Internal and External Focus of Attention During Gait Re-Education: An Observational Study of Physical Therapist Practice in Stroke Rehabilitation

Abstract

Background Focus of attention is known to play an important role in motor skill learning, yet little is known about how attention is directed within the context of stroke rehabilitation. Objective The aims of this study were: (1) to identify physical therapists' use of internal and external focus of attention during gait rehabilitation for individuals with hemiplegia following stroke and (2) to use the findings to design an experimental study examining the impact of focus of attention on learning poststroke. Design The study design involved direct nonparticipation observation of physical therapy treatment sessions. Methods Eight physical therapy treatment sessions, in which gait rehabilitation was taking place, were video recorded. Patients were aged between 36 and 85 years, and ranged from 7 to 216 days poststroke; physical therapists had between 3 and 12 years of experience in stroke rehabilitation. Data analysis took 2 forms: (1) clear definitions of internal and external focus of attention were agreed on via a consensus group and used to develop an analysis matrix through which incidences of instruction and feedback were identified, categorized, and counted; and (2) verbal dialogue was transcribed verbatim and transcripts were thematically analyzed to provide a detailed description of how instructions and feedback were used, illustrated by examples. Results The use of instructions and feedback (internal and external focus) was high; an average of one verbal instruction or feedback statement was delivered every 14 seconds. Sixty-seven percent of the statements were internally focused, 22% were externally focused, and 11% were of mixed focus. Unfocused statements (eg, “good”) also were used regularly. Patients were frequently encouraged to “think about” their performance. Limitations Observational data collection methods may result in changes in the behavior of those observed, which is a potential source of bias. The small sample size also was a limitation of the study. Conclusion Physical therapists frequently encouraged patients to be aware of their movements and their performance (internal focus). This approach may reduce automaticity and hinder learning and retention.

Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning

“…Observations or interviews of coaches and physical therapists confirm anecdotal evidence for the predominance of such approaches (Durham, Van Vliet, Badger, & Sackley, 2009;Halperin, Chapman, Martin, Abbiss, & Wulf, 2015;Johnson, Burridge, & Demain, 2013;Porter, Wu, & Partridge, 2010). Thus, instructors often neglect to enhance learners' expectancies, do not recognize and support their need for autonomy, and induce an internal focus of attention (Figure 8a).…”

Influence of attention alternation on movement-related cortical potentials in healthy individuals and stroke patients

“…In our experiment, when participants were asked to complete the auditory oddball task between dorsiflexion sets, their attentional focus was decreased internally, thus likely leading to a diminished learning process (Johnson et al, 2013). One of the aims of this study was to explore the effect of task repetition on cortical signal characteristics (Brunet et al, 2014).…”

The Effects of Implicit and Explicit Motor Learning in Gait Rehabilitation of People After Stroke: Protocol for a Randomized Controlled Trial (Preprint)

“…The definition indicates that the learner is aware of all the underlying facts and rules of the to-be-learned motor skill during the process of learning. In practice verbal explicit instructions are frequently used and often these instructions encourage patients to be aware of their own body movements 14 . For example, in gait training therapists tell patients to think about their performance e.g.…”

“…For example, in gait training therapists tell patients to think about their performance e.g. "Move your hips to the left and straighten your knee before stepping" 14 . In contrast to explicit learning, implicit motor learning progresses with no or minimal increase in verbal knowledge of movement performance (e.g., facts and rules) and without awareness 13 .…”

“…These different learning approaches could perhaps be placed on a continuum of which some approaches adopt more implicit and others more explicit characteristics of learning, rather than a distinct dichotomy 11 . Looking at current practice, therapists seem to have a preference for learning approaches that are related to explicit learning in which often high numbers of verbal explicit instructions are being used 14 .…”