CTRP3 is a protein that has been linked to a number of beneficial biological effects on metabolism, inflammation and survival signaling in a variety of tissues. However, very little is known about the protein in regards to human health.

Wagner and his mentors set out to examine CTRP3 levels in patients with symptoms requiring heart catheterization in order to identify the presence of obstructive coronary artery disease. What they found is that circulating CTRP3 levels had a different relationship with diabetes and obesity status between males and females. An article on the research was published in the journal, PeerJ, in October 2016. Wagner served as the lead author for the article, with Peterson serving as corresponding author. “For an undergraduate student to not only get this research experience, but have his study published in a scholarly journal such as PeerJ, says a lot about the student as well as about the institution that can offer such opportunities to its students,” Peterson said. “Marshall is dedicated to learning all he can and I have no doubt what he learned while at ETSU will carry within him as he moves through medical school and beyond.” “Having been chosen to have the opportunity to participate in clinical research, that resulted in a publication in my name, has been both rewarding and a great experience, especially since the opportunity is not given to everyone as an undergraduate student. Being able to work closely with both Dr. Clark and Dr. Peterson on our research project helped solidify my academic goals, as well as set me apart from other candidates when applying for admittance into medical schools, as well as military scholarships. This experience not only helped me build a strong resume, but I was also given the opportunity to realize that I have a passion for clinical research to better enhance the future of medicine. “

Educate Research in Physical Therapy

A few years ago, one of Dr. Trish King’s former students from the University of Tennessee-Memphis called her. She was working in home health and had noticed that almost all of her new patients listed incontinence as a problem. That problem, she noted to King, almost always remained on patients’ lists without being addressed as a part of their treatment. King, the chair of East Tennessee State University’s Department of Physical Therapy, talked with her former student and, over the phone, gave her instructions on basic exercises she could have her patients do to engage the pelvic floor muscles and potentially improve or eliminate incontinence. “She had awesome outcomes,” King recalled. Recognizing that incontinence is a significant health problem for older adults and noticing the need among physical therapists to better understand how the profession can help treat and prevent incontinence, King now focuses much of her research efforts on the topic. “There are physical therapists who specialize in pelvic floor rehabilitation, but much of it is done with internal devices,” King said. “The perception among physical therapists is that treating incontinence requires those internal techniques, but there are other, less invasive strategies we can use to engage those muscles that can have a positive effect.” Through a grant from ETSU’s undergraduate research collaborative, King and Jordan Johnson, an undergraduate pre-PT student, are aiming to provide training to home health care physical therapists about those strategies to treat incontinence in their patients. “The incidence of incontinence in home health care settings is just out the roof and there isn’t enough being done to address it,” King said. “Urinary incontinence with aging is linked to a higher fall risk, and fall risk is linked to decreased quality of life and mortality.” As part of the grant, King and Johnson will create and conduct a survey to obtain information from physical therapists about their understanding of the issue. They will then provide, through educational sessions, information to home health physical therapists on how to add exercise instruction into their treatment plan for applicable patients they are already seeing for unrelated physical therapy needs. Participating physical therapists will also be provided with tools and knowledge to track outcomes of the treatment. “There’s not been a lot of research done on the outcomes of the non-invasive treatment,” King said. “The hope is, out of this, will come information and outcomes that would help us put in place a training program for all home health agencies.” King and Johnson are working with Gentiva Home Health Care in Kingsport to conduct the research project.

Collaborate Collaborations in Allied Health

An interprofessional research team at East Tennessee State University has discovered that the prevalence of metabolic syndrome in Hispanic children is three times higher than the average rate for which it is found in the general population.

prevalence of metabolic syndrome in Hispanic children ages 2 to 10. Funded initially by a Tennessee Board of Regents diversity grant in 2014, the project involved gathering health data from 150 Hispanic children. Although the researchers are still analyzing that data, the preliminary results are staggering.

Metabolic syndrome is a clustering of several risk factors for cardiovascular disease. The factors also increase a person’s risk for diabetes “The statistics show a 15 percent prevalence of and stroke. They include elevated metabolic syndrome in this population. In triglycerides, abdominal obesity, systolthe general population, it is around 4 ic blood pressure and high glucose to 5 percent,” Alamian said. “This levels. Ultimately, the group population has metabolic synThe ETSU team’s research began drome at a higher proportion than hopes to develop some several years ago when Dr. any other population that has ever kind of intervention JoAnn Marrs, a faculty member been studied before.” project to reduce the with the ETSU College of Nursrate of metabolic The researchers hope to develop ing, was seeing patients at the enough preliminary data through syndrome present in Johnson City Community Health the study to seek additional grant Hispanic children. Center. funding for the research from places “I noticed a lot of Hispanic such as the National Institutes for Health, children with elevated triglyceride levels and Clark said. I really didn’t know where that was coming Ultimately, the group hopes to develop some from or why I was seeing it so much in this kind of intervention project to reduce the rate of population,” Marrs said. “I began metabolic syndrome present in Hispanic wondering if it was dietary or perhaps children. environmental or maybe even genetic.” “With the continued growth of the Hispanic Marrs teamed up with Dr. W. Andrew Clark, population, especially in this region, that is the ETSU College of Clinical and going to have repercussions on our health care Rehabilitative Health Sciences Associate Dean system if we don’t figure this out,” Marrs said. of Research, and ETSU College of Public “We need to come up with an intervention Health faculty members Drs. Arsham Alamian strategy.” and Jonathan Peterson to further study the 11

ETSU research team finds high prevalence of metabolic syndrome in Hispanic children.

