Stay Focused! The Effects of Internal and External Focus of Attention on Movement Automaticity in Patients with Stroke

Every story has two sides: evaluating information processing and ecological dynamics perspectives of focus of attention in skill acquisition

Directing our focus of attention appropriately during task execution can benefit outcome performance, cognitive efficiency, and physiological efficiency. For instance, individuals may benefit from adopting an external focus of attention (i.e., by focusing attention on the effects of one's movements on the environment) over an internal focus of attention (e.g., focusing on one's body movements). However, accounts concerning the theoretical functioning of such effects have primarily relied on hierarchical information processing perspectives; far less consideration has been given to potentially alternative explanations based on ecological dynamics, instances where an internal focus may be desirable over an external focus, and the associated applied implications. Within the present review, we: (a) outline the most recent developments in attentional focus research; (b) evaluate similarities and differences between information processing and ecological dynamics explanations of the focus of attention effect; (c) provide practical recommendations; and (d) discuss future research avenues. In doing so, a case is made for an "Ecological Dynamics Account of Attentional Focus" to act as an alternative to information processing-based hypotheses.

Does learning a skill with the expectation of teaching it impair the skill's execution under psychological pressure if the skill is learned with analogy instructions?

OBJECTIVE

Having learners practice a motor skill with the expectation of teaching it (versus an expectation of being tested on it) has been revealed to enhance skill learning. However, this improvement in skill performance is lost when the skill must be performed under psychological pressure due to 'choking under pressure.' The present study investigated whether this choking effect is caused by an accrual of declarative knowledge during skill practice and could be prevented if a technique (analogy instructions) to minimize the accrual of declarative knowledge during practice is employed.

DESIGN

We used a 2 (Expectation: teach/test) x 2 (Instructions: analogy/explicit) x 2 (Posttest: low-pressure/high-pressure) mixed-factor design, with repeated measures on the last factor.

METHODS

One-hundred fifty-six participants were quasi-randomly assigned (based on sex) to one of four groups. Participants in the teach/analogy and teach/explicit groups practiced golf putting with the expectation of teaching putting to another participant, and analogy instructions or explicit instructions, respectively. Participants in the test/analogy and test/explicit groups practiced golf putting with the expectation of being tested on their putting, and analogy instructions or explicit instructions, respectively. The next day all participants completed low- and high-pressure putting posttests, with their putting accuracy serving as the dependent variable.

RESULTS

We observed an Expectation x Instructions × Posttest interaction, such that a main effect of expectation was found in the low-pressure posttest, with the teach group exhibiting superior accuracy, and an Expectation × Instructions interaction was revealed for the high-pressure posttest. This interaction resulted from the teach group showing greater accuracy than the test group exclusively when receiving analogy instructions.

CONCLUSION

Results show that participants who practiced with the expectation of teaching exhibited superior learning and indicate that they choked under pressure likely due to their accrual of declarative knowledge during practice, since the choking effect was prevented by having them practice with analogy instructions. Accordingly, having learners practice with the expectation of teaching and techniques that minimize the accrual of declarative knowledge is recommended.

The difference in attentional focus during exercise affects attention resources

[Purpose] The purpose of this study was to investigate the effect of the difference in attentional focus, including the external focus (EF) or internal focus (IF) during exercise on attention resources from the viewpoint of the brain activity. [Participants and Methods] The study included 20 healthy adult participants randomly assigned to two groups: the EF and IF groups. The participants in each group received different verbal instructions before performing a tennis ball task, in which they threw a tennis ball on the floor at a target with their non-dominant hands as accurately as possible while sitting on a chair. During the task, oxygenated hemoglobin (oxy-Hb) in the right dorsolateral prefrontal cortex was continuously measured using a near-infrared spectroscopy device. The accuracy of the task and the change of oxy-Hb were statistically analyzed. [Results] Although there were no statistically significant differences between the groups, both accuracy of the task and oxy-Hb in the EF group were found to be higher than those in the IF group. [Conclusion] Our results showed that although the accuracy of motor control in the EF was superior to that in the IF, there is a possibility of increased attention resources in the EF compared to those in the IF.

Development of lower limb training interventions that promote an external focus of attention in people with stroke: a modified Delphi survey

Objective

To produce guidance and validated examples of tasks that promote an external focus of attention, for use in lower limb rehabilitation in an inpatient stroke care setting.

Design

Electronic survey, using e-Delphi methodology.

Participants

A multi-professional expert panel of 14 clinicians and researchers, with expertise in stroke rehabilitation and/or motor learning.

