Effect of Attentional Focus Instructions on Motor Learning and Performance of Patients with Central Nervous System and Musculoskeletal Disorders: a Systematic Review
Abstract
:1. Introduction
2. Materials and Methods
2.1. Protocol and Eligibility Criteria
2.2. Data Sources, Search, and Study Selection
(“attentional focus” OR “focus of attention” OR “attentional focusing” OR IFA OR EFA OR “External focus” OR “internal focus”) AND (performance OR balance OR “motor learning” OR instruction *).
2.3. Data Collection Process
2.4. Critical Appraisal of Studies
3. Results
3.1. Study Selection
3.2. Study Characteristics
3.3. Critical Appraisal of the Studies
3.4. Effect of Attentional Focus on CNS Disorders
3.4.1. Stroke
3.4.2. Idiopathic Parkinson
3.5. Effect of Attentional Focus on MSK Disorders
3.5.1. Ankle Sprain
3.5.2. Anterior Cruciate Ligament Reconstruction
4. Discussion
4.1. Effect of Attentional Focus on Performance and Motor Learning
4.2. Limits of Systematic Review
5. Conclusions
5.1. Implications for Research
5.2. Implications for Clinical Practice
Funding
Conflicts of Interest
Appendix A
Study | Motivation |
---|---|
Impact of focus of attention instructions on walking performance in individuals with and without history of stroke. DePaul et al. 2009 [34] | Observational Study |
Internal and EFA during gait re-education: an observational study of physical therapist practice in stroke rehabilitation. Johnson et al. 2013 [35] | Observational Study |
How physical therapists instruct patients with stroke: an observational study on attentional focus during gait rehabilitation after stroke. Kal et al. 2017 [36] | Observational Study |
The effects of attentional focus instructions on simulated upper extremity amputees’ movement kinematics when learning a novel functional task. McAlister 2006 [37] | Descriptive Study |
Effects of single-task versus dual-task training on balance performance in older adults: a double-blind, RCT. Silsupadol et al. 2009 [38] | No clear strategy to direct the attentional focus |
Interacting effects of cognitive load and adult age on the regularity of whole-body motion during treadmill walking. Verrel et al. 2009 [39] | No clear strategy to direct the attentional focus |
Effects of different focus of attention rehabilitative training on gait performance in Multiple Sclerosis patients. Shafizadeh et al. 2013 [40] | No clear strategy to direct the attentional focus |
Differences in attentional focus associated with recovery from sports injury: does injury induce an internal focus? Gray 2015 [41] | No clear strategy to direct the attentional focus |
Does attentional focus during balance training in people with Parkinson’s disease affect outcome? A randomized controlled clinical trial. Landers et al. 2016 [42] | No clear strategy to direct the attentional focus |
Improvement of arm movement patterns and endpoint control depends on type of feedback during practice in stroke survivors. Cirstea & Levin 2007 [43] | Attentional focus as feedback strategy |
Use of information feedback and attentional focus of feedback in treating the person with a hemiplegic arm. Durham et al. 2009 [44] | Analysis of therapist’s preference when applying attentional focus |
Intervention | |||||||
---|---|---|---|---|---|---|---|
Study | Patient | Task | Condition | Instruction | Outcome | Follow-Up | |
EFA (e.g.,) | IFA (e.g.,) | ||||||
Fasoli et al. [45] q-RCT | N. = 16 (both focus) Avg. Age = 61.2 years M/F = 10/6 Condition = stroke | Type = reaching N. trial = 8 Day = 1 | -Seated position; use of right/left hand. -Seated position; use of right/left hand. -Seated position; use of right/left hand | “Put this can from the shelf on to the table. Pay attention to the can”. “Put this apple off a shelf into a basket. Pay attention to the apple” | “Put this can from the shelf on to the table. Pay attention to your arms” “Put this apple off a shelf into a basket. Pay attention to your arms” | MT PV MU %TPV | RT: / TT: / |
Durham et al. [49] q-RCT | N. = 42 (both focus) Avg. Age = 61 years M/F = 30/12 Condition = Stroke | Task = Reach-to-Grasp N. trial = 96 Day = 1 | -The jar was placed at 90% of arm’s length. -Task A: thumb and index finger placed together over a mark placed 15 cm from the table edge in a midline position. -Task B/C: hand grasping the jar that was placed on the same 15 cm midline marker | “With this straw I have taped on, can you ensure you keep close to it as you approach the jar?” “To grip well, you need to curl around the jar more” | “try and bring your wrist back as well.” “grip with your thumb and all of your fingers” | MD PV TPV %TPV TPD %TPD PAS TPA %TPA PEE PSF PTF | RT: 5 min TT: / |
