Are the effects of internal focus instructions different from external focus instructions given during balance training in stroke patients? A double-blind randomized controlled trial

Kal, Elmar; Houdijk, Han; Kamp, John van der; Verhoef, Manon; Prosée, Rens; Groet, Erny; Winters, Marinus; Bennekom, Coen van; Scherder, E.J.A.

doi:10.1177/0269215518795243

Cited by 35 publications

(29 citation statements)

References 49 publications

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“…Given the weight of evidence supporting an association between internal focus of attention and disrupted motor performance on tasks normally regulated through “automatic” processes, any contradictory results would have been highly unexpected. Nevertheless, given the scale of recent and ongoing efforts to apply this perspective to various clinical (i.e., complex) contexts [e.g., (17, 18, 33)], it was important to re-establish these fundamental associations using an objective corroboration of the attention manipulation used. We suggest that our current observations in young adults fulfill this objective and, while further research is necessary to better-establish underlying mechanisms mediating this relationship, our findings help to establish a foundation from which we can evaluate the degree to which such associations translate to other contexts and populations.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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

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Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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“…The need for tailoring motor learning strategies was recently also confirmed by a randomized controlled trial comparing the effects of internal and external focus instructions. 33 Gait is a multivariate phenomenon with a pattern across the several parameters, and it is well known that a change of one gait parameter is generally accompanied by changes of other gait parameters. 34 A strength of the study is that a broad set of measures was used in order to measure the overall pattern of change.…”

Section: Discussionmentioning

confidence: 99%

The immediate influence of implicit motor learning strategies on spatiotemporal gait parameters in stroke patients: a randomized within-subjects design

et al. 2018

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“…The data described in this study come from two groups of patients. First, we used baseline data from stroke patients who participated in a RCT of Kal et al (recruited March 2016-February 2017) [18]. These data were used for the validation analyses only.…”

Section: Participantsmentioning

confidence: 99%

“…The SBT seems at least as sensitive as the BBS, which is commonly used in clinical practice. To illustrate this, we analyzed how many of the 51 patients who completed the 3-week training intervention in the study by Kal et al [18] achieved improvements in RStiff 2.5 and BBS that exceeded the respective MDCs of these measures. This was the case for twenty-four patients (47%) for the RStiff 2.5 measure, compared to 17 patients for the BBS (35%).…”

Section: Measurement Errormentioning

confidence: 99%

Validation of the stabilometer balance test: Bridging the gap between clinical and research based balance control assessments for stroke patients

et al. 2019

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Background: A pronounced discrepancy exists between balance assessments for stroke survivors that are used for clinical purposes and those used for research. Clinical assessments like the Berg Balance Scale generally have stronger ecological validity, whereas research-based assessments like posturography are generally more reliable and precise. We developed a stabilometer balance test (SBT) that aims to couple measurement reliability and precision to clinical meaningfulness by means of a personalized and adaptive test procedure. Research question: To examine the validity, reliability, and measurement error of the stabilometer balance test in inpatient stroke patients. Methods: In this cross-sectional study, inpatient stroke patients (FAC > 2) were tested on a stabilometer with adjustable resistance to mediolateral movement. A modified staircase procedure was used to adapt task difficulty (i.e., rotational stiffness) on a trial-by-trial basis. The main outcome was the threshold stiffness at which a patient could just stay balanced. Threshold stiffness was correlated with the Berg Balance Scale and posturography measurements to determine concurrent validity (N = 86). Test-retest reliability (N = 23) was analyzed with the Intraclass Correlation Coefficient (ICC). Floor and ceiling effects were assessed. The minimal detectable change was determined at individual and group level. Results: Threshold rotational stiffness moderately correlated with the Berg Balance Scale (r=−0.559, p < 0.001), and the absolute path length of the center of pressure during posturography (r=0.348, p = 0.006). Test-retest reliability was good to excellent (ICC=0.869; 95%CI=0.696-0.944). There were no floor or ceiling effects. The minimal detectable change was sufficiently small to detect relevant changes in balance control both on individual and group level. Relevance: The SBT is both a valid and reliable balance assessment in stroke patients. It is at least as precise as current clinically preferred measures and does not suffer from ceiling effects. Therefore, it is suitable for use in clinical practice as well as research.

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Are the effects of internal focus instructions different from external focus instructions given during balance training in stroke patients? A double-blind randomized controlled trial

Abstract: External focus instructions did not result in greater improvement in balance skill in stroke patients compared to internal focus instructions. Results suggest that tailoring instructions to the individual stroke patient may result in optimal improvements in motor skill.

Cited by 35 publications

References 49 publications

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

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

The immediate influence of implicit motor learning strategies on spatiotemporal gait parameters in stroke patients: a randomized within-subjects design

Validation of the stabilometer balance test: Bridging the gap between clinical and research based balance control assessments for stroke patients

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