Method

Each survey round consisted of two parts: 1) classification of specific exercise examples, shown using video and 2) the categorization of specific tratement adjuncts. The panel was asked to comment on: likely focus of attention of the performer; instructions that would promote an external focus of attention; and how the task set-up could be modified to promote an external focus of attention. Rounds 2 and 3 included a summary of results from the previous round, and revised/new examples. The panel were also asked to state their level of agreement with a series of statements that arose from the free text. Three rounds of survey were completed and the a priori threshold for agreement was set at 80%.

Results

Eighteen iterations of exercises were presented, and 12 were accepted as promoting an external focus of attention. In addition, six additional statements were generated based on open responses, leading to further specific guidance on facilitating an external focus of attention in clinical practice.

Conclusions

Commonly used rehabilitation exercises can be adapted to promote an external focus of attention, by altering the therapist’s use of instructions and/or altering the task set up. Treatment principles and examples of tasks that promote an external focus have been produced.

Overload of anxiety on postural control impairments in chronic stroke survivors: The role of external focus and cognitive task on the automaticity of postural control

Background

Despite the high prevalence of anxiety among chronic stroke survivors and evidence of its negative effects on postural control in healthy subjects, it is unclear whether anxiety also affects postural control in these patients. Recent evidence of improved postural control of healthy subjects by distracting the attention using an external focus (EF) or cognitive task, raises the question of whether similar benefits would be observed in stroke survivors. Thus, the current study aimed to investigate the effects of anxiety and distracting the attention on postural control of chronic stroke survivors in terms of both postural sway measures and neuromuscular regulation.

Methods

Postural sway measures and ankle muscle activity of chronic stroke survivors with the high and low level of anxiety (HA-stroke (n = 17), and LA-stroke (n = 17), respectively) and age-, sex-, height-, and weight-matched healthy subjects (n = 17) were assessed while standing on rigid and foam surfaces under following conditions: baseline, internal focus (IF), EF, simple and hard cognitive tasks (SC and HC, respectively).

Results

Stroke survivors, particularly HA-stroke participants, showed greater postural sway measures (i.e. postural instability) and enhanced co-contraction of ankle muscles (i.e. stiffening of the neuromuscular system) compared with healthy subjects. As opposed to baseline and IF conditions, postural instability and neuromuscular stiffening significantly reduced in EF condition and decreased more in cognitive task conditions, particularly HC condition.

Conclusions

The results suggest that anxiety enhances stroke-induced postural instability promoting improper neuromuscular control of posture with stiffening strategy, which can be alleviated by EF and cognitive tasks.

The effect of frequency of feedback on overground temporal gait asymmetry post stroke

BACKGROUND AND OBJECTIVES

Temporal gait asymmetry (TGA) affects 55% of people with stroke. This study investigated the effects of augmented feedback during overground gait training, on TGA.

METHODS

Eighteen people with chronic stroke were randomized to receive one of two feedback displays (A or B) and one of three feedback frequencies; no feedback (0%), after alternate walking trials (50%) or after every trial (100%). Display A depicted the TGA ratio as a vertical line along a horizontal axis with perfect symmetry in the middle. Display B depicted single limb stance duration of each leg as a bar graph. Participants completed 25 repetitions of 30 second trials with their assigned feedback (acquisition). Participants completed 10 repetitions of 30 second trials without feedback 24 hours later (retention). A pressure sensitive mat recorded TGA and speed. Changes in TGA and speed were investigated by plotting individual motor learning curves and fitting a curve with locally estimated scatterplot smoothing (LOESS) for each feedback group. An effect of feedback was defined a priori as a LOESS fitted curve with a decreasing slope from acquisition to retention.

RESULTS

LOESS curve exhibited a decreasing slope for TGA in the 100B group only and for speed in the 50A and 0FB groups.

DISCUSSION

This study provides preliminary evidence that visual feedback delivered at a high frequency during a single session of overground walking can change TGA post-stroke without reducing gait speed. An overground gait intervention with high frequency visual feedback to improve TGA post-stroke is worthwhile to investigate.

