Biomedical subjects

Gitendra Uswatte

Publications and source records attributed to Gitendra Uswatte.

At least 19 recordsLinked to original sources

PubMed2006

Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial.

CONTEXT: Single-site studies suggest that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year. OBJECTIVE: To compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months. DESIGN AND SETTING: The Extremity Constraint Induced Therapy Evaluation (EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003. PARTICIPANTS: Two hundred twenty-two individuals with predominantly ischemic stroke. INTERVENTIONS: Participants were assigned to receive either CIMT (n = 106; wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand) or usual and customary care (n = 116; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions); patients were stratified by sex, prestroke dominant side, side of stroke, and level of paretic arm function. MAIN OUTCOME MEASURES: The Wolf Motor Function Test (WMFT), a measure of laboratory time and strength-based ability and quality of movement (functional ability), and the Motor Activity Log (MAL), a measure of how well and how often 30 common daily activities are performed. RESULTS: From baseline to 12 months, the CIMT group showed greater improvements than the control group in both the WMFT Performance Time (decrease in mean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 seconds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% confidence interval {CI}, 12%-51%]; P<.001) and in the MAL Amount of Use (on a 0-5 scale, increase from 1.21 to 2.13 vs from 1.15 to 1.65; between-group difference, 0.43 [95% CI, 0.05-0.80]; P<.001) and MAL Quality of Movement (on a 0-5 scale, increase from 1.26 to 2.23 vs 1.18 to 1.66; between-group difference, 0.48 [95% CI, 0.13-0.84]; P<.001). The CIMT group achieved a decrease of 19.5 in self-perceived hand function difficulty (Stroke Impact Scale hand domain) vs a decrease of 10.1 for the control group (between-group difference, 9.42 [95% CI, 0.27-18.57]; P=.05). CONCLUSION: Among patients who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year. Trial Registration clinicaltrials.gov Identifier: NCT00057018.

Activities of Daily Living↗

PubMed2006

A placebo-controlled trial of constraint-induced movement therapy for upper extremity after stroke.

BACKGROUND AND PURPOSE: Constraint-Induced Movement therapy (CI therapy) is a neurorehabilitation technique developed to improve use of the more affected upper extremity after stroke. A number of studies have reported positive effects for this intervention, but an experiment with a credible placebo control group has not yet been published. METHODS: We conducted a placebo-controlled trial of CI therapy in patients with mild to moderate chronic (mean=4.5 years after stroke) motor deficit after stroke. The CI therapy group received intensive training (shaping) of the more affected upper extremity for 6 hours per day on 10 consecutive weekdays, restraint of the less affected extremity for a target of 90% of waking hours during the 2-week treatment period, and application of a number of other techniques designed to produce transfer to the life situation. The placebo group received a program of physical fitness, cognitive, and relaxation exercises for the same length of time and with the same amount of therapist interaction as the experimental group. RESULTS: After CI therapy, patients showed large (Wolf Motor Function Test) to very large improvements in the functional use of their more affected arm in their daily lives (Motor Activity Log; P<0.0001). The changes persisted over the 2 years tested. Placebo subjects showed no significant changes. CONCLUSIONS: The results support the efficacy of CI therapy for rehabilitating upper extremity motor function in patients with chronic stroke.

Adult↗

PubMed2006

Fragile self-esteem and affective instability in posttraumatic stress disorder.

Temporal fluctuations in self-esteem and affect are prominent features of several clinical conditions (e.g., depression), but there is an absence of empirical work examining their role in posttraumatic stress disorder (PTSD). Individuals who experience large fluctuations in self-evaluations and affect are considered more vulnerable to psychopathology than individuals able to adequately modulate their self-image and emotional responses. We examined the relevance of self-esteem and affective instability to PTSD. Veterans with and without PTSD completed 14 daily ratings of self-esteem, positive affect, negative affect, and gratitude. Compared to veterans without PTSD, veterans with PTSD exhibited more temporal fluctuations in self-esteem, negative affect, and gratitude, with a smaller effect for positive affect. For all veterans, self-esteem and negative affective instability was associated with diminished well-being. Except for self-esteem instability, most findings were substantially reduced after accounting for variance attributable to PTSD diagnoses and mean intensity levels over the 14-day monitoring period. These data suggest self-esteem instability is important in understanding the lives of veterans with and without PTSD.

