Are the effects of internal focus instructions different from external focus instructions given during balance training in stroke patients? A double-blind randomized controlled trial

Abstract

Objective:

This study aimed to assess if external focus instructions result in greater improvements in motor skill and automaticity compared to internal focus instructions in stroke patients.

Design:

Double-blind randomized controlled trial.

Setting:

Inpatient stroke rehabilitation unit.

Subjects:

A total of 63 stroke patients (Mean_age = 59.6 ± 10.7 years; Mean_{days since stroke} = 28.5 ± 16.6; Median_{Functional Ambulation Categories} = 4).

Interventions:

Patients were randomly assigned to an internal (N = 31) or external (N = 32) focus instruction group. Both groups practiced a balance board stabilization task, three times per week, for three weeks. Balance performance was assessed at baseline, and after one and three weeks of practice.

Main measures:

Primary outcome was the threshold stiffness (Nm/rad) at which patients could stay balanced. Secondary outcomes were patients’ sway (root-mean-square error in degrees) at the baseline threshold stiffness under single- and dual-task conditions, and their performance on the Timed Up and Go Test and Utrecht Scale for Evaluation of Rehabilitation.

Results:

Both groups achieved similar improvements in threshold stiffness (∆= 27.1 ± 21.1 Nm/rad), and single- (∆= 1.8 ± 2.3° root-mean-square error) and dual-task sway (∆= 1.7 ± 2.1° root-mean-square error) after three weeks of practice. No differences were found in improvements in clinical tests of balance and mobility. Patients with comparatively good balance and sensory function, and low attention capacity showed greatest improvements with external focus instructions.

Conclusion:

External focus instructions did not result in greater improvement in balance skill in stroke patients compared to internal focus instructions. Results suggest that tailoring instructions to the individual stroke patient may result in optimal improvements in motor skill.

Keywords

Stroke randomized controlled trial external focus of attention rehabilitation motor skill learning

Get full access to this article

View all access options for this article.

References

Nys

GMS

Van Zandvoort

MJE

De Kort

PLM

, et al. Cognitive disorders in acute stroke: prevalence and clinical determinants. Cerebrovasc Dis 2007; 23(5–6): 408–416.

Zinn

Bosworth

Hoenig

, et al. Executive function deficits in acute stroke. Arch Phys Med Rehabil 2007; 88(2): 173–180.

Dickey

Kagan

Lindsay

, et al. Incidence and profile of inpatient stroke-induced aphasia in Ontario, Canada. Arch Phys Med Rehabil 2010; 91(2): 196–202.

Wulf

Attentional focus and motor learning: a review of 15 years. Int Rev Sport Exerc Psychol 2013; 6(1): 77–104.

Lohse

Sherwood

Healy

AF.

How changing the focus of attention affects performance, kinematics, and electromyography in dart throwing. Hum Mov Sci 2010; 29(4): 542–555.

Shea

Wulf

Enhancing motor learning through external-focus instructions and feedback. Hum Mov Sci 1999; 18(4): 553–571.

Wulf

Dufek

Lozano

, et al. Increased jump height and reduced EMG activity with an external focus. Hum Mov Sci 2010; 29(3): 440–448.

Zachry

Wulf

Mercer

, et al. Increased movement accuracy and reduced EMG activity as the result of adopting an external focus of attention. Brain Res Bull 2005; 67(4): 304–309.

Chiviacowsky

Wulf

Wally

An external focus of attention enhances balance learning in older adults. Gait Posture 2010; 32(4): 572–575.

10.

Kal

Van Der Kamp

Houdijk

External attentional focus enhances movement automatization: a comprehensive test of the constrained action hypothesis. Hum Mov Sci 2013; 32: 527–539.

11.

Poolton

Maxwell

Masters

RSW

, et al. Benefits of an external focus of attention: common coding or conscious processing? J Sports Sci 2006; 24(1): 89–99.