How to Serve Faster in Tennis: The Influence of an Altered Focus of Attention and Augmented Feedback on Service Speed in Elite Players

ABSTRACT

Keller, M, Kuhn, YA, Lüthy, F, and Taube, W. How to serve faster in tennis: the influence of an altered focus of attention and augmented feedback on service speed in elite players. J Strength Cond Res 35(4): 1119-1126, 2021-Different approaches, such as providing augmented feedback (AF) or adopting an external focus of attention (EF), have been shown to directly enhance performance in recreational athletes. Furthermore, research has shown that combining AF with EF (AF + EF) results in superior performance compared to AF and EF alone. Here, we tested the influence of AF, EF, AF + EF, and an internal focus of attention (IF) on service speed in elite tennis players. High-level national tennis players (19.2 ± 3.7 years) were asked to serve flat serves to a target zone with maximum speed. With respect to service speed, a significant main effect of condition was found (p ≤ 0.001). Post hoc comparisons revealed faster serves for AF compared to control serves without instruction/feedback (p < 0.01) and compared to EF (p < 0.05), whereas no significant difference was found between EF and IF (p = 0.81). The fastest service speeds were found in the AF condition, whereas the combination of AF + EF did not further promote performance. The number of serves landed in the target zone did not differ between conditions (p = 0.17). Thus, no speed-accuracy trade-off was found, indicating that enhanced service speeds did not result in less serves landed in the target zone. Augmented feedback seems most beneficial to instantly enhance tennis serve performance. In contrast to previous studies with recreational sportsmen, EF did not differ from IF, providing further evidence that expertise level and task-relevant instructions mediate the influence of attentional focus on motor performance.

Effects of attentional focus on upper extremity motor performance in post stroke patients: A randomized pilot study

INTRODUCTION

To facilitate the command to the learner, therapist can use verbal cues for guidance: internal focus (own body) and external focus (consequence of movement in the environment).

OBJECTIVE

To examine the effects of different attentional focus on upper limb motor performance in post-stroke.

METHODS

Randomized controlled trial with 2 groups. Study realized at Integrated Clinic of the Faculty of Health Science at Trairi (Santa Cruz, Rio Grande do Norte, Brazil). Twelve participants allocated into 2 groups. Two motor tasks were used: task 1, reach-point; task 2, reach-grasp-fit, with the paretic extremity, using verbal commands directed by a trained therapist. In the first phase, Group 1 received commands with internal focus, while Group 2 was instructed with commands with external focus. After 1 week, the command type was changed between groups. The variables collected was movement time, velocity and number of peaks velocity.

RESULTS

Both attentional focus promoted significant differences in movement time and velocity, however, only Internal Focus provided significant results in both tasks of the same variables.

DISCUSSION

The benefits of 1 attentional focus on the other are not fully confirmed. However, not receiving any kind of attention guidance compromises motor performance. The results support the hypothesis that the benefits of the External Focus are accentuated when preceded by the Internal Focus.

CLINICAL TRIAL REGISTRATION

Research Ethics Committee of the Faculty of Helth Science at Trairi (Facisa - UFRN)- Number CAAE 2.625.609, approved on April 13, 2018; Brazilian Registry of Clinical Trials - RBR-4995cr approved on July 4, 2019 retrospectively registered (http://www.ensaiosclinicos.gov.br/rg/RBR-4995cr/).

Assessing the Development of Fine Motor Control in Elementary School Children Using Drawing and Tracing Tasks

Adequately quantifying fine motor control is imperative for understanding individual motor behavior development and mastery. We recently showed that using different tasks to evaluate fine motor control may produce different results, suggesting that multiple measures for fine motor control may be evaluating different skills and/or underlying processes. Specifically, drawing behavior may depend on internal cueing, whereas tracing depends more on external cueing. To better understand how an individual develops a certain preference for cueing, we evaluated fine motor control in 265 typically developing children (aged 6-11) by measuring their accuracy for both drawing and tracing a circle. Our results first confirmed that there was no significant correlation between tracing and drawing task performances during this phase of development and, secondly, showed a significant developmental improvement in tracing, especially between 2nd and 3rd graders, whereas drawing ability improved only moderately. We discuss the potential roles of attentional focus and cognitive development as possible influencing factors for these developmental patterns. We conclude that using both a drawing and tracing task to evaluate fine motor control is rapid, economic and valuable for monitoring motor development among elementary school children.

Does learning a skill with the expectation of teaching it impair the skill's execution under psychological pressure if the skill is learned with analogy instructions?

OBJECTIVE

Having learners practice a motor skill with the expectation of teaching it (versus an expectation of being tested on it) has been revealed to enhance skill learning. However, this improvement in skill performance is lost when the skill must be performed under psychological pressure due to 'choking under pressure.' The present study will investigate whether this choking effect is caused by an accrual of declarative knowledge during skill practice and could be prevented if a technique (analogy instructions) to minimize the accrual of declarative knowledge during practice is employed.

DESIGN

We will use a 2 (Expectation: teach/test) x 2 (Instruction: analogy/explicit) x 2 (Posttest: high-pressure/low-pressure) mixed-factor design, with repeated measures on the last factor.