Mückel & Mehrholz [50] RCT | N.= 20 (10 IFA, 10 EFA) Avg. Age = 72.2 years M/F = 11/9 Condition = Stroke | Task = Lateral body weight shift N. trial = 3 Day = 1 | -Patients sat on a sensor mat placed on a therapy bench, back unsupported. -External focus group: a green point was placed on the bench 20 cm lateral from the trochanter major of the ipsilesional trunk side | “Shift your body weight as much as possible toward the green circle without using your arms” | “Shift your body weight as much as possible toward your “healthy side” without using your arms” | IBWS APCOM | RT: / TT: / |
Kal et al. [51] | N.= 39 (both focus) Avg. Age = 62.6 years M/F = 17/22 Condition = Stroke | Task = Single leg stepping N. trial = 24 Day = 3 | -Seated comfortable, use of paretic/non-paretic leg. -A line was taped to the floor, in EFA conditions | “Alternately placing the foot in front of and behind the line” | “Alternately flexing and extending the leg” | MS MF DTCs | RT: / TT: / |
Sakurada et al. [53] q-RCT | N.= 28 (both focus) Avg. Age = 64.9 years M/F = 10/18 Condition = Acute Stroke | Task = tracing a trajectory N. Trial = 30 Day = 1 | -Seated on a chair or wheelchair in front of a desk with a monitor and wireless mouse -Distance between the participant’s eyes and the monitor was approximately 70 cm | “Direct attention to the cursor on the monitor” | “Direct attention to your hand movements” | HME HV | RT: / TT: / |
Kim et al. [54] q-RCT | N. = 33 (18 IFA, 15 EFA) Avg. Age = 58.1 years M/F = 14/16 Condition = Stroke | Task = tracing a trajectory N. Trial = 960 max repetitions per session (12 session) Day = 28 | -Seated with seat belt with shoulder/hip straps -In front of monitor -EFA affected arm was occluded from view | “Focus their attention at a video monitor and to move a yellow ball to various targets on the clock design” | “Focus their attention to the movement of their affected arm during training” | JI FMA WMFT MCQ | RT: 4 week TT: / |
Intervention | |||||||
---|---|---|---|---|---|---|---|
Study | Patient | Task | Condition | Instruction | Outcome | Follow-Up | |
EFA (e.g.,) | IFA (e.g.,) | ||||||
Landers et al. [46] q-RCT | N. = 22 (both focus) Avg. Age = 72.7 years M/F = 17/5 Condition = idiopathic Parkinson (stage II or III) | Task = balance N. trial = 3 Day = 1 | -Standing position; fixed support surface surround; eyes open -Standing position; fixed support surface; visual surround eyes closed -Standing position; surface sway referenced support and fixed surround; eyes open | “Put an equal amount of pressure on the rectangles” “Put an equal amount of pressure on the rectangles” | “Put an equal amount of for on your feet” “Put an equal amount of pressure on your feet” | ES | RT: / TT: / |
Wulf et al. [47] q-RCT | N. = 14 (both focus) Avg. Age = 71.1 years M/F = 10/4 Condition = Idiopathic Parkinson (stage II or III) | Task = balance N. trial = 4 Day = 1 | -Standing position; unstable surface | “Minimize movements of the disk” | “Minimize movements of your feet” | COP | RT: / TT: / |
Kakar et al. [48] RCT | N. = 24 (12 IFA, 12 EFA) Avg. Age = 53.1 years M/F = 17/7 Condition = Idiopathic Parkinson (stage II or III) | Task = Throw Darts N. trial = 90 Day = 2 | -1-m diameter circular target -Target height was 1.70 m, 3 m from the participant | “Look at the center of the board carefully for a few seconds.” “While throwing the dart, concentrate on its flight directly toward the target” | “Before throwing, concentrate on your finger motions and the correct position.” “While throwing, straighten all fingers simultaneously so that at the end of the throw, your hand is directed forwards and your elbow is fully straightened” | MRE | RT: 24 h TT: 24 h |
Beck & Almeida [52] q-RCT | N.= 19 (both focus) Avg. Age = 71.4 years M/F = 17/2 Condition = Idiopathic Parkinson (stage II or III) | Task = Balance N. Trial = 18 Day = 2 | -Stand over Biodex Balance System SD -On or off medication state | “Focus on minimizing the movements of the platform” | “Focus on minimizing the movements of their feet” | PSI | RT: / TT: / |