ETSUâ&#x20AC;&#x2122;s College of Clinical and Rehabilitative Health Sciences research team from left to right: Dr. Arsham Alamian, Dr. JoAnn Marrs, Dr. W. Andrew Clark, Dr. Jonathan Peterson

Collaborate Collaborations in Speech-Language Pathology

Collaboration is key for speech-language pathologists and registered dietitians. Dr. Brenda Louw and Dr. Michelle Lee know they need each other. The East Tennessee State University faculty members have been in their respective professions long enough to recognize the importance of collaboration in order to benefit their patients. What these two women – Louw, a speech-language pathologist, and Lee, a registered dietitian – have also realized, however, is that training students in these two fields to collaborate is uncommon at institutions of higher education. “In general, we just don’t teach that very well in our programs,” said Lee, an associate professor in the ETSU College of Clinical and Rehabilitative Health Sciences’ Department of Allied Health Sciences. “Instead, we discover the significance of collaboration when we get into the real world, when we become practicing professionals.” Louw and Lee are hoping to change that through their research efforts. They received the College of Clinical and Rehabilitative Health Sciences Dean’s Research Enhancement Award and now have surveyed more than 100 speech language pathologists and more than 200 registered dietitians to see if they collaborate with each other on a regular basis and whether their training as students prepared them for effective collaboration. “For speech-language pathologists, we found the clinical settings in which they worked really determined if and to what extent they collaborate,” Louw said. “It was not anything related to their education that affected collaboration.” Lee is still analyzing the data gathered from the surveying of registered dietitians, but said she expects similar responses and results. Following their analysis, the pair next hope to survey program directors at colleges and universities to determine the level of interprofessional training regarding their professions that is happening in the classroom. “I have a feeling most are not until the students get in their clinicals and, by chance, see it being done in practice,” Lee said. 13

Collaborate continued.... Registered dietitians, Lee noted, often look to speech-language pathologists for help with patients who have swallowing issues or might be choking a lot. In turn, speech-language pathologists utilize registered dietitians to ensure diets recommended to patients based on texture needs also meet nutritional needs of those individuals, she said. “Once we have our data analyzed and understand both perspectives, we want to develop an education module to incorporate into speech-language pathology and dietetics education. Collaboration can only really happen if you are familiar with the other person’s profession,” Louw said. “I think it will bring the two professions together much earlier and you won’t have to wait to discover and learn this in practice.” Ultimately, Louw said, clients would benefit from possible joint assessments and more integrated treatment of health issues.

ETSU’s College of Clinical and Rehabilitative Health Sciences Faculty Dr. Michelle Lee (left) and Dr. Brenda Louw (right)

Collaborate Collaborations in Allied Health

Collaboration is key for nutrition faculty member Michelle Johnson. For Michelle Johnson, collaboration is always the name of the game. Johnson, the dietetic internship director for the East Tennessee State University College of Clinical and Rehabilitative Health Sciences’ nutrition program and interim undergraduate director for nutrition, prides herself on always being open to unique opportunities to work with others in various professions. “Collaboration is just who I am. That is how I like to work,” Johnson said. “It’s always so important to have all the players involved and everyone’s opinion counts. That’s just my internal philosophy.” That internal philosophy has led to her involvement in various interprofessional and collaborative projects, including a multi-college consortium focused on increasing the number of interprofessional practitioners prepared to work in the field of neurodevelopmental disorders. The Vanderbilt Consortium LEND (Leadership Education in Neurodevelopmental Disabilities), or VCL, expanded from Middle Tennessee to ETSU in the fall of 2016. In addition to ETSU and Milligan, the VCL also includes faculty and trainees from Belmont University, Meharry Medical College, Milligan College, Tennessee State University, the University of Tennessee, Vanderbilt University and Family Voices of Tennessee. The purpose of the consortium is to reduce and prevent neurodevelopmental disabilities and related disabilities in children and to increase family-centered, community-based, culturally competent, interdisciplinary services. The VCL focuses on preparing graduate- and post-graduate-level health professionals to assume leadership roles and develop interprofessional team skills through a 300-hour certificate program that is in addition to the scholar’s regular education program. As a faculty member involved with the LEND project, Johnson serves as a mentor to the LEND scholars. “They are learning about various aspects of different neurodevelopmental disorders, but also about leadership and interprofessional practice,” Johnson explained. “The evidence is clear that interprofessional practice improves patient care. The goal is to enhance the students’ training so they have a deeper understanding of how it works.”

Collaborate continued.... The ETSU team working on the LEND project includes faculty members from nutrition, speech, audiology, physical therapy, special education, psychology and social work.

Johnson said. “Undernutrition in children with neurodevelopmental disorders is a growing concern and evidence strongly supports an interprofessional approach to the care of children with feeding challenges.”

Johnson is currently working with Johnson hopes her work with nutrition graduate student Victoria Johnson hopes her work with the the LEND grant will not only Zaleski, a LEND scholar, as well as LEND grant will not only lead to lead to improved patient care, Teresa Boggs, speech-language improved patient care, but a richer but a richer understanding for pathology clinical director for ETSU, understanding for her students of what her students of what it means and Milligan occupational therapy it means to work in an interprofessional to work in an interprofessional faculty member Christy Isbell to environment. environment. enhance interprofessional practice of the “I’ve had a lot of opportunities since I have Positive Eating Program housed at ETSU’s Nave been here to be involved in collaborative projects,” Center. she said. “And I encourage my students to seek out those “We recently submitted an abstract specific to the Positive Eating Program and an interprofessional approach to the treatment of neurodevelopmental feeding challenges,”

opportunities as well, even if those opportunities are completely outside of what they expected they’d be doing.”

ETSU’s Nutrition faculty Michelle Johnson (left) and nutrition graduate student Victoria Zaleski

Research Data Across Departments Books, Book Chapters, Editor of Book, Monographs, Clinical Manual Published/Performed 4 2

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Allied Health