External focus instructions reduce postural instability in individuals with Parkinson disease

An external focus promotes motor learning of an aiming task in individuals with hearing impairments

Research has shown that external relative to internal focus (IF) instructions may improve motor performance as well as cognitive function (e.g., attentional stability and task-focus). The aim of the study was to examine the influence of attentional focus instructions on skill acquisition and learning of an aiming task in individuals with hearing impairments. The participants (N = 39, Mage = 17.87 ± 1.88 years) performed a bowling task with their dominant hand to knock down as many pins as possible. On day 1, they were randomly divided into three attentional focus groups; IF (focus on your throwing hand), external focus (EF) (focus on the pins), and control (no-focus) instructions. Each participant performed 36 trials, divided into 3 blocks of 12 trials. Attentional focus instructions were given before each block, with a brief reminder provided after each 3 trials. On day 2, retention and transfer (further distance) tests were performed. Results showed that while there were no significant differences between groups in the pre-test, the EF group outperformed both IF and control groups in retention and transfer tests. No significant difference was found between the control and IF. The findings suggest that the advantages of the external relative to the IF and no-focus instructions may generalize to individuals with hearing impairments.

Effect of coaching the sit-to-stand motion and attentional focus

[Purpose] The present study investigated whether (1) "standing up while bowing" is effective for promoting the sit-to-stand (STS) motion and (2) whether this coaching promotes internal focus. [Participants and Methods] The participants included 17 healthy adults who performed the 30-s chair stand test with two sets of verbal instructions. The verbal instructions were as follows: "Please stand up as many times as possible for 30 s" (control condition) and "Please stand up while bowing as many times as possible for 30 s" (bowing condition). The participants performed the tests successively under the two conditions. In the 30-s chair stand test, a three-axis accelerometer was attached to the participants and the sagittal STS motion was filmed using a video camera. After the 30-s chair stand test, we used the modified Movement-Specific Reinvestment Scale (MSRS) to evaluate attentional focus. Differences in the measurements were analyzed using the Wilcoxon signed-rank test or paired t-test for each condition. [Results] Statistical analysis revealed significant differences in the CS-30 count, time from sitting to standing, time from sitting to lift-off, time from lift-off to standing, and the trunk tilt angle on lift-off. Regarding the questionnaire, Statistical analysis revealed significant differences in the MSRS and "conscious motor processing". [Conclusion] These results suggest that "standing up while bowing" has limited effectiveness in promoting the STS motion because the coaching promotes internal focus.

Influence of Verbal Instruction on Gait Training in Parkinson Disease: A Randomized Controlled Trial

OBJECTIVE

Verbal instruction is one of the most commonly used methods that therapists use to correct walking pattern for people with Parkinson disease. This study aimed to compare the long-term training effects of two different verbal instructions that either asked the participants to "take big steps" or "strike the ground with the heel" on walking ability in individuals with Parkinson disease.

DESIGN

Forty-five participants with Parkinson disease were randomized into the big-step or heel strike group. The participants underwent 12 sessions of treadmill and overground gait training. Throughout the interventions, the big-step group received an instruction to "take big steps," while the heel strike group received an instruction to "strike the ground with your heel." The primary outcome was gait performance, including velocity, stride length, cadence, and heel strike angle. The participants were assessed before, immediately after, and 1 mo after training.

RESULTS

Both groups showed significant improvements in gait performance after training. The heel strike group showed continuous improvements in velocity and stride length during the follow-up period; however, the big-step group showed slightly decreased performance.

CONCLUSIONS

A verbal instruction emphasizing heel strike can facilitate long-term retention of walking performance in people with Parkinson disease.

Different types of combined training programs to improve postural balance in single and dual tasks in children with intellectual disability

The study explored the effects of two combined training (Strength-Proprioceptive versus Cognitive-Balance) programs on postural balance during single-task and dual-task conditions in children with intellectual disability. The postural balance and the second cognitive-task performances were evaluated before and after 8-week of training in two groups: Strength-Proprioceptive Group (n = 12) and Cognitive-Balance Group (n = 10). Results showed that, in both groups and regardless of the training effect, the postural balance performance was significantly (p < 0.05) altered in the dual-task condition compared to the single-task one. After-training session, postural balance performance was improved significantly (p < 0.001) for all task conditions. After training session, the second cognitive-task performance was improved in the Strength-Proprioceptive Group (p < 0.001) and Cognitive-Balance Groupe (p < 0.05). In conclusion, the combined training programs, Strength-Proprioceptive and Cognitive-Balance, improved postural balance performance in single-task and dual-task conditions in children with intellectual disability.

The effects of attentional focus on speech motor control in adults who stutter with and without social evaluative threat

PURPOSE

We sought to investigate the effects of cued attentional shifts on speechmotor control in adults who stutter (AWS) and adults who do not stutter (ANS) when speaking under low and high social stress conditions.

METHOD

Thirteen AWS' and 10 ANS' lip aperture (LA) and posterior tongue (PT) movements were assessed under a Cued-Internal and Cued-External attentional focus condition with and without social stress induction (i.e. speaking to an audience). Skin conductance levels were used to measure a stress response. Speech motor control was assessed by measuring movement duration and variability of movement for LA and PT using the spatial temporal index (STI).

RESULTS

A significant Group x Condition interaction was found for LA STI. Post-hoc comparisons indicated AWS' LA STI significantly decreased under Cued External Focus conditions during both low and high social stress. No significant Group x Condition interaction was found for PT STI. AWS showed significantly slower tongue movements (PT) across all low and high social stress conditions; however, there was no significant Group x Condition interaction for PT or LA.

DISCUSSION

Findings yield preliminary insights into the role of attentional focus on speech motor control when speaking during high social stress. Theoretical and clinical implications are discussed.

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.

Acute effects of lumbosacral mobilization on balance and functional activities in idiopathic Parkinson's disease:A randomised controlled trial

BACKGROUND

Decreased axial rotation, impaired coordination between axial segments and axial tone contribute to gait, balance and postural disorders in Parkinson's Disease.

AIMS

The aim of our study was to examine the acute effects of lumbosacral mobilization on balance and functional activities in patients with idiopathic Parkinson's Disease.

METHODS

This study was a randomized controlled clinical trial conducted at Hacettepe University. The study included 28 patients with Parkinson's Disease who were between stage 2-3 according to the Modified Hoehn&Yahr Staging Scale. Participants were randomised to the study group, including 10 minutes of lumbosacral mobilization, or the control group, including no intervention. The Unified Parkinson's Disease Rating Scale (UPDRS), Modified Parkinson's Activity Scale (MPAS), Dynamic Gait Index (DGI), and static posturography test (Modified Clinical Test of Sensory Interaction and Balance - mCTSIB) were all examined twice.

RESULTS

The UPDRS, MPAS, DGI values and the composite score with the soft ground eyes open condition in the mCTSIB were improved in the study group (p < 0.05). DGI and MPAS values reached the level of significance between the groups (p < 0.05).

CONCLUSION

This study is the first to examine the effect of lumbosacral mobilization on balance and functional activities in patients with Parkinson's disease. Lumbosacral mobilization is an effective method in PwPD. Lumbosacral mobilization may be an alternative way for these patients to improve their balance and functional activities.