METHODS

A minimum of 148 participants will be quasi-randomly assigned (based on sex) to one of four groups. Participants in the teach/analogy and teach/explicit groups will practice golf putting with the expectation of teaching putting to another participant, and analogy instructions or explicit instructions, respectively. Participants in the test/analogy and test/explicit groups will practice golf putting with the expectation of being tested on their putting, and analogy instructions or explicit instructions, respectively. The next day all participants will complete low- and high-pressure putting posttests, with their putting accuracy serving as the dependent variable.

Role of Instruction Adherence During Highly Structured Robotic Arm Training on Motor Outcomes for Individuals After Chronic Stroke

The aim of this study was to examine the effects of instruction adherence on upper limb motor outcomes after highly structured intervention. A secondary data analysis was completed using mixed linear modeling design. Thirty chronic stroke survivors with moderate-to-severe arm impairment were assigned explicit movement instructions and completed 12 robotic therapy sessions for 4 wks. Instruction adherence was measured weekly using the Manipulation Check Questionnaire. Motor outcomes were measured at baseline, discharge, and at 4-wk follow-up using the Fugl-Meyer Assessment-Upper Extremity and Wolf Motor Function Test-Functional Ability Scale. There were no effects of adherence-related variables on upper limb motor outcomes (P > 0.2). Participant scores improved for both Fugl-Meyer Assessment-Upper Extremity and Wolf Motor Function Test-Functional Ability Scale from baseline to follow-up (P < 0.001). Participants improved motor function after 12 wks of robotic training; however, instruction adherence did not affect motor improvement. Adherence to explicit information may play a limited role in motor learning for stroke survivors with moderate-to-severe arm impairment during highly structured training protocols.

Impact of adding a simultaneous cognitive task in the elbow's range of movement during arm curl test in women with fibromyalgia

BACKGROUND

Fibromyalgia symptoms cause a significant reduction in the ability to perform daily life activities. These activities require the ability to perform more than one task simultaneously. The main objective of this study was to evaluate how dual-task could modify range of movement, duration of repetitions and performance in the arm curl test in healthy controls and patients with fibromyalgia.

METHODS

Twenty women participated in this study, divided into two groups: 1) patients with fibromyalgia (N = 10, age = 52.00 [5.08]) and 2) age- and gender-matched healthy controls (N = 10; age = 51.60 [4.09]). The participants had to perform the arm curl test in two conditions: single test condition and performing a dual-task. The dual-task condition consisted of remembering three random unrelated words.

RESULTS

Patients with fibromyalgia completed fewer repetitions than controls during dual-task condition (p-value = 0.015). Furthermore, both groups showed a significant decrease in the range of movement in the dual-task condition when comparing the mean of the three first repetitions with the three last ones (p-value < 0.05).

INTERPRETATION

The motor task might be prioritized over the cognitive task at the beginning of the test. However, at the end of the test, the cognitive task could require more attention due to the increased time since the words were heard, and also the motor task could require less attention after some repetitions have been performed. Thus, the addition of a cognitive task could lead to a less conscious execution of the motor task at the end of the test, which may be consistent with a reduced range of movement.

Prefrontal activity predicts individual differences in optimal attentional strategy for preventing motor performance decline: a functional near-infrared spectroscopy study

Directing attention to movement outcomes (external focus; EF), not body movements (internal focus; IF), is a better cognitive strategy for motor performance. However, EF is not effective in some healthy individuals or stroke patients. We aimed to identify the neurological basis reflecting the individual optimal attentional strategy using functional near-infrared spectroscopy. Sixty-four participants (23 healthy young, 23 healthy elderly, and 18 acute stroke) performed a reaching movement task under IF and EF conditions. Of these, 13 healthy young participants, 11 healthy elderly participants, and 6 stroke patients showed better motor performance under EF conditions (EF-dominant), whereas the others showed IF-dominance. We then measured prefrontal activity during rhythmic hand movements under both attentional conditions. IF-dominant participants showed significantly higher left prefrontal activity than EF-dominant participants under IF condition. In addition, receiver operating characteristic analysis supported that the higher activity in the left frontopolar and dorsolateral prefrontal cortices could detect IF-dominance as an individual's optimal attentional strategy for preventing motor performance decline. Taken together, these results suggest that prefrontal activity during motor tasks reflects an individual's ability to process internal body information, thereby conferring IF-dominance. These findings could be applied for the development of individually optimized rehabilitation programs.