Intervention | |||||||
---|---|---|---|---|---|---|---|
Study | Patient | Task | Condition | Instruction | Outcome | Follow-Up | |
EFA (e.g.,) | IFA (e.g.,) | ||||||
Laufer et al. [55] RCT | N. = 40 (20 IFA, 20EFA) Avg. Age = 20.8 years M/F = 36/4 Condition = Ankle Sprain (grade 1–2) | Task = balance N. trial = 20 Day = 4 | -Standing position on unstable platform | “Keep your balance by stabilizing the platform” | “Keep your balance by stabilizing your body” | OSI APSI MLSI | RT: 48 h TT: / |
Rotem-Lehrer & Laufer [56] RCT | N. = 36 (20 IFA, 16 EFA) Avg. Age = 20.9 years M/F = 36/0 Condition = Ankle Sprain (grade 1–2) | Task = balance N. trial = 20 Day = 4 | -Standing position on unstable platform | “Keep your balance by stabilizing the platform” | “Keep your balance by stabilizing your body” | OSI APSI MLSI | RT: / TT: 48 h |
Gokeler et al. [57] RCT | N. = 16 (8 IFA, 8 EFA) Avg. Age = 23.2 years M/F = 9/7 Condition = ACLr | Task = single leg jump N. trial = 5 Day = 1 | -Stand on one leg -Land on the same leg | “Jump as far as you can. While you are jumping, I want you to think about pushing yourself off as hard as possible from the floor” | “Jump as far as you can. While you are jumping, I want you to think about extending your knees as rapidly as possible” | MD KVAIC PKVA TPVA VA KFAIC PKFA TPKFA FA | RT:0 h TT: / |
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Study | Eligibility Criteria | Subject Random Allocation | Concealed Allocation | Comparability at Baseline | Blinding Subject | Blinding Therapist | Blinding Assessor | Follow-up Evaluations | Intention-to-Treat Analysis | A Between-Group Statistical Comparison | A Point Measure | Score | Quality |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Fasoli et al. [45] | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 3/10 | Poor |
Landers et al. [46] | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 2/10 | Poor |
Wulf et al. [47] | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 3/10 | Poor |
Kakar et al. [48] | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 7/10 | Good |
Durham et al. [49] | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 6/10 | Good |
Mückel & Mehrholz [50] | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 7/10 | Good |
Kal et al. [51] | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 2/10 | Poor |
Beck & Almeida [52] | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 3/10 | Poor |
Sakurada et al. [53] | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 4/10 | Fair |
Kim et al. [54] | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 6/10 | Good |
Laufer et al. [55] | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 7/10 | Good |
Rotem-Leherer & Laufer [56] | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 1 | 1 | 5/10 | Fair |
Gokeler et al. [57] | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 5/10 | Fair |
Study | Outcome | Post Hoc Test (EFA vs. IFA) or Anova |
---|---|---|
Fasoli et al. [45] | MT PV MU %TPV | Significant improvement during all three tasks executed when given EFA instructions vs. IFA instructions (p < 0.05). Significant improvement during one task when giving EFA instructions vs. IFA instructions (p = 0.019). No difference between EFA and IFA groups (p > 0.05). |
Durham et al. [49] | MD PV TPV %TPV TPD %TPD PAS TPA %TPA PEE PSF PTF | During task A, a significantly increased %TPV (p = 0.039) was found using EFA compared with IFA. EFA group had significantly less MD (p = 0.008) and increased %TPD (p = 0.01) during task B. Significant interaction effects between focus and order were found (IFA → EFA). Significant reduction in MD (p = 0.0018) and increase in %TPA (p = 0.04) during task B. Significant increase in TPD (p = 0.0017) during task C. No significant difference for the other outcomes. |
Mückel & Mehrholz [50] | IBWS APCOM | Significant improvement in IBWS with EFA, compared with IFA (p = 0.006). No significant difference in APCOM (p = 0.085). |
Kal et al. [51] | MS MF DTCs | During single-task there was not significant difference in movement speed between two attentional strategies (p = 0.341). There was not significant interaction between focus and leg (p = 0.387). Higher Fugl-Meyer score showed improvements in movement speed in EFA condition than IFA condition (β = 2.32). Higher movement reinvestment score showed decreases in movement speed in EFA condition than in IFA condition. IFA showed generally leaning to lower DTCs compared with EFA but was not significant. Better attentional capacity seemed to reduce DTCs in EFA (β = −2.98) than IFA (β = −0.62). |