The order of attentional focus instructions affects how postural control processes compensate for multisensory mismatch: a crossover study

Directing attention during balance training can have an immediate and lasting impact on a patient's balance and ultimately decrease the risk of future falls. However, it is unclear how attention can best be utilized to improve postural control. The current study uses a 2 × 2 crossover design to investigate the potential impact of receiving multiple verbal instructions during a single session of sensorimotor control testing for balance. Twenty-eight healthy adults were tasked to balance on a rocker board while immersed in virtual reality (VR). The VR created a multisensory mismatch between visual VR motion and body motion. The strength of the relationship between visual motion and body motion was measured to assess visual dependence. Alpha and theta frequency bands in electroencephalography (EEG) recordings were also analyzed to identify potential neural correlates of visual dependence and postural stability. Participants were randomized into two groups: one group was first instructed to keep the board leveled (external focus) and then instructed to keep both feet leveled (internal focus) to help maintain stability. The other group was given these two instructions in reverse order. Analyses focused on time, instruction, and group effects from receiving multiple instructions. Results revealed that when participants are given external focus first, and internal focus second, they are more likely to demonstrate lower visual dependence and better postural stability throughout the entire session than participants given internal focus first and external focus second. However, channel-level EEG analyses did not reveal differences between the groups. Current findings suggest that the order of attentional focus instructions may influence how the postural control system resolves sensory incongruence during a single testing session.

Knowledge and use of extrinsic feedback characteristics: A survey of current practice among Brazilian physical therapists

OBJECTIVES

This study aimed to identify the knowledge about the different characteristics of and the use of extrinsic feedback (EF) by Brazilian physical therapists.

METHODS

This is a cross-sectional study, and we used an internet-based survey with questions about knowledge and application of extrinsic feedback in clinical practice. We analyzed the responses in relation to the best available evidence on motor control and learning. We recruited Brazilian registered physical therapists from different regions in Brazil. Participants' demographics and survey responses were analyzed using descriptive statistics.

RESULTS

Two hundred and forty-six Brazilian physical therapists participated in the study. Most participants affirmed not knowing the definition of EF (55.69%), confirmed using some form of EF in their clinical practice (86.59%), and reported using it in 50% to 90% of their patients (26.42%). Brazilian physical therapists reported using mainly summary feedback (69.10%) with external focus of attention (63.41%). Participants reported using concurrent feedback (82.83%) and delivered it after every exercise repetition (63.82%). Most participants (43.09%) did not assess learning retention. Answers were similar regardless of education level or time from graduation.

CONCLUSIONS

The results of this survey suggest that Brazilian physical therapists do not have sufficient knowledge about the different characteristics of EF; however, they do consider EF useful and use it for most of their patients. Brazilian physical therapists adopted adequate content characteristics of EF but not adequate use of timing characteristics of EF.

Analysis of Postural Stability Following the Application of Myofascial Release Techniques for Low Back Pain-A Randomized-Controlled Trial

INTRODUCTION

Low back pain (LBP) is one of the most frequently observed disorders of the musculoskeletal system in the modern population. It is suggested that myofascial disorders in the highly innervated thoracolumbar fascia (TLF), reported in patients with LBP, may be an underlying cause of the ailment. Research also confirms that patients with LBP demonstrate poorer postural stability compared with individuals without the condition. Myofascial release techniques (MFR) are additional therapeutic options that complement existing therapies and help provide a more holistic treatment for chronic LBP (CLBP).

OBJECTIVE

Evaluation of changes in postural stability following one MFR intervention applied to CLBP subjects immediately after manual therapy and after a month. It was hypothesized that postural stability is going to aggravate immediately after the MFR intervention and improve one month after treatment compared with the baseline results before the treatment.

METHODS

113 patients with CLBP participated in a randomized-controlled trial. The experimental group (n = 59) received one MFR intervention, whereas the control group (n = 54) did not receive any therapeutic intervention. Posturography was performed to determine experimental group's immediate response to the therapy and to evaluate the experimental and control groups' responses to the therapy one month after the intervention.

RESULTS

Only 2 out of 12 comparisons of stabilometric parameters demonstrated reliable effects that are in line with our research hypotheses. Even though both comparisons were observed for therapy outcomes within the experimental group, no reliable differences between the groups were found.

CONCLUSIONS

A single MFR treatment in the TLF did not affect postural stability in CLBP patients in the experimental group. Further studies are needed to extend the findings by performing a series of holistic MFR treatments applied to a larger area of the body surface that would induce more general tissue changes and thus having a greater impact on postural stability.

Treating the musician rather than the symptom: The holistic tools employed by current practices to attend to the non-motor problems of musicians with task-specific focal dystonia

Musicians Focal Dystonia (MFD) is a task-specific movement disorder affecting highly skilled musicians. The pathophysiology is poorly understood, and the available treatments are unable to fully and reliably rehabilitate the affected skill. Recently, the exclusively neurological nature of the condition has been questioned, and additional psychological, behavioral, and psychosocial contributing factors were identified. However, very little is known about how these factors influence the recovery process, and how, if at all, they are addressed in ongoing practices. For this study, 14 practitioners with substantial experience in working with musicians with MFD were interviewed about the elements in their approach which are directed at the cognition, emotions, attitudes, and behaviors of their patients and clients. A wide variety of tools were reported in three areas: (1) creating a supportive learning environment and addressing anxiety and perfectionism, (2) using body-oriented methods to optimize the playing behaviors and (3) consciously channeling the focus of attention to guide the physical retraining exercises and establishing new habits. The study also revealed that in-depth knowledge of the instrumental technique is profitable to retrain the impaired motor patterns. Therefore, the importance of including music educators in developing new therapeutic approaches will also be highlighted.

The Path to Translating Focus of Attention Research Into Canadian Physiotherapy, Part 1: Physiotherapists’ Self-Reported Focus of Attention Use Via a Study-Specific Questionnaire

The focus of attention literature has shown robust findings for the benefits of providing statements that focus on the movement effect or outcome (external focus of attention [EFOA]) as opposed to focusing on the movement kinematics (internal focus of attention). Observational studies, however, have revealed that physiotherapists use fewer EFOA statements than internal focus of attention statements in their practice. Most evidence in this regard has been from non-Canadian physiotherapists working in stroke rehabilitation; consequently, we sought to examine whether Canadian physiotherapists working with various rehabilitation populations also use EFOA statements to a lesser extent than internal focus of attention statements. The “Therapists’ Perceptions of Motor Learning Principles Questionnaire (TPMLPQ)” was thus designed and data from 121 Canadian physiotherapists showed low relative frequencies of EFOA use (31.3% ± 14%) averaged across six hypothetical scenarios. A higher EFOA was reported, however, for two of the six scenarios: a functional reaching scenario (55.5% ± 37.0%) and pelvic floor task (65.6% ±32.9%). This data suggest that the findings of EFOA benefits have not been widely translated into Canadian physiotherapy settings; furthermore, the findings of the scenario-dependency warrant future investigation into factors, such as task characteristics, that may influence physiotherapists’ FOA use.

Motor Memory Consolidation Deficits in Parkinson's Disease: A Systematic Review with Meta-Analysis

BACKGROUND

The ability to encode and consolidate motor memories is essential for persons with Parkinson's disease (PD), who usually experience a progressive loss of motor function. Deficits in memory encoding, usually expressed as poorer rates of skill improvement during motor practice, have been reported in these patients. Whether motor memory consolidation (i.e., motor skill retention) is also impaired is unknown.

OBJECTIVE

To determine whether motor memory consolidation is impaired in PD compared to neurologically intact individuals.

METHODS

We conducted a pre-registered systematic review (PROSPERO: CRD42020222433) following PRISMA guidelines that included 46 studies.

RESULTS

Meta-analyses revealed that persons with PD have deficits in retaining motor skills (SMD = -0.17; 95% CI = -0.32, -0.02; p = 0.0225). However, these deficits are task-specific, affecting sensory motor (SMD = -0.31; 95% CI -0.47, -0.15; p = 0.0002) and visuomotor adaptation (SMD = -1.55; 95% CI = -2.32, -0.79; p = 0.0001) tasks, but not sequential fine motor (SMD = 0.17; 95% CI = -0.05, 0.39; p = 0.1292) and gross motor tasks (SMD = 0.04; 95% CI = -0.25, 0.33; p = 0.7771). Importantly, deficits became non-significant when augmented feedback during practice was provided, and additional motor practice sessions reduced deficits in sensory motor tasks. Meta-regression analyses confirmed that deficits were independent of performance during encoding, as well as disease duration and severity.