Affect↗

PubMed2006

Validity of accelerometry for monitoring real-world arm activity in patients with subacute stroke: evidence from the extremity constraint-induced therapy evaluation trial.

OBJECTIVE: To examine the psychometric properties of an objective method for assessing real-world arm activity in a large sample with subacute stroke. DESIGN: Validation study. SETTING: Community. PARTICIPANTS: Persons 3 to 9 months poststroke (N=169) with mild to moderate motor impairment of their hemiparetic arm enrolled in a multisite, randomized clinical trial of constraint-induced movement therapy. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants wore an accelerometer on each arm outside the laboratory for 3 days before and after treatment or an equivalent no-treatment period. They also completed the Actual Amount of Use Test (AAUT), which is an observational measure of spontaneous more-impaired arm use, and the Motor Activity Log (MAL), which is an interview assessing more-impaired arm use in daily life. RESULTS: Low-pass-filtered accelerometer recordings were reliable (r range, >.8) and stable (P range, >.48). Their validity was also supported. Correlations calculated across all participants at baseline between the ratio of more-impaired to less-impaired arm accelerometer recordings and AAUT and MAL scores were .60 and .52, respectively. CONCLUSIONS: Accelerometry provides an objective, real-world index of more-impaired arm activity with good psychometric properties.

Activities of Daily Living↗

PubMed2006

Gratitude and hedonic and eudaimonic well-being in Vietnam war veterans.

Little information exists on the contribution of psychological strengths to well-being in persons with post-traumatic stress disorder (PTSD). Data from other populations suggest that gratitude, defined as the positive experience of thankfulness for being the recipient of personal benefits, may have salutary effects on everyday functioning. We investigated whether dispositional gratitude predicted daily hedonic and eudaimonic well-being in combat veterans with and without PTSD. We also examined associations between daily gratitude and daily well-being across time. Veterans with PTSD, compared to those without PTSD, exhibited significantly lower dispositional gratitude; no differences were found on daily gratitude. Dispositional gratitude predicted greater daily positive affect, percentage of pleasant days over the assessment period, daily intrinsically motivating activity, and daily self-esteem over and above effects attributable to PTSD severity and dispositional negative and positive affect in the PTSD group but not the non-PTSD group. Daily gratitude was uniquely associated with each dimension of daily well-being in both groups. Although preliminary, these results provide support for the further investigation of gratitude in trauma survivors.

Affect↗

PubMed2006

The influence of neuropsychological characteristics on the use of CI therapy with persons with traumatic brain injury.

The great prevalence of traumatic brain injury (TBI) and its high economic costs make reducing TBI-related disability a national health care priority. In our research laboratory, CI therapy has been found to significantly improve upper extremity function for persons with chronic TBI. The results have suggested that persons with TBI are less likely to adhere to critical components of the CI therapy protocol than participants with stroke in other studies. Treatment outcomes have also been more variable. Our findings suggest that some cognitive skills appear related to treatment outcome. In addition, cognitive and behavioral deficits, commonly seen with participants with TBI, challenge the delivery of the standard CI therapy protocol with some persons. We discuss the implications of these neuropsychological factors for CI therapy used for chronic TBI and propose further research to more thoroughly investigate these issues.

Adult↗

PubMed2006

Contribution of the shaping and restraint components of Constraint-Induced Movement therapy to treatment outcome.

Two important components of Constraint-Induced Movement therapy are thought to be intense training of the more-impaired arm and physical restraint of the less-impaired arm. This preliminary study examined the effects of type of training (task-practice, shaping) and restraint (sling, half-glove, no restraint) on treatment outcomes. Seventeen individuals at least 1-year post-stroke with mild/moderate upper extremity motor deficit were consecutively assigned to Sling and Task-practice, Sling and Shaping, Half-glove and Shaping, and Shaping Only groups. Task-practice involved repetitive more-impaired arm training on functional tasks for 6 hr/day for 10 consecutive weekdays. Shaping differed from task-practice in that task demands were progressively increased and immediate performance feedback was provided frequently and systematically. "Sling" groups placed the less-impaired arm in a resting hand-splint/sling assembly for most waking hours over the 2-week intervention, while the "Half-glove" group wore a modified gardening glove as a reminder not to use the more affected arm in the life situation. There were no between-group differences in outcome at post-treatment, although two-years afterwards Sling & Task-practice and Half-glove & Shaping participants showed larger and smaller retention of gains, respectively, than those in the Sling & Shaping group. Thus, long-term outcomes may have been affected by type of more-impaired arm motor training and less-impaired arm restraint. These variables, however, were confounded with between-group differences in training intensity, limiting confidence in this conclusion.