Sakurada et al. [53] | HME HV | Subjects with visual dominance showed more accurate movement under the EFA condition, while patients with kinesthetic dominance showed more accurate movement under the IFA condition. EFA showed a significantly faster hand velocity in both groups (visual and kinesthetic dominance; p = 0.0009). |
Kim et al. [54] | JI FMA WMFT MCQ | There were no between-group differences for JI at discharge and follow-up. There were significant differences in within-group for JI-EFA and JI-IFA from baseline to discharge and baseline to follow-up (p < 0.0005; p < 0.0005). WMFT and FMA there were not between-group significant statistically difference at discharge to follow-up. Scores of WMFT and FMA were significant within-groups across time (p < 0.0005). The MCQ did not report any statistically significant difference between-group. |
Study | Outcome | Post Hoc Test (EFA vs. IFA) or Anova |
---|---|---|
Landers et al. [46] | ES | No significant EFA advantages for overall group (p > 0.05); benefits of EFA in fallers group under sway referenced condition (p < 0.05). |
Wulf et al. [47] | COP | More-effective performance with the EFA than with IFA (p < 0.001). |
Kakar et al. [48] | MRE | EFA had significantly less MRE for the acquisition phase (p = 0.004) and the transfer phase (p = 0.003 [block 1]; p = 0.006 [block 2]). EFA had a less MRE for the retention phase but the difference was not statistically significant (p = 0.052). |
Beck & Almeida [52] | PSI | IFA group had a significantly lower anterior-posterior sway during OFF medication, compared control group (no instructions, p = 0.02) or to the EFA (p = 0.04). No difference in medial-lateral sway. IFA group had significantly lower sway displacement and variability during off medications compared with the IFA (p < 0.01) and EFA (p < 0.01) conditions during on medications. |
Study | Outcome | Post Hoc Test (EFA vs. IFA) or Anova |
---|---|---|
Laufer et al. [55] | OSI APSI MLSI | In the EFA group at the most stable position (level 6) increased efficacy was observed in the APSI (p < 0.001) and in the OSI (p = 0.030) stability index. At level 4 improvements were noted either in EFA and IFA group. |
Rotem-Lehrer & Laufer [56] | OSI APSI MLSI | Significant improvement in all stability measures only in the EFA group (p < 0.05) while the IFA Group demonstrated a significant difference between pre- and post-training in only one stability measure. No significant difference between the groups (EFA and IFA) either pre-training or post-training. |
Gokeler et al. [57] | MD KVAIC PKVA TPVA VA KFAIC PKFA TPF FA | Significant improvement of KFIC in the injured leg in the EFA group (p = 0.04). Significant improvement of PKF in both leg in the EFA (p = 0.01). IFA group TPKF was significantly shorter than EFA, in both legs (non-injured p = 0.01; injured p = 0.02). No significant difference for the other outcomes. |
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Piccoli, A.; Rossettini, G.; Cecchetto, S.; Viceconti, A.; Ristori, D.; Turolla, A.; Maselli, F.; Testa, M. Effect of Attentional Focus Instructions on Motor Learning and Performance of Patients with Central Nervous System and Musculoskeletal Disorders: a Systematic Review. J. Funct. Morphol. Kinesiol. 2018, 3, 40. https://doi.org/10.3390/jfmk3030040
Piccoli A, Rossettini G, Cecchetto S, Viceconti A, Ristori D, Turolla A, Maselli F, Testa M. Effect of Attentional Focus Instructions on Motor Learning and Performance of Patients with Central Nervous System and Musculoskeletal Disorders: a Systematic Review. Journal of Functional Morphology and Kinesiology. 2018; 3(3):40. https://doi.org/10.3390/jfmk3030040
Chicago/Turabian StylePiccoli, Alessandro, Giacomo Rossettini, Simone Cecchetto, Antonello Viceconti, Diego Ristori, Andrea Turolla, Filippo Maselli, and Marco Testa. 2018. "Effect of Attentional Focus Instructions on Motor Learning and Performance of Patients with Central Nervous System and Musculoskeletal Disorders: a Systematic Review" Journal of Functional Morphology and Kinesiology 3, no. 3: 40. https://doi.org/10.3390/jfmk3030040