CONCLUSION

Our results align with the neurodegenerative models of PD progression and motor learning frameworks and emphasize the importance of developing targeted interventions to enhance motor memory consolidation in PD.

[Attentional focus instructions for therapeutic exercise in people with musculoskeletal disorders. A scoping review]

Attentional focus instructions are verbal strategies that could maximize the effects of exercise. The objective of this review was to explore and synthesize the available evidence on the incorporation of attentional focus instruction in the exercise of people with musculoskeletal disorders. A search of 11 databases was carried out until October 2020. Of 4,227 studies identified in the searches, 15 were included. The studies showed deficiencies in the conceptualization and definition of attentional focus instructions. The available evidence indicates that external focus is effective in improving motor learning and function. However, methodological limitations, clinical heterogeneity, the small number of articles included, and new experimental studies challenge the conclusions of the systematic reviews available to date. Attentional focus instructions in musculoskeletal disorders is an emerging field and requires further research. This review is a guide for future studies.

Focus of Attention in Voice Training

OBJECTIVE

The vast majority of motor learning studies investigating focus of attention have found that an external focus of attention (focusing on the effect of a movement) results in enhanced performance and learning, compared to an internal focus of attention (focusing on the body movement itself). The present study attempts to determine if the high incidence of internal focus of attention instruction that has been reported in the realm of athletics is replicated in voice training.

METHODS

Two hundred and seventy-eight singers, who were at least 18 years old and taking voice lessons, were recruited to participate in an anonymous research survey entitled "Instructions given to singers in voice lessons." The main six questions asked singers to report phrases or instructions that their studio voice teachers gave them in regard to posture, breathing and/or support, tone clarity and/or onset of tone, space and/or resonance, articulation, and reducing tension.

RESULTS

Approximately 50.83% of the total responses were classified as inducing an external focus, 39.42% were classified as internal focus, 6.48% used a combination of both internal and external focus, and 3.27% were categorized as miscellaneous.

CONCLUSIONS

The results of this study indicate that voice teachers use both external and internal attentional focus directives in the voice studio. Given the robust body of literature supporting the use of external focus, it is noteworthy that the current study found that external focus is used more often than internal focus in voice training.

Apathy exacerbates postural control impairments in stroke survivors: The potential effects of cognitive dual-task for improving postural control

Apathy is a stressor and debilitating common condition for both stroke survivors and their caregivers. However, its effects on the postural control of these patients have not yet been investigated. Improved postural stability through withdrawing attention from postural control by concurrent cognitive task (i.e. dual-task condition) has been reported previously, but the effect of apathy, as a confounding factor, remains unknown. This study aimed to examine the effects of apathy and dual-task condition on postural control of chronic stroke survivors from biomechanical and neurophysiological perspectives. Twenty non-apathetic stroke survivors, 20 apathetic stroke survivors, and 20 sex-, age-, weight-, and height-matched healthy subjects were assessed using different postural sway measures and electromyography activity of ankle and hip muscles while quietly standing on rigid and foam surfaces under single-task, easy dual-task, and difficult dual-task conditions. The results showed postural instability and neuromuscular stiffening of stroke survivors, particularly apathetic stroke survivors, compared with healthy controls as evidenced by significantly greater postural sway measures and increased co-contraction of ankle muscles as well as hip muscles. Notably, concurrently performing a cognitive task significantly reduced postural instability and neuromuscular stiffening in chronic stroke survivors even in those with apathy. In conclusion, apathy exacerbates postural control impairments in chronic stroke survivors promoting an inefficient conscious mode of postural control. It is recommended that distracting the attention away from postural control by performing a concurrent cognitive task can be considered an effective strategy while designing interventions for improving postural control in apathetic stroke survivors.

Attentional focus effect on dual-task walking in Parkinson's disease with and without freezing of gait

In Parkinson's disease, the optimal attentional focus strategy for dual-task walking may vary with freezing of gait (FOG), due to different severities of impaired automaticity. The study aimed to investigate (i) the immediate effect of attentional focus on dual-task walking in participants with and without FOG, and (ii) the training effect of attentional focus on walking, FOG, and falls. In experiment 1, FOG and non-FOG groups (16 participants each) performed a dual-task of holding two interlocking rings apart while walking, either without attention instruction or with instructions to focus attention internally or externally. Gait parameters and ring-touching times were measured. In experiment 2, 30 participants with FOG were randomized to 6 weeks of dual-task training with internal-focus or external-focus instruction. Before and after training, we recorded timed up-and-go (TUG) and TUG dual-task (TUGdt) in on-medication and off-medication states, and the numbers of FOG episodes and falls. The non-FOG group showed less step length variability and shorter ring-touching times with external-focus. The FOG group showed less step length variability, less cadence, increased gait velocity, and longer step lengths with internal-focus compared to external-focus and no-focus instructions. Both internal-focus and external-focus training reduced FOG and falls after intervention, but only internal-focus training reduced TUG and TUGdt in both on-medication and off-medication states. Our findings suggest external-focus would enhance walking automaticity and the concurrent task accuracy for non-freezers, whereas for freezers, internal-focus could increase gait stability and lead to a more positive effect on improving locomotion control and reducing falling risk.

Dominance of Attention Focus and Its Electroencephalogram Activity in Standing Postural Control in Healthy Young Adults

Attention focus changes performance, and external focus (EF) improves performance compared to internal focus (IF). However, recently, the dominance of attention focus, rather than the effectiveness of unilateral EF, has been examined. Although the positive effects of EF on standing postural control have been reported, the dominance of attention focus has not yet been examined. Therefore, the purpose of this study was to examine the dominance of attention focus and its neural mechanism in standing postural control using electroencephalography (EEG). A standing postural control task under IF and EF conditions was performed on healthy young men. Gravity center sway and cortical activity simultaneously using a stabilometer and an EEG were measured. Participants were classified into IF-dominant and EF-dominant groups according to their index of postural stability. The EEG was analyzed, and cortical activity in the theta-wave band was compared between the IF-dominant and EF-dominant groups. Significant neural activity was observed in the left parietal lobe of the IF-dominant group in the IF condition, and in the left frontal lobe of the EF-dominant group in the EF condition (p < 0.05). Differences in EEG activity between IF-dominant and EF-dominant groups, in standing postural control, were detected. This contributes to the development of training methods that consider attentional focus dominance in postural control.

Individual Sensory Modality Dominance as an Influential Factor in the Prefrontal Neurofeedback Training for Spatial Processing: A Functional Near-Infrared Spectroscopy Study

Neurofeedback is a neuromodulation technique used to improve brain function by self-regulating brain activity. However, the efficacy of neurofeedback training varies widely between individuals, and some participants fail to self-regulate brain activity. To overcome intersubject variation in neurofeedback training efficacy, it is critical to identify the factors that influence this type of neuromodulation. In this study, we considered that individual differences in cognitive ability may influence neurofeedback training efficacy and aimed to clarify the effect of individual working memory (WM) abilities, as characterized by sensory modality dominance, on neurofeedback training efficacy in healthy young adults. In particular, we focused on the abilities of individuals to retain internal (tactile or somatosensory) or external (visual) body information in their WM. Forty participants performed functional near-infrared spectroscopy-based neurofeedback training aimed at producing efficient and lower-level activity in the bilateral dorsolateral prefrontal cortex and frontopolar cortex. We carried out a randomized, sham-controlled, double-blind study that compared WM ability before and after neurofeedback training. Individual WM ability was quantified using a target searching task that required the participants to retain spatial information presented as vibrotactile or visual stimuli. Participants who received feedback information based on their own prefrontal activity showed gradually decreasing activity in the right prefrontal area during the neurofeedback training and demonstrated superior WM ability during the target searching task with vibrotactile stimuli compared with the participants who performed dummy neurofeedback training. In comparison, left prefrontal activity was not influenced by the neurofeedback training. Furthermore, the efficacy of neurofeedback training (i.e., lower right prefrontal activity and better searching task performance) was higher in participants who exhibited tactile dominance rather than visual dominance in their WM. These findings indicate that sensory modality dominance in WM may be an influential neurophysiological factor in determining the efficacy of neurofeedback training. These results may be useful in the development of neurofeedback training protocols tailored to individual needs.