Revisiting the Relationship Between Internal Focus and Balance Control in Young and Older Adults

Research highlights the detrimental effect that directing too much conscious attention toward movement can have on postural control. While this concept has received support from many studies, recent evidence demonstrates that this principle does not always translate to aging clinical populations. Given the increasing clinical interest in this topic, the current study evaluated if the original notion (that an internal focus results in compromised balance performance) is upheld in young and older adults during a challenging balance task where we are able to objectively corroborate changes in attentional focus; using an electroencephalography (EEG) method previously identified as an objective indicator of conscious movement control. This method assesses the neural coherence, or "communication," between T3 (verbal-analytical) and Fz (motor-planning) regions of the brain. Thirty-nine young and 40 older adults performed a challenging balance task while holding a 2-meter pole under two randomized conditions: Baseline and Internal focus of attention (directing attention internally toward movement production). Results showed that young adults demonstrated increased EEG T3-Fz coherence in conjunction with increased sway path during the Internal focus condition. However, no significant differences were observed in older adults between conditions for any measure. The current study provides supporting evidence for the detrimental effect that adopting an Internal focus can have on postural control-especially in populations able to govern these processes in a relatively "automatic" manner (e.g., young adults). However, this work illustrates that such observations may not readily translate between populations and are not robust to age-related changes. Further work is necessary to examine mechanisms underlying this clear translational issue.

Individual optimal attentional strategy during implicit motor learning boosts frontoparietal neural processing efficiency: A functional near-infrared spectroscopy study

INTRODUCTION

Optimal focus of attention is a crucial factor for improving motor learning. Most previous studies have shown that directing attention to movement outcome (external focus; EF) is more effective than directing attention to body movement itself (internal focus; IF). However, our recent studies demonstrated that the optimal attentional strategy in healthy and clinical populations varies depending on individual motor imagery ability. To explore the neurological basis underlying individual optimal attentional strategy during motor learning tasks, in the present study, we measured frontoparietal activities using functional near-infrared spectroscopy (fNIRS).

METHODS

Twenty-eight participants performed a visuomotor learning task requiring circular tracking. During the task, the participants were required to direct their attention internally or externally. The individual optimal attentional strategy was determined by comparing the after-effect sizes between the IF and EF conditions.

RESULTS

Fifteen participants showed larger after-effects under the EF condition (External-dominant), whereas the others showed larger after-effects under the IF condition (Internal-dominant). Based on the differences in neural activities between Internal- and External-dominant groups, we identified the right dorsolateral prefrontal cortex (Brodmann area 46) and right somatosensory association cortex (Brodmann area 7) as the neural bases associated with individual optimal attentional strategy during motor learning. Furthermore, we observed a significant negative correlation, that is, lower activity in these areas was associated with a larger after-effect size under the optimal attentional strategy.

CONCLUSION

Our findings demonstrated that more efficient neural processing in the frontoparietal area under the individual optimal attentional strategy can accelerate motor learning.

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

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 (Meanage = 59.6 ± 10.7 years; Meandays since stroke = 28.5 ± 16.6; MedianFunctional 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.

The placebo effect in the motor domain is differently modulated by the external and internal focus of attention

Among the cognitive strategies that can facilitate motor performance in sport and physical practice, a prominent role is played by the direction of the focus of attention and the placebo effect. Consistent evidence converges in indicating that these two cognitive functions can influence the motor outcome, although no study up-to-now tried to study them together in the motor domain. In this explorative study, we combine for the first time these approaches, by applying a placebo procedure to increase force and by manipulating the focus of attention with explicit verbal instructions. Sixty healthy volunteers were asked to perform abduction movements with the index finger as strongly as possible against a piston and attention could be directed either toward the movements of the finger (internal focus, IF) or toward the movements of the piston (external focus, EF). Participants were randomized in 4 groups: two groups underwent a placebo procedure (Placebo-IF and Placebo-EF), in which an inert treatment was applied on the finger with verbal information on its positive effects on force; two groups underwent a control procedure (Control-IF and Control-EF), in which the same treatment was applied with overt information about its inefficacy. The placebo groups were conditioned about the effects of the treatment with a surreptitious amplification of a visual feedback signalling the level of force. During the whole procedure, we recorded actual force, subjective variables and electromyography from the hand muscles. The Placebo-IF group had higher force levels after the procedure than before, whereas the Placebo-EF group had a decrease of force. Electromyography showed that the Placebo-IF group increased the muscle units recruitment without changing the firing rate. These findings show for the first time that the placebo effect in motor performance can be influenced by the subject’s attentional focus, being enhanced with the internal focus of attention.