Aged↗

PubMed2006

Employment in households with stroke after Constraint-Induced Movement therapy.

Randomized controlled clinical studies show that Constraint-Induced Movement therapy (CI therapy) improves impaired arm function in patients with stroke. Little is known about how this therapy affects employment of patients or their caregivers. Individuals more than 1-year post-stroke (N=121) were retrospectively surveyed about their activities and employment prior to stroke, after stroke but before CI therapy and after CI therapy. They were also asked if someone had stopped working to be a caregiver and if that person had resumed employment. Before stroke, 48% of patients had been employed; this fell to 22% after stroke and did not significantly rise after CI therapy with most of the newly unemployed moving into a permanent retirement status before starting CI therapy. Among the CI therapy patients, one-quarter (29/121) reported that someone had limited their employment to take care of them following their stroke. After CI therapy, more than 60% (18/29) of caregivers returned to employment. Our preliminary finding regarding return to work by caregivers of stroke patients post-CI therapy warrants further study using prospective methods and randomized, controlled designs.

Aged↗

PubMed2006

A treatment for a chronic stroke patient with a plegic hand combining CI therapy with conventional rehabilitation procedures: case report.

Constraint-Induced Movement therapy (CI therapy) is a recognized rehabilitation approach for persons having stroke with mild to moderately severe motor upper extremity deficits. To date, no rehabilitation treatment protocol has been proven effective that addresses both motor performance and spontaneous upper extremity use in the life situation for chronic stroke participants having severe upper extremity impairment with no active finger extension or thumb abduction. This case report describes treatment of a chronic stroke participant with a plegic hand using a CI therapy protocol that combines CI therapy with selected occupational and physical therapy techniques. Treatment consisted of six sessions of adaptive equipment and upper extremity orthotics training followed by a three-week, six-hour daily intervention of CI therapy plus neurodevelopmental treatment. Outcome measures included the Motor Activity Log for very low functioning patients (Grade 5 MAL), upper extremity portion of the Fugl-Meyer Motor Assessment, Graded Wolf Motor Function Test - for very low functioning patients (gWMFT- Grade 5), and Modified Ashworth Scale. The participant showed improvement on each outcome measure with the largest improvement on the Grade 5 MAL. In follow-up, the participant had good retention of his gains in motor performance and use of his more affected arm for real world activities after 3 months; after a one-week brush-up at 3 months, and at one year post-treatment.

Behavior Therapy↗

PubMed2005

Reliability and validity of the upper-extremity Motor Activity Log-14 for measuring real-world arm use.

BACKGROUND AND PURPOSE: In research on Constraint-Induced Movement (CI) therapy, a structured interview, the Motor Activity Log (MAL), is used to assess how stroke survivors use their more-impaired arm outside the laboratory. This article examines the psychometrics of the 14-item version of this instrument in 2 chronic stroke samples with mild-to-moderate upper-extremity hemiparesis. METHODS: Participants (n=41) in the first study completed MALs before and after CI therapy or a placebo control procedure. In addition, caregivers independently completed a MAL on the participants. Participants (n=27) in the second study completed MALs and wore accelerometers that monitored their arm movements for 3 days outside the laboratory before and after an automated form of CI therapy. RESULTS: Validity of the participant MAL Quality of Movement (QOM) scale was supported. Correlations between pretreatment-to-posttreatment change scores on the participant QOM scale and caregiver MAL QOM scale, caregiver MAL amount of use (AOU) scale, and accelerometer recordings were 0.70, 0.73, and 0.91 (P<0.01), respectively. Internal consistency (alpha>0.81), test-retest reliability (r>0.91), stability, and responsiveness (ratio>3) of the participant QOM scale were also supported. The participant AOU and caregiver QOM and AOU scales were internally consistent, stable, and sensitive, but were not reliable. CONCLUSIONS: The participant MAL QOM scale can be used exclusively to reliably and validly measure real-world, upper-extremity rehabilitation outcome and functional status in chronic stroke patients with mild-to-moderate hemiparesis.