Autonomy and focus of attention in medical motor skills learning: a randomized experiment

BACKGROUND

The 'OPTIMAL' (Optimizing Performance Through Intrinsic Motivation and Attention for Learning) theory of motor learning suggests that autonomy, external focus of attention, and perceived competence can improve learning of simple motor tasks. The authors hypothesized that enhanced (vs. routine) autonomy and external (vs. internal) focus of attention would improve first-try performance of two medical motor tasks.

METHODS

The authors conducted a randomized two-by-two factorial design study with high school students as participants. Task instructions promoted either enhanced or routine autonomy, and either external or internal focus of attention. These conditions were replicated in a crossover design for two common medical tasks (chest compressions on a manikin and a Fundamentals of Laparoscopic Surgery peg transfer task). Primary outcomes were objective measures of task performance (chest compression deviation from target depth; peg transfer time with penalties for errors). Secondary outcomes included subjective perceptions of confidence, autonomy, and workload.

RESULTS

One hundred thirty-three high school students participated in this study. The primary outcomes concerning enhanced vs. routine autonomy demonstrated no statistically significant difference in either task (chest compression depth deviation: difference -0.7 mm [score range 0 to 37.5 mm]; 95% confidence interval (CI95) -3.85, 2.41; p = .65; peg transfer penalized time: rate ratio 1.03; CI95 0.91, 1.31; p = .79). The authors likewise found no statistically significant difference for external vs. internal focus of attention (depth deviation: difference 1.1 mm; CI95 -2.04, 4.17; p = .50; penalized time: rate ratio 0.89; CI95 0.75, 1.13; p = .33). The authors found no statistically significant differences for either comparison in confidence, autonomy and workload (p > .09; differences ranged from -0.83 to 0.79 [scale range 0 to 10]).

CONCLUSIONS

First-try performance of chest compressions and peg transfer by novice learners is not significantly affected by enhanced (vs. routine) autonomy or external (vs. internal) focus of attention.

Rehabilitation in movement disorders: From basic mechanisms to clinical strategies

Movement disorders encompass a variety of conditions affecting the nervous system at multiple levels. The pathologic processes underlying movement disorders alter the normal neural functions and could lead to aberrant neuroplastic changes and to clinical phenomenology that is not expressed only through mere motor symptoms. Given this complexity, the responsiveness to pharmacologic and surgical therapies is often disappointing. Growing evidence supports the efficacy of neurorehabilitation for the treatment of movement disorders. Specific form of training involving both goal-based practice and aerobic training could drive and modulate neuroplasticity in order to restore the circuitries dysfunctions and to achieve behavioral gains. This chapter provides an overview of the alterations expressed in some movement disorders in terms of clinical signs and symptoms and plasticity, and suggests which ones and why tailored rehabilitation strategies should be adopted for the management of the different movement disorders.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

Empirical Evidence for the Functionality Hypothesis in Motor Learning: The Effect of an Attentional Focus Is Task Dependent

A large body of research suggests that during learning motor skills, focusing on environmental effects of the movement (external focus) generally leads to better performance than focusing on one’s own body (internal focus). The functionality hypothesis states, in contrast, that the superiority of any attentional focus is task dependent. The present study aimed to test the predictions of the latter and searched for underlying mechanisms and task characteristics for one or the other focus being more functional. In Experiment 1, we examined whether the internal focus is superior in a difficult body-oriented balance task. In Experiment 2, we added visual feedback and investigated whether this would enhance the functionality of the external focus. In both experiments, the participants stood one-legged on a balance board and had to shift their centre of pressure (COP) to predefined target points. Per instruction, they were asked to interpret their attentional focus on the COP as either internal (the sole of the foot) or external (the platform). In Experiment 1, the external focus was induced through a mental image. The internal focus group performed significantly better, thereby supporting the functionality hypothesis. In Experiment 2, the COP was dynamically visualized on a screen. The internal focus superiority vanished. We suggest that the internal focus is more functional in motor-learning situations that provide more effect information through body-internal senses than through body-external senses. In these cases, the external focus hampers learning because it is associated with additional cognitive load.

Postural Control in Older Adults During and Following a 12-Week Balance Training Intervention With Attentional Focus Instructions

Adults (N = 54, 80.78 ± 6.08 years) who reported falling during the previous 12 months participated in a 12-week wobble board training program with internal focus or external focus (EF) instructions. Verbal manipulation checks were performed after training sessions as a self-report of the attentional foci used. The percentage of sessions in which participants reported using an EF (EFSR) was subsequently calculated. Mean velocity and mean power frequency in the anterior–posterior (MVELOAP and MPFAP) and medial–lateral (MVELOML and MPFML) direction were assessed during a 35-s wobble board task at Weeks 0, 6, 12, 13, 16, and 20, with the latter three as retention tests. Piecewise linear growth models estimated treatment effects on individual growth trajectories of MVELOAP and ML and MPFAP and ML during intervention and retention periods. Regardless of condition, MVELOML significantly decreased (π = −.0019, p = .005) and MPFML increased (π = .025, p < .02) during the intervention period. In analyses including interaction terms, participants in the EF group who reported greater EFSR had superior progression of MPFAP during the intervention (π = .0013, p = .025). Verbal manipulation checks suggest a preference for and advantage of EF for facilitating postural control performance and automaticity.

Does an Externally Focused Dual-task Mitigate Real-time Conscious Postural Control in Older Adults?

Objectives: This study first examined whether real-time conscious postural control (reinvestment) and postural sway increase with different postural difficulties on a compliant surface among older adults. The second objective was to investigate the effect of an externally focused dual-task on real-time reinvestment and postural sway under a relatively challenging standing position. Method: Thirty-two community-dwelling older adults (mean age = 72.09, SD = 4.18 years) were recruited. Participants performed balance tasks in four standing positions in a randomized order on a balance foam pad. The four positions included wide-based standing on foam (WBF), narrow-based standing on foam (NBF), tandem-based standing on foam (TBF) and tandem-based standing on foam with an externally focused dual-task (TBFE). Throughout all the balance tasks, participants' real-time reinvestment and body sway were indicated by the Alpha2 T3-Fz Electroencephalogram (EEG) coherence and the total sway length (TSL), respectively. Results and Discussion: Our results revealed no significant difference in real-time reinvestment among different standing positions while postural sway increased from WBF to NBF and reduced from NBF to TBF. We also demonstrated that when performing a relatively challenging standing task on a compliant surface, an externally focused dual-task (TBFE), compared to a baseline single task (TBF), can neither mitigate real-time reinvestment nor improve balance performance in community-dwelling older adults with good balance capability. Potential explanations and implications are discussed.