Effect of Attentional Focus Instructions on Motor Learning and Performance of Patients with Central Nervous System and Musculoskeletal Disorders: a Systematic Review

Exercise is one of the main rehabilitative interventions, commonly used to improve performance and motor learning. During the application of attentional focus strategies, External Focus of Attention (EFA) aiming at the movement effect has been reported to have more efficacy than Internal Focus of Attention (IFA) aiming at movement characteristics in healthy subjects. There are not many studies that compare the EFA and IFA instructions in people with Musculoskeletal (MSK) and Central Nervous System disorders (CNS). The purpose of this systematic review is to determine if IFA or EFA, in patients with CNS or MSK, may improve performance and have some effects on motor learning. Databases used for research: PubMed, CINAHL, Cochrane Library, PEDro, PsycINFO, SCOPUS. Inclusion criteria: Randomized Controlled Trial, quasi-Randomized Controlled Trial, enrolled subjects with CNS or with MSK and compared the efficacy of EFA and IFA. The studies suggest that the EFA is better than IFA in affecting the movement execution in patients with MSK, while conflicted findings emerge in presence of CNS disorders. Studies included in the qualitative analysis showed heterogeneous methodological features in study design and conductance, so results must be interpreted with caution.

Application of motor learning in neurorehabilitation: a framework for health-care professionals

Learning motor skills is an essential part of most rehabilitation processes. Facilitating and supporting motor learning is particularly challenging in neurological rehabilitation: patients who suffer from neurological diseases experience both physical limitations and difficulties of cognition and communication that affect and/or complicate the motor learning process. Therapists (e.g. physiotherapists and occupational therapists) who work in neurorehabilitation are therefore continuously searching for the best way to facilitate patients during these intensive learning processes. To support therapists in the application of motor learning, a framework was developed, integrating knowledge from the literature and the opinions and experiences of international experts. This article presents the framework, illustrated by cases from daily practice. The framework may assist therapists working in neurorehabilitation in making choices, implementing motor learning in routine practice, and supporting communication of knowledge and experiences about motor learning with colleagues and students. The article discusses the framework and offers suggestions and conditions given for its use in daily practice.

The Basal Ganglia: More than just a switching device

The basal ganglia consist of a variety of subcortical nuclei engaged in motor control and executive functions, such as motor learning, behavioral control, and emotion. The striatum, a major basal ganglia component, is particularly useful for cognitive planning of purposive motor acts owing to its structural features and the neuronal circuitry established with the cerebral cortex. Recent data indicate emergent functions played by the striatum. Indeed, cortico-striatal circuits carrying motor information are paralleled by circuits originating from associative and limbic territories, which are functionally integrated in the striatum. Functional integration between brain areas is achieved through patterns of coherent activity. Coherence belonging to cortico-basal ganglia circuits is also present in Parkinson's disease patients. Excessive synchronization occurring in this pathology is reduced by dopaminergic therapies. The mechanisms through which the dopaminergic effects may be addressed are the object of several ongoing investigations. Overall, the bulk of data reported in recent years has provided new vistas concerning basal ganglia role in the organization and control of movement and behavior, both in physiological and pathological conditions. In this review, basal ganglia functions involved in the organization of main movement categories and behaviors are critically discussed. Comparatively, the multiplicity of Parkinson's disease symptomatology is also revised.

Individual Differences Influencing Immediate Effects of Internal and External Focus Instructions on Children's Motor Performance

PURPOSE

A large pool of evidence supports the beneficial effect of an external focus of attention on motor skill performance in adults. In children, this effect has been studied less and results are inconclusive. Importantly, individual differences are often not taken into account. We investigated the role of working memory, conscious motor control, and task-specific focus preferences on performance with an internal and external focus of attention in children.

METHODS

Twenty-five children practiced a golf putting task in both an internal focus condition and external focus condition. Performance was defined as the average distance toward the hole in 3 blocks of 10 trials. Task-specific focus preference was determined by asking how much effort it took to apply the instruction in each condition. In addition, working memory capacity and conscious motor control were assessed.

RESULTS

Children improved performance in both the internal focus condition and external focus condition (ŋ_p² = .47), with no difference between conditions (ŋ_p² = .01). Task-specific focus preference was the only factor moderately related to the difference between performance with an internal focus and performance with an external focus (r = .56), indicating better performance for the preferred instruction in Block 3.

CONCLUSION

Children can benefit from instruction with both an internal and external focus of attention to improve short-term motor performance. Individual, task-specific focus preference influenced the effect of the instructions, with children performing better with their preferred focus. The results highlight that individual differences are a key factor in the effectiveness in children's motor performance. The precise mechanisms underpinning this effect warrant further research.