Activities of Daily Living↗

PubMed2005

Social anxiety and posttraumatic stress in combat veterans: relations to well-being and character strengths.

There are few studies examining the relationship between psychopathology and positive experiences and traits. Although initial studies suggest persons with posttraumatic stress disorder (PTSD) are at increased risk for excessive social anxiety, there have been no studies to date evaluating how these conditions might interact to affect positive experiences and traits. Using self-report scales, informant ratings, and experience-sampling methodologies, we examined the association of social anxiety with well-being and character strengths in veterans with and without PTSD. Controlling for PTSD and trait negative affect, social anxiety was negatively related to global ratings of well-being and character strengths. Social anxiety also accounted for incremental variance in day-to-day well-being (i.e., daily affect balance, percentage of pleasant days, positive social activity, self-esteem, gratitude) over a 14-day assessment period. Although veterans with PTSD reported lower levels of global and daily well-being and character strengths than veterans without PTSD, a diagnosis of PTSD failed to exhibit unique relationships with these constructs. Building on a growing body of work, these data suggest that social anxiety is uniquely associated with disturbances in positive experiences, events, and traits. Our findings support the value of directly addressing social anxiety in the study and treatment of PTSD.

Anxiety Disorders↗

PubMed2005

AutoCITE: automated delivery of CI therapy with reduced effort by therapists.

BACKGROUND AND PURPOSE: To evaluate the effectiveness of a device that automates Constraint-Induced Movement therapy (CI therapy), termed AutoCITE, when only partially supervised by therapists. METHODS: Twenty-seven participants with chronic stroke trained with AutoCITE for 3 hours per day for 10 consecutive weekdays. Participants were assigned to 1 of 3 groups in a fixed irregular order (ie, in alternating blocks): supervision from a therapist for 100%, 50%, or 25% of training time. RESULTS: The effect sizes of the treatment gains for the 3 groups on the Motor Activity Log (MAL) were very large and for the Wolf Motor Function Test they were large (all P<0.001) but were not significantly different from one another. Gains were comparable to those previously reported for participants who received an equal amount of standard one-on-one CI therapy without the device. At 1-month and long-term follow-up, gains from pretreatment on the MAL were also significant (P<0.001). CONCLUSIONS: These results demonstrate that AutoCITE training with greatly reduced supervision from a therapist is as effective as standard one-on-one CI therapy.

Activities of Daily Living↗

PubMed2005

Distributed form of constraint-induced movement therapy improves functional outcome and quality of life after stroke.

OBJECTIVE: To evaluate the effectiveness of a distributed version of constraint-induced movement therapy (CIMT). DESIGN: Within-subjects control intervention study. SETTING: Outpatient rehabilitation center. PARTICIPANTS: Eleven persons with chronic stroke. All had active extension of at least 20 degrees at the wrist and at least 10 degrees for each finger of the more-affected hand. INTERVENTIONS: Intensive motor training of the more-affected arm for 3 hours a day for 20 days; restraint of the other arm for 9.3 hours daily to limit its use. This intervention provides the same amount of training as provided in the conventional CIMT therapy protocol (60 h) but distributes training time over twice the number of days. MAIN OUTCOME MEASURES: Real-world (Motor Activity Log) and laboratory motor activity (Wolf Motor Function Test, Frenchay Arm Test, Nine Hole Peg Test), strength (grip force) and spasticity (Ashworth Scale), and quality of life (QOL; Stroke Impact Scale) were assessed. RESULTS: Participants showed significant improvements in more-affected arm real-world motor activity, laboratory motor activity, strength and spasticity, as well as in some aspects of QOL, up to 6 months after treatment ( P .05). CONCLUSIONS: Distributed CIMT is a promising intervention for improving motor function and QOL in patients with chronic stroke.

Adult↗

PubMed2005

Ambulatory monitoring of arm movement using accelerometry: an objective measure of upper-extremity rehabilitation in persons with chronic stroke.