Loss of Motor Stability After Sports-Related Concussion: Opportunities for Motor Learning Strategies to Reduce Musculoskeletal Injury Risk

Current best practices to direct recovery after sports-related concussion (SRC) typically require asymptomatic presentation at both rest and during a graduated exercise progression, and cognitive performance resolution. However, this standard of care results in a significantly elevated risk for musculoskeletal (MSK) injury after return-to-sport (RTS). The elevated risk is likely secondary to, in part, residual neurophysiological and dual-task motor stability deficits that remain despite RTS. These deficits present as a loss of autonomous control of gait and posture and an increased need for cognition for motor stability. Thus, the incorporation of strategies that can enhance motor stability and restore autonomous control of gait and posture during SRC recovery and RTS progression may facilitate a reduction of the elevated risk of secondary MSK injury. We provide a theoretical framework for the application of motor learning principles to restore autonomous gait and postural stability after SRC via incorporation, or targeted manipulation, of external focus, enhanced expectations, autonomy support, practice schedule variability, and dual-task strategies during rehabilitation and RTS training.

The effects of dual-task training on balance and gross motor function in children with spastic diplegia

The purpose of this study was to investigate changes in dynamic balance and gross motion function when dual-task training was performed on an unstable support surface by children with spastic diplegia. The subjects of this study were 14 children (experimental group n=7, control group n=7) who were medical diagnosed with spastic diplegia. Both groups were administered treatment for 30 min, 2 times a week for 8 weeks, with the experimental group performing dual-task exercise in which cognitive tasks related to daily living were performed while maintaining balance on an unstable surface, and the control group being administered neurodevelopmental treatment. Balance and gross motor function Assessments were conducted before intervention and after 8 weeks of intervention. Wilcoxon signed-rank test was performed to analyze changes in balance, gross motor function in the group, and the Mann–Whitney test was conducted to compare the differences between the two groups before and after intervention. The results showed that there was a statistically significant difference in both groups when balance in a sitting position and gross motor function (P<0.05). There was a statistically significant difference between the two groups in balance and gross motor function assessment (P<0.05). Based on the results of this study, it was confirmed that dual-task training improves balance, gross motor function in children with spastic diplegia. Therefore, dual-task training may be considered as an effective method of intervention method in the functional aspect of children with spastic diplegia.

Beauty That Moves: Dance for Parkinson's Effects on Affect, Self-Efficacy, Gait Symmetry, and Dual Task Performance

Background: Previous studies have investigated the effects of dance interventions on Parkinson’s motor and non-motor symptoms in an effort to develop an integrated view of dance as a therapeutic intervention. This within-subject study questions whether dance can be simply considered a form of exercise by comparing a Dance for Parkinson’s class with a matched-intensity exercise session lacking dance elements like music, metaphorical language, and social reality of art-partaking.

Methods: In this repeated-measure design, 7 adults with Parkinson’s were tested four times; (i) before and (ii) after a Dance for Parkinson’s class, as well as (iii) before and (iv) after a matched-intensity exercise session. Physiological measures included heart rate and electrodermal activity. Self-reported affect and body self-efficacy were collected. Gait symmetry and dual task cost were analyzed using the 6 min walking test (6MWT) and Timed-Up-and-Go test (TUG), respectively.

Results: Average heart rate was the same for both conditions, while electrodermal activity was higher during Dance for Parkinson’s. Significant differences were found in body self-efficacy, beauty subscale, symmetry of gait, and dual task performance.

Conclusion: Dance, compared to an exercise intervention of matched intensity, yields different outcomes through the means of intrinsic artistic elements, which may influence affective responses, the experience of beauty, self-efficacy, and gait performance.

Comparison of postural control in older adults under different dual-task conditions: A cross-sectional study

BACKGROUND

and purpose: Performing a cognitive task while maintaining postural stability, known as "dual-task" condition, can increase the cognitive demand and reduce the postural control capacity. The inability to allocate attention to postural control under dual-task conditions may lead to balance impairments, particularly in older adults. The present study aimed to compare the effects of different dual-task conditions of backward counting (BC) and visual attention (VA) on older adults' postural balance performance.

METHODS

Twenty asymptomatic volunteers (mean age: 70.4 ± 4.1 years) were recruited. Participants stood on a foam surface placed over a force plate, and displacement and sway velocity of their center of pressure (COP) in anterior-posterior (AP) and medial-lateral (ML) directions were recorded under three conditions: BC dual-task, VA dual-task (control of center of mass with a laser pointer), and quiet stance as the control task (CT).

RESULTS

Repeated measures ANOVA showed a significant difference in AP and ML sway velocities between conditions with p-values of 0.039 and 0.042, respectively. The LSD post-hoc test revealed that the BC task significantly increased AP sway velocity compared to the CT (p = 0.013), and the VA task significantly increased ML sway velocity compared to the CT (p = 0.034) and the BC tasks (p = 0.026). There were no statistically significant differences between conditions for ML (p = 0.058) and AP (p = 0.350) displacements and total sway velocity (p = 0.051).

CONCLUSION

Older adults' postural stability can be impaired under dual-task conditions and the present study revealed that various dual tasks increase postural sway in different directions.

Does focus of attention alter craniocervical flexion test motor learning? A randomized controlled trial

OBJECTIVE

To evaluate the effects of three different foci of attention (internal, external and mixed) on motor learning using craniocervical flexion test in inexperienced participants.

METHODS

Ninety healthy young adults, with no experience in the task, practiced the craniocervical flexion test under three different focus of attention: a) Mixed Focus (internal plus external), b) Internal Focus, and c) External Focus. We assessed immediate, post-training, and retention (one week after the last training session) aspects of motor learning by quantifying (i) the activity of the superficial cervical flexors muscles, (ii) craniocervical range of motion, and (iii) the performance on the craniocervical flexion test.

RESULTS

None of the groups showed any significant immediate, post-training, or retention effects on superficial neck flexors activity and craniocervical range of motion progression. At immediate assessment, mixed focus had greater craniocervical flexion performance than external (MD 0.9, 95%CI 0.2 to 1.5), and internal foci (MD 1.4, 95%CI 0.8 to 2.1). At post-training, mixed focus led to better craniocervical performance compared to external (MD 1.6, 95%CI 0.8 to 2.4) and internal foci (MD 2.7, 95%CI 1.9 to 3.5). External focus had better scores on the craniocervical flexion test performance than internal focus (MD 1.1, 95%CI 0.3 to 1.9). Results remained similar at retention, with mixed focus being superior to internal (MD 2.3, 95%CI 1.7 to 3) and external foci (MD 1.5, 95%CI 0.9 to 2.1) on craniocervical flexion test performance. Similarly, the performance on the craniocervical flexion test performance remained similar at retention between external and internal foci (MD 0.9, 95%CI 0.2 to 1.5).

CONCLUSION

In inexperienced asymptomatic participants, different foci of attention were not able to change cervical muscle activity and craniocervical range of motion during the craniocervical flexion test. Mixed focus was better than external and internal focus on the craniocervical flexion test. These findings were retained after one week.

Maximal force production requires OPTIMAL conditions

The OPTIMAL theory of motor learning identifies several motivational and attentional factors that draw out latent motor performance capabilities. One implication of the OPTIMAL theory of motor learning (Wulf & Lewthwaite, 2016) is that standardized motor performance assessments likely do not reflect maximal capabilities unless they are "optimized" with appropriate testing conditions. The present study examined the effects of three key motivational (enhanced expectancies, EE, and autonomy support, AS) and attentional (external focus, EF) variables in the OPTIMAL theory on maximum force production. In Experiment 1, a handgrip strength task was used. EE, AS, and EF were implemented, in a counterbalanced order, on consecutive trial blocks in an optimized group. A control group performed all blocks under neutral conditions. While there were no group differences on Block 1 (baseline), the optimized group outperformed the control group on all other blocks. In Experiment 2, participants performed two one-repetition maximum (1-RM) squat lift tests, separated by one week. Two groups, an optimized group and control group, had similar 1-RM values on the first test performed under neutral conditions. However, on the second test, a group performing under optimized conditions (EE, AS, EF) showed an increase in 1-RM, while there was no change from the first to the second test for a control group. We argue that standard test conditions may not produce true maximal performance. The findings corroborate the importance of key factors in the OPTIMAL theory and should be applied to ensure accurate strength performance assessment.