Over-focused? The relation between patients' inclination for conscious control and single- and dual-task motor performance after stroke

BACKGROUND

Many stroke patients are inclined to consciously control their movements. This is thought to negatively affect patients' motor performance, as it disrupts movement automaticity. However, it has also been argued that conscious control may sometimes benefit motor performance, depending on the task or patientś motor or cognitive capacity.

AIM

To assess whether stroke patients' inclination for conscious control is associated with motor performance, and explore whether the putative association differs as a function of task (single- vs dual) or patientś motor and cognitive capacity.

METHODS

Univariate and multivariate linear regression analysis were used to assess associations between patients' disposition to conscious control (i.e., Conscious Motor Processing subscale of Movement-Specific Reinvestment Scale; MSRS-CMP) and single-task (Timed-up-and-go test; TuG) and motor dual-task costs (TuG while tone counting; motor DTC%). We determined whether these associations were influenced by patients' walking speed (i.e., 10-m-walk test) and cognitive capacity (i.e., working memory, attention, executive function).

RESULTS

Seventy-eight clinical stroke patients (<6 months post-stroke) participated. Patients' conscious control inclination was not associated with single-task TuG performance. However, patients with a strong inclination for conscious control showed higher motor DTC%. These associations were irrespective of patients' motor and cognitive abilities.

CONCLUSION

Patients' disposition for conscious control was not associated with single task motor performance, but was associated with higher motor dual task costs, regardless of patients' motor or cognitive abilities.

CLINICAL RELEVANCE

Therapists should be aware that patients' conscious control inclination can influence their dual-task performance while moving. Longitudinal studies are required to test whether reducing patients' disposition for conscious control would improve dual-tasking post-stroke.

Randomized Trial on the Effects of Attentional Focus on Motor Training of the Upper Extremity Using Robotics With Individuals After Chronic Stroke

OBJECTIVE

To compare the long-term effects of external focus (EF) and internal focus (IF) of attention after 4 weeks of arm training.

DESIGN

Randomized, repeated-measures, mixed analysis of variance.

SETTING

Outpatient clinic.

PARTICIPANTS

Individuals with stroke and moderate-to-severe arm impairment living in the community (N=33; withdrawals: n=3).

INTERVENTIONS

Four-week arm training protocol on a robotic device (12 sessions).

MAIN OUTCOME MEASURES

Joint independence, Fugl-Meyer Assessment, and Wolf Motor Function Test measured at baseline, discharge, and 4-week follow-up.

RESULTS

There were no between-group effects for attentional focus. Participants in both groups improved significantly on all outcome measures from baseline to discharge and maintained those changes at 4-week follow-up regardless of group assignment (joint independence EF condition: F_1.6,45.4=17.74; P<.0005; partial η²=.39; joint independence IF condition: F_2,56=18.66; P<.0005; partial η²=.40; Fugl-Meyer Assessment: F_2,56=27.83; P<.0005; partial η²=.50; Wolf Motor Function Test: F_2,56=14.05; P<.0005; partial η²=.35).

CONCLUSIONS

There were no differences in retention of motor skills between EF and IF participants 4 weeks after arm training, suggesting that individuals with moderate-to-severe arm impairment may not experience the advantages of an EF found in healthy individuals. Attentional focus is most likely not an active ingredient for retention of trained motor skills for individuals with moderate-to-severe arm impairment, whereas dosage and intensity of practice appear to be pivotal. Future studies should investigate the long-term effects of attentional focus for individuals with mild arm impairment.

Effects of attentional focus on walking stability in elderly

INTRODUCTION

Balance performance in the elderly is related to psychological factors such as attentional focus. We investigated the effects of internal vs. external focus of attention and fall history on walking stability in healthy older adults.

METHOD

Walking stability of twenty-eight healthy older adults was assessed by applying random unilateral decelerations on a split-belt treadmill and analysing the resulting balance recovery movements. The internal focus instruction was: concentrate on the movement of your legs, whereas the external focus instruction was: concentrate on the movement of the treadmill. In both conditions participants were asked to look ahead at a screen. Outcome measures were coefficient of variation of step length and step width, and characteristics of the centre of mass velocity time-series as analysed using statistical parametric mapping. Fall history was assessed using a questionnaire.

RESULTS

After each perturbation participants required two to three strides to regain a normal gait pattern, as determined by the centre of mass velocity response. No effects were found of internal and external focus of attention instructions and fall history on any of the outcome measures.

