Highlights
- •Participants improved on motor outcomes after engaging in high-repetition robotics arm training.
- •There were no differences between external focus or internal focus of attention on retention of motor skills after 4 weeks of arm training.
- •Individuals with moderate-to-severe arm impairment may not experience the advantages of an external focus during motor training 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.
Abstract
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: F1.6,45.4=17.74; P<.0005; partial η2=.39; joint independence IF condition: F2,56=18.66; P<.0005; partial η2=.40; Fugl-Meyer Assessment: F2,56=27.83; P<.0005; partial η2=.50; Wolf Motor Function Test: F2,56=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.
Keywords
List of abbreviations:
EF (external focus), FMA (Fugl-Meyer Assessment), IF (internal focus), WMFT (Wolf Motor Function Test)To read this article in full you will need to make a payment
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References
- Attention and effort.Prentice Hall, New Jersey1973
- Attention and motor skill learning.Human Kinetics, Champaign2007
- Motor learning and control: concepts and application.9th ed. McGraw Hill, New York2011
- An external focus of attention enhances motor learning in children with intellectual disabilities.J Intellect Disabil Res. 2013; 57: 627-634
- The automaticity of complex motor skill learning as a function of attentional focus.Q J Exp Psychol A. 2001; 54: 1143-1154
- Increasing the distance of an external focus of attention enhances learning.Psychol Res. 2003; 67: 22-29
- Optimizing performance through intrinsic motivation and attention for learning: the OPTIMAL theory of motor learning.Psychon Bull Rev. 2016; 23: 1382-1414
- The effects of attentional focus on jump performance and knee joint kinematics in patients after ACL reconstruction.Phys Ther Sport. 2015; 16: 114-120
- External attentional focus enhances movement automatization: a comprehensive test of the constrained action hypothesis.Hum Mov Sci. 2013; 32: 527-539
- On the advantage of an external focus of attention: a benefit to learning or performance?.Hum Mov Sci. 2014; 33: 120-134
- Effects of attentional focus, self-control, and dyad training on motor learning: implications for physical rehabilitation.Phys Ther. 2000; 80: 373-385
- Enhancing motor learning through external-focus instructions and feedback.Hum Mov Sci. 1999; 18: 553-571
- Enhanced retention of drop vertical jump landing technique: a randomized controlled trial.Hum Mov Sci. 2016; 45: 84-95
- Attentional focus and motor learning: a review of 10 years of research.E-Journal Bewegung und Training. 2007; 1: 1-11
- Directing attention to movement effects enhances learning: a review.Psychon Bull Rev. 2001; 8: 648-660
- Attention and motor performance: preferences for and advantages of an external focus.Res Q Exerc Sport. 2001; 72: 335-344
- Effect of instructions on functional reach in persons with and without cerebrovascular accident.Am J Occup Ther. 2002; 56: 380-390
- Attentional focus of feedback for improving performance of reach-to-grasp after stroke: a randomised crossover study.Physiotherapy. 2014; 100: 108-115
- Stay focused! The effects of internal and external focus of attention on movement automaticity in patients with stroke.PLoS One. 2015; 10: e0136917
- Robotic assessment of upper limb motor function after stroke.Am J Phys Med Rehabil. 2012; 91: S255-S269
- Kinematic robot-based evaluation scales and clinical counterparts to measure upper limb motor performance in patients with chronic stroke.Neurorehabil Neural Repair. 2010; 24: 62-69
- Changing motor synergies in chronic stroke.J Neurophysiol. 2007; 98: 757-768
- The fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties.Neurorehabil Neural Repair. 2002; 16: 232-240
- A standardized approach to the fugl-meyer assessment and its implications for clinical trials.Neurorehabil Neural Repair. 2013; 27: 732-741
- Rasch analysis staging methodology to classify upper extremity movement impairment after stroke.Arch Phys Med Rehabil. 2013; 94: 1527-1533
- Measurement structure of the Wolf Motor Function Test: implications for motor control theory.Neurorehabil Neural Repair. 2010; 24: 791-801
- The reliability of the Wolf Motor Function Test for assessing upper extremity function after stroke.Arch Phys Med Rehabil. 2001; 82: 750-755
- Assessing Wolf motor function test as outcome measure for research in patients after stroke.Stroke. 2001; 32: 1635-1639
- G*Power 3: a flexible stastistical power and analysis program for the social, behavioral, and biomedical sciences.Behav Res Methods. 2007; 39: 175-191
- Robotic therapy for chronic motor impairments after stroke: follow-up results.Arch Phys Med Rehabil. 2004; 85: 1106-1111
- Robot-aided neurorehabilitation: a robot for wrist rehabilitation.IEEE Trans Neural Syst Rehabil Eng. 2007; 15: 327-335
- Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke.Neurorehabil Neural Repair. 2008; 22: 305-310
- An external focus of attention attenuates balance impairment in patients with Parkinson's disease who have a fall history.Physiotherapy. 2005; 91: 152-158
- Attentional focus effects in balance acrobats.Res Q Exerc Sport. 2008; 79: 319-325
- External focus instructions reduce postural instability in individuals with Parkinson disease.Phys Ther. 2009; 89: 162-168
- The learning advantages of an external focus of attention in golf.Res Q Exerc Sport. 1999; 70: 120-126
- Enhancing the learning of sport skills through external-focus feedback.J Mot Behav. 2002; 34: 171-182
- An external focus of attention enhances golf shot accuracy in beginners and experts.Res Q Exerc Sport. 2007; 78: 384-389
- Increased movement accuracy and reduced EMG activity as the result of adopting an external focus of attention.Brain Res Bull. 2005; 67: 304-309
- Analyzing the dynamics of hand tremor time series.Biol Cybern. 1992; 66: 479-484
- The dynamical structure of tremor in tardive dyskinesia.Chaos. 1995; 5: 43
- Comparison of robotics, functional electrical stimulation, and motor learning methods for treatment of persistent upper extremity dysfunction after stroke: a randomized controlled trial.Arch Phys Med Rehabil. 2015; 96: 981-990
- Effect of a task-oriented rehabilitation program on upper extremity recovery following motor stroke: the ICARE randomized clinical trial.JAMA. 2016; 315: 571-581
- Body-weight–supported treadmill rehabilitation after stroke.N Engl J Med. 2011; 364: 2026-2036
Article info
Publication history
Published online: June 24, 2017
Footnotes
Current affiliation for Kim, Department of Occupational Therapy, Steinhardt School Culture, Education, and Human Development, New York University, New York, NY.
Supported by the Mitchell Leaska Dissertation Award, Steinhardt School Culture, Education, and Human Development, New York University.
Clinical Trial Registration No.: NCT02890446.
Disclosures: Kim has been a paid guest speaker at the HOSPI Robotics Training Seminar discussing the clinical application of the InMotion ARM robot in June 2014. The other authors have nothing to disclose.
Identification
Copyright
© 2017 by the American Congress of Rehabilitation Medicine