Gait Stability in Older Adults During Level-Ground Walking: The Attentional Focus Approach

OBJECTIVES

The objective of this study was to investigate the effect of attentional focus instructions on gait stability during level-ground walking among older adults.

METHODS

We recruited 140 community-dwelling older adults (mean age = 70.3 years, SD = 4.7 years) from elderly community centers in Hong Kong. The experiment included assessments on participant's characteristics and walking trials. During walking trials, each participant was invited to walk at a self-selected pace along a 6-m walkway. Internal focus instructions (Internal condition), external focus instructions (External condition), or no instruction (Control condition) were given in a randomized order for three trials per condition, giving a total of nine walking trials. Spatial and temporal gait parameters were measured.

RESULTS

Results showed significantly higher body sway and variability of swing and stance time under Internal condition relative to External and Control conditions. Moreover, reduced velocity and shorter steps were demonstrated under Internal condition relative to External and Control conditions.

DISCUSSION

External focus instructions did not improve gait stability in older adults when compared to Control condition. Internal focus instructions appear to compromise gait stability. Future research should investigate if walking instructions that refer to body movements explicitly compromise gait rehabilitation for older adults in clinical settings.

Internal focus instruction increases psychological stress with conscious motor processing and deteriorates motor performance in dart throwing

Internal focus attention strategies have been found to diminish motor performance. This study attempted to elucidate this finding using the constrained action hypothesis and the theory of reinvestment through exploring their underlying mechanisms. Sixty-one young participants completed a self-paced "dart throwing" motor task to examine the effects of internal focus instruction, compared with no focus instruction, on conscious motor processing (reinvestment), psychological stress, and motor performance. Participants threw darts with standardized internal focus and no focus instructions given before each trial block of dart throwing. Motor performance was indicated by the throw accuracy and throw time. Stress was measured using a galvanic skin response probe. An insight into real-time conscious motor processing (reinvestment) was provided by the electroencephalography coherence between T3 and Fz locations on the scalp. Results indicated that internal focus instruction could cause participants to have lower throw accuracy (p = 0.008), longer throw time (p = 0.001), higher stress (p = 0.001) and higher real-time conscious motor processing (reinvestment) (p = 0.001) than no focus instruction. The significant results imply that internal focus instruction should be avoided in the self-paced motor task learning due to its detrimental effects.

Effect of a Concurrent Cognitive Task, with Stabilizing Visual Information and Withdrawal, on Body Sway Adaptation of Parkinsonian's Patients in an Off-Medication State: A Controlled Study

Background: In persons with Parkinson's disease (pwPD) any additional somatosensory or distractor interference can influence the posture. When deprivation of vision and dual-task are associated, the effect on biomechanical performance is less consistent. The aim of this study was to evaluate the role of the visual deprivation and a cognitive task on the static balance in earlier stage PD subjects. Methods: Fifteen off-medication state pwPD (9 women and 6 men), 67.7 ± 7.3 years old, diagnosed PD since 5.4 ± 3.4 years, only Hoehn and Yahr state 2 and fifteen young control adults (7 women and 8 men) aged 24.9 ± 4.9 years, performed semi-tandem task under four randomized experimental conditions: eyes opened single-task, eyes closed single-task, eyes opened dual-task and eyes closed dual-task. The center of pressure (COP) was measured using a force plate and electromyography signals (EMG) of the ankle/hip muscles were recorded. Traditional parameters, including COP pathway length, ellipse area, mediolateral/anteroposterior root-mean-square and non-linear measurements were computed. The effect of vision privation, cognitive task, and vision X cognitive was investigated by a 2 (eyes opened/eyes closed) × 2 (postural task alone/with cognitive task) repeated-measures ANOVA after application of a Bonferroni pairwise correction for multiple comparisons. Significant interactions were further analyzed using post-hoc tests. Results: In pwPD, both COP pathway length (p < 0.01), ellipse area (p < 0.01) and mediolateral/anteroposterior root-mean-square (p < 0.01) were increased with the eyes closed, while the dual-task had no significant effect when compared to the single-task condition. Comparable results were observed in the control group for who COP pathway was longer in all conditions compared to eyes opened single-task (p < 0.01) and longer in conditions with eyes closed compared to eyes opened dual-task (p < 0.01). Similarly, all differences in EMG activity of pwPD were exclusively observed between eyes opened vs. eyes closed conditions, and especially for the forward leg's soleus (p < 0.01) and backward tibialis anterior (p < 0.01). Conclusions: These results in pwPD without noticeable impairment of static balance encourage the assessment of both visual occlusion and dual-task conditions when the appearance of significant alteration during the dual-task could reveal the subtle worsening onset of the balance control.

Does Attention Modify Contributions to Heaviness Perception?

Purpose: The current study investigated the effect of attention on heaviness perception and its physiological and kinematic contributions. Method: Participants lifted objects that varied in mass and volume while their muscle activity and movement were recorded. Participants were instructed to pay attention to their arm (internal) or the object (external). Results: While heaviness perception did not change as a function of attention, whether muscle activity and movement combined for perception differed across attention conditions. Specifically, muscle activity and movement combined to significantly predict heaviness perception in the external condition, but not the internal condition. Additionally, movement was more salient for perception in both conditions compared to previous research investigating the contribution of muscle activity and movement to heaviness perception. Conclusion: It is suggested that these results support the constrained action hypothesis, which suggests that adopting an external focus of attention benefits motor task performance and learning, and should be further explored in the context of a theory of haptic perception that suggests that the medium for haptic perception is the multifractal tensegrity structure of the body.

Distinct bilateral prefrontal activity patterns associated with the qualitative aspect of working memory characterized by individual sensory modality dominance

In addition to quantitative individual differences in working memory (WM) capacity, qualitative aspects, such as enhanced sensory modality (modality dominance), can characterize individual WM ability. This study aimed to examine the neurological basis underlying the individual modality dominance component of WM using functional near-infrared spectroscopy (fNIRS). To quantify the degree of individual WM modality dominance, 24 participants were required to find seven hidden targets and hold their spatial location and appearance order with vibrotactile or visual stimuli aids. In this searching task, eight participants demonstrated higher performance with the tactile condition (tactile-dominant) whereas sixteen demonstrated visual dominance. We then measured prefrontal activity by fNIRS during memorization of visual stimulus numbers while finger tapping as a cognitive-motor dual-task. Individual modality dominance significantly correlated with bilateral frontopolar and dorsolateral prefrontal activity changes over repeated fNIRS sessions. In particular, individuals with stronger visual dominance showed marked decreases in prefrontal area activity. These results suggest that distinct processing patterns in the prefrontal cortex reflect an individual’s qualitative WM characteristics. Considering the individual modality dominance underlying the prefrontal areas could enhance cognitive or motor performance, possibly by optimizing cognitive resources.

The Effects of Attentional Focus Instructions Specific to Body Movements on Movement Quality and Performance

Contexts: Directing an individual's attention to the effect of the movements (external focus) has been shown to improve performance than directing attention to body movements (internal focus). However, the effect of attentional focus instructions specific to movement quality has not been investigated thoroughly.

OBJECTIVE

To compare the effects of internal and external focus instructions specific to body movements.

DESIGN

Mixed design, 2 (sex) × 2 (instructions).