DISCUSSION

We conclude that, compared to an internal focus of attention instruction, external focus to the walking surface does not lead to improved balance recovery responses to gait perturbations in the elderly.

Improved motor performance in patients with acute stroke using the optimal individual attentional strategy

It is believed that motor performance improves when individuals direct attention to movement outcome (external focus, EF) rather than to body movement itself (internal focus, IF). However, our previous study found that an optimal individual attentional strategy depended on motor imagery ability. We explored whether the individual motor imagery ability in stroke patients also affected the optimal attentional strategy for motor control. Individual motor imagery ability was determined as either kinesthetic- or visual-dominant by a questionnaire in 28 patients and 28 healthy-controls. Participants then performed a visuomotor task that required tracing a trajectory under three attentional conditions: no instruction (NI), attention to hand movement (IF), or attention to cursor movement (EF). Movement error in the stroke group strongly depended on individual modality dominance of motor imagery. Patients with kinesthetic dominance showed higher motor accuracy under the IF condition but with concomitantly lower velocity. Alternatively, patients with visual dominance showed improvements in both speed and accuracy under the EF condition. These results suggest that the optimal attentional strategy for improving motor accuracy in stroke rehabilitation differs according to the individual dominance of motor imagery. Our findings may contribute to the development of tailor-made pre-assessment and rehabilitation programs optimized for individual cognitive abilities.

Influence of focus of attention, reinvestment and fall history on elderly gait stability

Falls represent a substantial risk in the elderly. Previous studies have found that a focus on the outcome or effect of the movement (external focus of attention) leads to improved balance performance, whereas a focus on the movement execution itself (internal focus of attention) impairs balance performance in elderly. A shift toward more conscious, explicit forms of motor control occurs when existing declarative knowledge is recruited in motor control, a phenomenon called reinvestment. We investigated the effects of attentional focus and reinvestment on gait stability in elderly fallers and nonfallers. Full body kinematics was collected from twenty-eight healthy older adults walking on a treadmill, while focus of attention was manipulated through instruction. Participants also filled out the Movement Specific Reinvestment Scale (MSRS) and the Falls Efficacy Scale International (FES-I), and provided details about their fall history. Coefficients of Variation (CV) of spatiotemporal gait parameters and Local Divergence Exponents (LDE) were calculated as measures of gait variability and gait stability, respectively. Larger stance time CV and LDE (decreased gait stability) were found for fallers compared to nonfallers. No significant effect of attentional focus was found for the gait parameters, and no significant relation between MSRS score (reinvestment) and fall history was found. We conclude that external attention to the walking surface does not lead to improved gait stability in elderly. Potential benefits of an external focus of attention might not apply to gait, because walking movements are not geared toward achieving a distinct environmental effect.

Physiotherapists use a great variety of motor learning options in neurological rehabilitation, from which they choose through an iterative process: a retrospective think-aloud study

PURPOSE

The goal of this study was to examine which motor learning options are applied by experienced physiotherapists in neurological rehabilitation, and how they choose between the different options.

METHODS

A descriptive qualitative approach was used. A purposive sample of five expert physiotherapists from the neurological ward of a rehabilitation center participated. Data were collected using nine videotaped therapy situations. During retrospective think-aloud interviews, the physiotherapists were instructed to constantly "think aloud" while they were watching their own videos.

RESULTS

Five "operators" were identified: "act", "know", "observe", "assess" and "argue". The "act" operator consisted of 34 motor learning options, which were clustered into "instruction", "feedback" and "organization". The "know", "observe", "assess" and "argue" operators explained how therapists chose one of these options. The four operators seem to be interrelated and together lead to a decision to apply a particular motor learning option.

CONCLUSIONS

Results show that the participating physiotherapists used a great variety of motor learning options in their treatment sessions. Further, the decision-making process with regard to these motor learning options was identified. Results may support future intervention studies that match the content and process of therapy in daily practice. The study should be repeated with other physiotherapists. Implications for Rehabilitation The study provided insight into the way experienced therapist handle the great variety of possible motor learning options, including concrete ideas on how to operationalize these options in specific situations. Despite differences in patients' abilities, it seems that therapists use the same underlying clinical reasoning process when choosing a particular motor learning option. Participating physiotherapists used more than the in guidelines suggested motor learning options and considered more than the suggested factors, hence adding practice based options of motor learning to the recommended ones in the guidelines. A think-aloud approach can be considered for peer-to-peer and student coaching to enhance discussion on the motor learning options applied and the underlying choices and to encourage research by practicing clinicians.