OBJECTIVE: To evaluate the reliability and validity of accelerometry for measuring upper-extremity rehabilitation outcome. DESIGN: Validation study. SETTING: Data recorded in the community. PARTICIPANTS: Consecutive Constraint-Induced Movement therapy (CIMT) patients (n = 10) and volunteer community residents with stroke (n = 10). All participants were more than 1 year poststroke and had mild to moderate motor impairment of the more affected arm. INTERVENTION: All study participants were asked to wear accelerometers outside the laboratory for 3 days immediately before and after treatment, or for an approximately equivalent no-treatment period (controls). MAIN OUTCOME MEASURES: Participants wore an accelerometer on each arm, the chest, and the more affected leg and completed the Motor Activity Log (MAL), which is a semistructured interview of real-world arm use. RESULTS: Test-retest reliability of transformed accelerometer recordings was greater than .86. There was also a large increase in the ratio of transformed more- to less-impaired arm recordings in CIMT therapy patients (d' = 0.9, P < .05), while there was no change for controls. The correlation between this parameter and the MAL was .74 (P < .001). CONCLUSIONS: Accelerometry provides an objective, real-world index of upper-extremity rehabilitation outcome and has good psychometric properties.

Activities of Daily Living↗

PubMed2005

Use of CI therapy for improving motor ability after chronic CNS damage: a development prefigured by paul Bach-y-Rita.

Dr. Paul Bach-y-Rita was one of the very few investigators to maintain that the motor ability of patients with chronic stroke and other types of damages to the nervous system is modifiable, and was certainly the most influential voice articulating this view in the second part of the 20th century. In my laboratory starting in 1986, we developed a clearly specified approach to neurorehabilitation treatment, found in placebo-controlled studies to be successful in producing substantial improvement in the use of an extremity affected by chronic stroke, traumatic brain injury, cerebral palsy, and other types of central nervous system injury. The work from my laboratory therefore confirms the landmark view of Bach-y-Rita.

Adult↗

PubMed2004

Automated Constraint-Induced Therapy Extension (AutoCITE) for movement deficits after stroke.

We report progress in the development of AutoCITE, a workstation that delivers the task practice component of upper-limb Constraint-Induced Movement therapy and that can potentially be used in the clinic or the home without the need for one-on-one supervision from a therapist. AutoCITE incorporates a computer and eight task devices arranged on a modified cabinet. Task performance is automatically recorded, and several types of feedback are provided. In preliminary testing, nine chronic stroke subjects with mild to moderate motor deficits practiced with AutoCITE for 3 h each weekday for 2 weeks. Subjects wore a padded mitt on the less-affected hand for a target of 90% of their waking hours. In terms of effect sizes, gains were large and significant on the Motor Activity Log, and moderate to large on the Wolf Motor Function Test. These gains were comparable to the gains of a matched group of 12 subjects who received standard Constraint-Induced Movement therapy.

Adult↗

PubMed2003

Improved motor recovery after stroke and massive cortical reorganization following Constraint-Induced Movement therapy.

Constraint-Induced Movement therapy (CI therapy) has been demonstrated to improve motor function and upper extremity (UE) use of persons with hemiparesis resulting from chronic stroke through two separate but linked mechanisms, overcoming learned nonuse, and facilitating use-dependent cortical reorganization. The principles of CI therapy and adaptations of the basic techniques have been used successfully with diagnostic categories other than stroke that involve disability greater than what is warranted by the organic condition of the individual. Because neuroimaging and transcranial magnetic stimulation studies indicate that many of these conditions involve abnormalities of cortical organization, CI therapy might therefore be viewed as a technique that achieves clinical efficacy by correcting disorders of brain plasticity. CI therapy constitutes a new approach to neurorehabilitation and, with continued investigation, elaboration, and application to clinical settings, it seems to hold considerable promise.

Animals↗

PubMed2003

Constraint-induced movement therapy: bridging from the primate laboratory to the stroke rehabilitation laboratory.

In this laboratory we have developed a set of techniques that randomized controlled studies indicate can substantially reduce the motor deficit of patients with mild to moderately severe chronic strokes. The techniques, termed Constraint-Induced Movement therapy (CI therapy), involve motor restriction of the less-affected arm while at the same time intensively training the more-affected arm. The intervention was derived directly from basic research with monkeys. The primary difference between CI therapy and conventional physical therapy is in the duration and intensity of the treatment. The greatly improved extremity function produced in the laboratory transfers to the activities of daily living outside the clinic. Treatment gains persisted for the two years tested. Converging data from seven experiments has shown that CI therapy produces massive alterations in brain organization and function correlated with the large improvements in motor ability that it produces.

Animals↗