SETTINGS

Laboratory setting.

PARTICIPANTS

A total of 40 participants (males, n = 20; mean [SD]; age = 22.0 [2.19] y; height = 179.33 [5.90] cm; mass = 77.7 [13.04] kg; females, n = 20; age = 22.0 [3.87] y; height = 164.84 [5.80] cm; mass = 71.48 [20.66] kg) were recruited.

INTERVENTION

Participants completed 2 consecutive jumps (ie, a forward jump from a height and then a maximal vertical jump) with internal focus and external focus instructions. External focus was elicited by placing pieces of tape on the participants' legs.

MAIN OUTCOME MEASURES

Landing quality was measured by the Landing Error Scoring System to assess movement quality, and the vertical jump height was measured by Vertec.

RESULTS

The performance results showed that the external focus condition resulted in superior vertical jump height compared with the internal focus condition (P < .05). Although landing quality did not show significant differences between 2 conditions, the effect size (η2 = .09) indicated that landing quality was better when participants adopted an external, rather than an internal focus of attention (P = .07).

CONCLUSIONS

The body-oriented instructions can be provided externally by adding artificial external cues and directing attention to them. Importantly, the findings were evident in a qualitative assessment that can be adopted by practitioners. The results suggest that practitioners should adopt an external focus cue for performance and also consider using an external focus for movement quality.

Adaptation of balancing behaviour during continuous perturbations of stance. Supra-postural visual tasks and platform translation frequency modulate adaptation rate

When humans are administered continuous and predictable perturbations of stance, an adaptation period precedes the steady state of balancing behaviour. Little information is available on the modulation of adaptation by vision and perturbation frequency. Moreover, performance of supra-postural tasks may modulate adaptation in as yet unidentified ways. Our purpose was to identify differences in adaptation associated to distinct visual tasks and perturbation frequencies. Twenty non-disabled adult volunteers stood on a platform translating 10 cm in antero-posterior (AP) direction at low (LF, 0.18 Hz) and high frequency (HF, 0.56 Hz) with eyes open (EO) and closed (EC). Additional conditions were reading a text fixed to platform (EO-TP) and reading a text stationary on ground (EO-TG). Peak-to-peak (PP) displacement amplitude and AP position of head and pelvis markers were computed for each of 27 continuous perturbation cycles. The time constant and extent of head and pelvis adaptation and the cross-correlation coefficients between head and pelvis were compared across visual conditions and frequencies. Head and pelvis mean positions in space varied little across conditions and perturbation cycles but the mean head PP displacements changed over time. On average, at LF, the PP displacement of the head and pelvis increased progressively. Adaptation was rapid or ineffective with EO, but slower with EO-TG, EO-TP, EC. At HF, the head PP displacement amplitude decreased progressively with fast adaptation rates, while the pelvis adaptation was not apparent. The results show that visual tasks can modulate the adaptation rate, highlight the effect of the perturbation frequency on adaptation and provide evidence of priority assigned to pelvis stabilization over visual tasks at HF. The effects of perturbation frequency and optic flow and their interaction with other sensory inputs and cognitive tasks on the adaptation strategies should be investigated in impaired individuals and considered in the design of rehabilitation protocols.

The Effects of Attentional Focus Instruction on the Performance of a Whole-Body Coordination Task in Children With Developmental Coordination Disorder

BACKGROUND AND AIM

Previous studies have supported the advantages of an external focus of attention (EFA) relative to an internal focus of attention (IFA) in healthly adults. However, effects of attentional focus instructions on skill performance and acquisition in children are equivocal. The aim of this study was to examine the effects of attentional focus instructions on performance of a whole body coordination task in children with and without developmental coordination disorder (DCD).

METHODS

Children with DCD (n = 18) and typically developing (TD) children (n = 21) (9-10 years) were asked to perform 3 countermovement vertical jumps in the IFA (Concentrate on the swing of your arms), EFA (Concentrate on getting as close to the ceiling as possible), and control conditions.

RESULTS

The results showed that regardless of children's motor development proficiency, the jump height and vertical take-off velocity (V_TO) were higher in EFA relative to both IFA and Con conditions. In addition, V_TO was significantly higher in the Con relative to IFA condition.

CONCLUSION

The results of the current study showed that EFA relative to IFA instructions could enhance the neuromuscular activation of dynamic contractions of the leg muscles in both children with and without DCD. The findings suggest that the beneficial effects of EFA relative to IFA instructions on children's motor performance is identical across children with different levels of motor proficiency.

Choose your words wisely: Optimizing impacts on standardized performance testing

BACKGROUND

The OPTIMAL theory of motor learning identifies motivational (enhanced expectancies, EE, and autonomy support, AS) and attentional (an external attentional focus, EF) factors that affect motor performance and learning [1]. One implication of this theory is that standardized clinical and laboratory assessments of physical capacity and motor performance that do not incorporate optimizing conditions may underestimate true maximal capabilities. The influence of "optimized" conditions on a clinical-applied test of balance control was examined with healthy participants. Given the motor performance benefits of optimized conditions predicted by the OPTIMAL theory, it was hypothesized that providing participants with information that induced EE, provided them with AS, and promoted their use of EF would reduce balance errors and postural sway.

METHODS

We used as an exemplar assessment, the Balance Error Scoring System (BESS), and center-of-pressure (COP) velocity measurements of postural sway. Participants performed under two different conditions, separated by two days: an optimized (EE, AS, and EF) condition and a control ("neutral") condition, with sample-wide order counterbalancing. In each condition, participants performed three stances (double-leg, single-leg, and tandem) on two support surfaces (firm and foam). Stance order was participant-determined in the optimized condition and, for the control condition, yoked to a participant in the optimized condition.

RESULTS

Participants committed fewer balance errors in the optimized condition than in the control condition (p < .001) and their resultant COP velocity in the optimized condition was lower than that in the control condition (p = .004). BESS scores were correlated with resultant COP velocity (r = .593, p < .001).

SIGNIFICANCE

Our results demonstrated the impact of implementing optimized, as opposed to "neutral" control, conditions for better insight into balance capabilities in normal and challenging situations. Practitioners' roles in mediating test situations and using subtle wording to promote optimized performance may have consequential impacts on motor assessment outcomes.

The Shape of Water: How Tai Chi and Mental Imagery Effect the Kinematics of a Reach-to-Grasp Movement

The aim of the present study was to investigate the effect of Tai Chi (TC) and mental imagery (MI) on motor performance. MI is the ability of representing different types of images and it can be improved through constant practice (e.g., of TC). The majority of previous literature has mainly investigated the impact of this mental factor by means of qualitative indexes, whereas studies considering more rigorous measures such as kinematic parameters are rare. In this vein, little is known about how MI can affect reach-to-grasp, one of the most studied models in kinematic research. The present study attempts to fill that gap by investigating the relationship between MI and motor performance in TC, a practice that largely promotes the adoption of mental training. One TC master, four instructors, ten apprentices and fifteen untrained participants were requested to reach toward and grasp an object while mentally representing one out of five different images related to water with an increasing degree of dynamicity and expansion (i.e., still water, flowing water, wave, whirlpool, and opening water flower). Kinematic profiles of movements were recorded by means of six infra-red cameras using a 3-D motion analysis system. We tested whether: (i) focusing on MI during the task would help in optimizing motor efficiency, and (ii) expertise in TC would be reflected in higher flexibility during the task. The results indicate that kinematics is highly sensitive to MI and TC practice. In particular, our main finding suggests a statistically significant general improvement in motor efficiency for the TC group and a beneficial effect for all the participants when focusing on the most expansive image (i.e., opening water flower). Moreover, regression analysis indicates that MI and TC practice make online control more flexible in an experience-based way. These results have important implications for the use of mental imagery and TC in the retraining of motor function in people with physical disabilities.