12.

Wulf

McNevin

Shea

CH.

The automaticity of complex motor skill learning as a function of attentional focus. Q J Exp Psychol A 2001; 54(4): 1143–1154.

13.

Kal

van den Brink

Houdijk

, et al. How physical therapists instruct patients with stroke: an observational study on attentional focus during gait rehabilitation after stroke. Disabil Rehabil 2017; 40: 1154–1165.

14.

Fasoli

Trombly

Tickle-Degnen

, et al. Effect of instructions on functional reach in persons with and without cerebrovascular accident. Am J Occup Ther 2002; 56(4): 380–390.

15.

Muckel

Mehrholz

Immediate effects of two attention strategies on trunk control on patients after stroke. A randomized controlled pilot trial. Clin Rehabil 2014; 28(7): 632–636.

16.

Durham

Sackley

Wright

, et al. Attentional focus of feedback for improving performance of reach-to-grasp after stroke: a randomised crossover study. Physiotherapy 2014; 10: 108–115.

17.

Kal

Van Der Kamp

Houdijk

, et al. Stay focused! The effects of internal and external focus of attention on movement automaticity in patients with stroke. PLoS ONE 2015; 10: e0136917.

18.

Kim

Hinojosa

Rao

, et al. Randomized trial on the effects of attentional focus on motor training of the upper extremity using robotics with individuals after chronic stroke. Arch Phys Med Rehabil 2017; 98: 1924–1931.

19.

Bamford

Sandercock

Dennis

, et al. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991; 337(8756): 1521–1526.

20.

Post

van

Port

Kap

, et al. Development and validation of the Utrecht Scale for Evaluation of Clinical Rehabilitation (USER). Clin Rehabil 2009; 23: 909–917.

21.

Charlson

Szatrowski

Peterson

, et al. Validation of a combined comorbidity index. J Clin Epidemiol 1994; 47(11): 1245–1251.

22.

Holden

Gill

Magliozzi

, et al. Clinical gait assessment in the neurologically impaired. Reliability and meaningfulness. Phys Ther 1984; 64(1): 35–40.

23.

Berg

Wood-Dauphinee

Williams

, et al. Measuring balance in the elderly: validation of an instrument. Can J Public Health 1992; 83: S7–S11.

24.

Flansbjer

Holmbäck

Downham

, et al. Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med 2005; 37(2): 75–82.

25.

Podsiadlo

Richardson

The timed “up and go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39(2): 142–148.

26.

Verhage

Intelligentie en leeftijd: onderzoek bij Nederlanders van twaalf tot zevenzeventig jaar [Intelligence and age: study with Dutch people aged 12 to 77]. Assen: Van Gorcum, 1964.

27.

Brinckenkamp

Oosterveld

De d2 Aandachts- En Concentratietest, Nederlandse Bewerking van de “Aufmerksamheits Belastung Test.” Amsterdam: Hogrefe Publishing, 2007.

28.

Wechsler

Wechsler Memory Scale—Revised. New York: The Psychological Corporation, 1987.

29.

D’Elia

Satz

Uchiyama

, et al. Color Trails Test: professional manual. Odessa

: Psychological Assessment Resources, 1996.

30.

Stolk-Hornsveld

Crow

Hendriks

, et al. The Erasmus MC modifications to the (revised) Nottingham Sensory Assessment: a reliable somatosensory assessment measure for patients with intracranial disorders. Clin Rehabil 2006; 20(2): 160–172.

31.

Kal

Houdijk

Van Der Wurff

, et al. The inclination for conscious motor control after stroke: validating the Movement-Specific Reinvestment Scale for use in inpatient stroke patients. Disabil Rehabil 2016; 38: 1097–1106.

32.

Brouwer

Kal

Van der Kamp

, et al. Validation of the stabilometer balance test: bridging the gap between clinical and research based balance control assessments for stroke patients. Gait Posture. Under review. Preprint available at: https://dspace.library.uu.nl/handle/1874/351824

33.