Motor-cognitive approach and aerobic training: a synergism for rehabilitative intervention in Parkinson's disease

Parkinson's disease (PD) results in a complex deterioration of motor behavior. Effective pharmacological or surgical treatments addressing the whole spectrum of both motor and cognitive symptoms are lacking. The cumulative functional impairment may have devastating socio-economic consequences on both patients and caregivers. Comprehensive models of care based on multidisciplinary approaches may succeed in better addressing the overall complexity of PD. Neurorehabilitation is a highly promising non-pharmacological intervention for managing PD. The scientific rationale beyond rehabilitation and its practical applicability remain to be established. In the present perspective, we aim to discuss the current evidence supporting integrated motor-cognitive and aerobic rehabilitation approaches for patients with PD while suggesting a practical framework to optimize this intervention in the next future.

Are attentional instruction and feedback type affect on learning of postural and supra-postural tasks?

Optimum postural control and balance is dependent on the individual, the environment, and the task limitations. Thus, the present study investigated the effect of attentional instruction and feedback type on postural and supra-postural tasks. The 96 participants aged 11-19 years with attention deficit hyperactivity disorder (ADHD) were randomly assigned to one of the eight groups such as attentional instruction (internal and external), feedback (external and internal), and task (postural and supra-postural). Following a pre-test, the participants underwent four training sessions. Each session included 20 trials of 30 s with 20 s of rest between trials. Twenty-four hours after the training session, they performed two trials of warm-up and then took part in a retention test. Twenty-four hours after the retention test, they again performed two trials of warm-up and then participated in the transfer test. The result showed that the external attentional feedback and external attentional instruction groups performed better on supra-postural and postural tasks than the other experimental groups (P > 0.05). The external attentional instruction group performed better on postural and supra-postural tasks in the delayed retention and transfer tests (P > 0.05). Also, the external feedback group scored highest on postural and supra-postural tasks in the delayed retention and transfer tests. The results suggest that external attentional feedback and instruction is more effective than internal attention when learning supra-postural tasks to maintain balance.

The effects of different attentional focus on poststroke gait

Attention may influence the motor performance of poststroke patients. The attentional focus implies “where” attention is focused while performing a specific movement. Focusing attention on the inside of the body while performing a specific exercise is called an internal focus (IF) and focus on the external environment is called an external focus (EF). This study examined the effect of attention on the gait of patients with chronic stroke. Sixteen subjects voluntarily participated in the study. The subjects were guided to walk while maintaining the required attentional focus, which is control, IF, and EF condition. Dependent variables were as follows: step length, stride length, step width, 10-m walk time, and weight distribution on the paretic limb. The results are as follows. First, the step length and the stride length were observed to be longer in the EF condition. Second, 10-m walk time was faster in EF condition. Third, under the EF condition, more weight was applied to the paretic limb. We suggest that EF instruction useful to improve the poststroke gait.

Effects of Internal and External Attentional Focus on Postural Response to a Sliding Stance Surface

The present study examined whether an internal or external attentional focus would affect participants’ feet-in-place balance response to postural stance perturbations. A movable platform automatically slid forward or backward while healthy participants stood on it and (a) performed no cognitive activity (control), (b) focused on the pelvis or upper body sway (internal focus), (c) memorized a number displayed immediately before the platform slid (external focus), or (d) kept the equilibrium of an unstable cylinder over the arm (external focus). The forward displacement of the pelvis induced by the platform sliding forward was smaller when participants focused on their pelvic sway, although such effect was absent when they focused on their upper body sway, indicating that the internal focus was effective for the postural response when attention was paid to the pelvic sway. Regarding an external attention focus, the forward displacement of the pelvis induced by the platform sliding forward was smaller when participants focused on the equilibrium of an unstable object over the arm, but this effect was absent when they focused on the number, indicating that an external focus was only effective when the unstable object focused upon was relevant to the equilibrium of one’s own body. No attentional intervention was effective during backward sliding of the support surface, indicating that central set for responding to postural perturbation depends on the direction of the postural perturbation.

Motor Behavior Concepts in the Study of Balance: A Scoping Review

Previous research suggests that using Fitts' law; attentional focus or challenge point framework (CPF) is beneficial in balance control studies. A scoping review was conducted to examine studies that utilized these motor behavior concepts during balance control tasks. An extensive literature search was performed up to January 2018. Two independent reviewers conducted a study selection process followed by data extraction of the search results. Forty-six studies were identified, with 2 studies related to CPF, 12 studies related to Fitts' law and 32 studies related to focus of attention. The CPF appears to be a useful method for designing a progressive therapeutic program. Fitts' law can be used as a tool for controlling the difficulty of motor tasks. Focus of attention studies indicate that adopting an external focus of attention improves task performance. Overall, studies included in this review report benefit when using the selected motor behavior concepts. However, the majority (>80%) of studies included in the review involved healthy populations, with only three clinical trials. In order to ascertain the benefits of the selected motor behavior concepts in clinical settings, future research should focus on using these concepts for clinical trials to examine balance control among people with balance impairments.

Effects of attentional focus on movement coordination complexity

Attentional focus affects performance and learning of motor tasks. An external attentional focus (on the effects of movement) can lead to more efficient and effective movements compared to an internal focus (on body movement itself). According to the "constrained action hypothesis", an external focus facilitates fast and reflexive movement control while an internal focus leads to disruption of automatic coordination processes. Such disruption should be apparent in the complexity of movement. In this study, multiscale entropy measures were used to investigate if the external focus is related to superior coordination complexity compared to internal focus. Twenty participants were divided in two groups that balanced over an unstable platform in fourteen trials over two days, either with internal or external focus of attention instructions, followed by seven retention trials on the third day. Multiscale entropy measures were used to quantify complexity of motions of the platform, the participant, and the composite of participant and platform motions. Results were contrary to expectations. For the external focus group, despite better overall performance, multiscale entropy values of participant and composite motions were lower in some scales compared to the internal focus group, especially in the first and last days. This may be consistent with previous findings that predictability increases during learning of a balance task. Results also indicate the need to identify the correct physiological interpretation of single or multiscale entropy measures. Further investigation is needed to establish if entropy differences are causally related to performance and learning advantages of the external focus.

External relative to internal attentional focus enhances motor performance and learning in visually impaired individuals

Background: Research has demonstrated the advantages of an external relative to internal focus of attention for enhancing motor performance and learning across diverse tasks, contexts and populations. However, research has yet to examine whether this finding holds true for individuals who have a major visual impairment in discrete and locomotion-based continuous motor tasks.Methods: In experiment 1, twenty-four visually impaired participants were asked to kick a soccer ball with their dominant foot to a target 7 meters away. Participants performed 10 trials within an internal focus (concentration on inside of the foot), external focus (concentration on the ball), and control (no focus instructions) conditions, in a counterbalanced order. In experiment 2, thirty-nine visually impaired adults were asked to ride a rehabilitation Pedalo for a distance of 7 meters. Participants were randomly assigned to either an internal focus (focus on the feet), external focus (focus on the platform), or control (no focus instructions) group. Retention and transfer tests were conducted on day 2.Results: An external focus resulted in more accurate kicks and faster pedalo movement times compared to an internal focus.Conclusions: These findings indicate that visual information does not mediate external focus benefits for motor performance and learning.Implications for RehabilitationPractitioners should use instructions that encourage visually impaired individuals who are going through rehabilitation to adopt an appropriate focus of attention for enhancing motor performance and learning of discrete or locomotion-based motor skills.Instructions that foster an external focus, relative to an internal focus, enhances performance of both discrete and continuous motor skills in individuals with visual impairment.