Mercer

Freburger

Chang

S-H

, et al. Measurement of paretic-lower-extremity loading and weight transfer after stroke. Phys Ther 2009; 89(7): 653–664.

34.

Cheng

Liaw

Wong

, et al. The sit-to-stand movement in stroke patients and its correlation with falling. Arch Phys Med Rehabil 1998; 79(9): 1043–1046.

35.

Cheng

Liaw

, et al. Symmetrical body-weight distribution training in stroke patients and its effect on fall prevention. Arch Phys Med Rehabil 2001; 82(12): 1650–1654.

36.

Karmali

Chaudhuri

, et al. Determining thresholds using adaptive procedures and psychometric fits: evaluating efficiency using theory, simulations, and human experiments. Exp Brain Res 2016; 234(3): 773–789.

37.

Taylor

Creelman

CD.

PEST: efficient estimates on probability functions. J Acoust Soc Am 1967; 41(4): 782–787.

38.

Poolton

Masters

RSW

Maxwell

JP.

The relationship between initial errorless learning conditions and subsequent performance. Hum Mov Sci 2005; 24(3): 362–378.

39.

Kleynen

Braun

Bleijlevens

, et al. Using a Delphi technique to seek consensus regarding definitions, descriptions and classification of terms related to implicit and explicit forms of motor learning. PLoS ONE 2014; 9(6): e100227.

40.

Van Ginneken

Poolton

Masters

RSW

, et al. Comparing the effects of conscious monitoring and conscious control on motor performance. Psychol Sport Exerc 2017; 30: 145–152.

41.

Smulders

van Swigchem

de Swart

BJM

, et al. Community-dwelling people with chronic stroke need disproportionate attention while walking and negotiating obstacles. Gait Posture 2012; 36(1): 127–132.

42.

McCulloch

Attention and dual-task conditions: physical therapy implications for individuals with acquired brain injury. J Neurol Phys Ther 2007; 31(3): 104–118.

43.

Holm

A simple sequentially rejective multiple test procedure. Scand J Stat 1979; 6: 65–70.

44.

White

Horton

Carpenter

, et al. Strategy for intention to treat analysis in randomised trials with missing outcome data. BMJ 2011; 342: d40.

45.

Deci

Ryan

RM.

Self-determination theory: a macrotheory of human motivation, development, and health. Can Psychol 2008; 49(3): 182–185.

46.

Orrell

Masters

RSW

Eves

FF.

Reinvestment and movement disruption following stroke. Neurorehabil Neural Repair 2009; 23(2): 177–183.

47.

Kleynen

Braun

Beurskens

, et al. Investigating the Dutch Movement-Specific Reinvestment Scale in people with stroke. Clin Rehabil 2012; 27(2): 160–165.

48.

Masters

Maxwell

The theory of reinvestment. Int Rev Sport Exerc Psychol 2008; 1(2): 160–183.

49.

Sakurada

Nakajima

Morita

, et al. Improved motor performance in patients with acute stroke using the optimal individual attentional strategy. Sci Rep 2017; 7: 40592.

50.

Lohse

Buchanan

Miller

Underpowered and overworked: problems with data analysis in motor learning studies. J Mot Learn Dev 2016; 4(1): 37–58.

51.

Kal

Winters

Van Der Kamp

, et al. Is implicit motor learning preserved after stroke? A systematic review with meta-analysis. PLoS ONE 2016; 11: e0166376.

52.

Kal

Prosée

Winters

, et al. Does implicit motor learning lead to greater automatization of motor skills compared to explicit motor learning? A systematic review. PLoS ONE Under review.

53.

De Melker Worms

JLA

Stins

van Wegen

EEH

, et al. Influence of focus of attention, reinvestment and fall history on elderly gait stability. Physiol Rep 2017; 5(1): e13061.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.38 MB