Focus of Attention Effect on Sit to Stand Symmetry in Individuals Post Chronic Stroke: A Randomized Cross-over Trial
Phase: NA
Conditions: Stroke
Sponsor: Western Carolina University

 
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THE EFFECT OF FOCUS OF ATTENTION ON MOTOR PERFORMANCE AND LEARNING DURING A SIT 
TO STAND TASK IN INDIVIDUALS POST CHRONIC STROKE 
 
 
 
 
 
 
WESTERN CAROLINA UNIVERSITY 
DEPARTMENT OF PHYSICAL THERAPY 
COLLEGE OF HEALTH SCIENCES 
 
BY 
ASHLEY WATAMURA, PT, DPT, PHD, NCS 
March 19, 2025 
 
 
 
 
 
 
 
 
 
CLINICAL TRAILS ID NUMBER: 1799540-1 

 
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INTRODUCTION 
More than 795,000 people have a stroke in the United States each year, one every 40 
seconds (Virani et al., 2020), leading to 7.6 million Americans who have had a stroke (Tsao et al., 
2022). The direct and indirect yearly costs of stroke equate to 103.5 billion dollars in the United 
States (Girotra et al., 2020). Due to the growing aging population and the declining mortality rate 
the prevalence of stroke is projected to increase by 3.5 million by 2030 (Virani et al., 2020). 
Further, stroke remains the leading cause of long term disability (Tsao et al., 2022) with greater 
than 50 percent of stroke survivors being chronically disabled (Katzan, 2013; Lopez et al., 2006). In 
addition, ability to perform daily activities, cognition, and quality of life decline at a more significant 
rate in individuals post stroke than those without stroke (Dhamoon et al., 2010; Dhamoon et al., 
2012; Levine et al., 2015). Many of these individuals’ physical limitations depend on the 
impairments they sustain after their stroke. 
Impairments seen post stroke depend on the area of the brain that was damaged due to 
ischemia. Common impairments following stroke include weakness, hypertonicity, spasticity, 
abnormal synergies, decreased sensation, visual changes, and changes in cognitive processing 
(Connell et al., 2008; Gittins et al., 2021; Ward, 2012). These impairments often lead to other 
limitations in function including the ability to perform bed mobility, sit to stand, transfers, and gait 
(LeBrasseur et al., 2006). 
Sit to stand is one of the main transitions individuals make, occurring over 60 times a day in 
community dwelling older adults (Dall & Kerr, 2010). There is a significant relationship between 
ability to rise from a chair and independence with ADL’s (Alexander et al., 2000). This transition is 
also necessary for independent ambulation. Multiple factors can limit one’s ability to stand up. Riley 
et al. (1997) found that decreased knee extensor torque and reduced ground reaction forces are the 
root cause of why older adults have difficulty standing up.  

 
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Individuals post stroke demonstrate altered sit to stand and often exhibit abnormal muscle 
activation patterns in multiple key muscles, including the anterior tibialis, soleus (Silva et al., 2013), 
rectus femoris, and transverse abdominis (Lee et al., 2015). They also present with decreased knee 
moment on the affected side resulting in a less efficient sit to stand transition (Van Bladel et al., 
2021). In addition, individuals post stroke demonstrate increased trunk displacement in the 
mediolateral direction towards the unaffected side and weight distribution asymmetry. Cheng et al. 
(1998) found that individuals post stroke who were classified as fallers took more time to stand, 
had more mediolateral sway, and pushed less force through the affected lower extremity during sit 
to stand (Cheng et al., 1998).  
Sit to stand training is essential during rehabilitation post stroke to improve the ability to 
stand with a more normal biomechanical pattern and to positively impact other aspects of mobility. 
After sit to stand training, individuals post stroke were able to translate their body weight forward 
further with greater quadriceps activation (Kerr et al., 2019). They also had a more symmetrical 
weight distribution between both sides during sit to stand (Kerr et al., 2019). Several studies 
underline the importance of sit to stand training with a focus on increasing use of the affected lower 
extremity. For example, individuals post stroke who were trained with increased use of their 
affected side during sit to stand decreased their fall risk compared to those trained using a 
symmetrical foot placement (Liu et al., 2016). Forced use training of the affected lower extremity 
also lead to increased muscle activity in the affected limb, improved balance, gait kinematics, gait 
symmetry, gait velocity, and quality of life (Abdullahi et al., 2021; Billinger et al., 2010; Hsu et al., 
2017; Wu et al., 2019; Yu et al., 2015).  
While stroke is the leading cause of disability in the United States (US) (Virani et al., 2020), 
the amount of time in rehabilitation being received continues to decrease (Granger et al., 2009). 
The rising prevalence, high incidence, and short time in rehabilitation for individuals post stroke 
make the efficiency of rehabilitation for this population increasingly more important. Specifically, 

 
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therapists need to adopt effective instructional and feedback strategies to increase efficiency of 
motor learning.  
Based on a number of studies, simply changing two to three words of instruction can lead to 
more effective outcomes (Wulf, 2013). This impactful change in instruction is based on focus of 
attention research, exploring the difference between internal and external focus instruction. An 
internal focus refers to thinking about one’s own body movements, while an external focus is 
focusing on an outcome or impact on the environment. An example of internal focus is thinking 
about what one’s shoulders or arm is doing while shooting a basketball, while an external focus 
would be thinking about the effect on the ball or the basket (Wulf et al., 2001). Over 80 studies have 
compared internal and external focus of attention (Wulf, 2013). This research has been conducted 
in healthy individuals of all ages, with various levels of experience, and during multiple different 
sports such as golf, soccer, darts, archery, tennis, and volleyball (Kakebeeke et al., 2013; Kal et al., 
2013; Wulf, 2013). Despite some methodological quality concerns in some of these studies, 
including lack of control groups and lack of retention trials (Kal et al., 2018), research in the healthy 
adult and sports population, thus far, have supported that an external focus of attention leads to 
better outcomes (Kakebeeke et al., 2013; Wulf, 2013). Two main theories may explain why external 
focus is more effective than internal focus. The first is the conscious processing theory which states 
that having an internal focus overloads the working memory (Masters, 1992) The second is the 
constrained action hypothesis which proposes that having an internal focus of attention reduces 
automatic movement processes (McNevin et al., 2000; Wulf et al., 2001).  
Whether having an internal focus is more or less effective than having an external focus of 
attention is generally unknown, especially in certain populations. Specifically, effects  of attentional 
focus in motor learning after stroke is largely undetermined. Individuals post stroke may respond 
differently to focus of attention compared to healthy adults due to their impairments and cerebral 
changes. Individuals post stroke can have decreased executive function including information 

 
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processing (Zinn et al., 2007). Also, these individuals may lose some motor automaticity leading 
them to consciously try to control their movement (Orrell et al., 2009). This impaired information 
processing and loss of automaticity might result in a different response to focus of attention 
instruction and feedback than non-stroke populations. 
The research in the stroke population related to focus of attention is sparse and 
contradictory. Some studies show an external focus being detrimental to movement fluency (Kal et 
al., 2015), while others find that an external focus leads to better outcomes (Aloraini et al., 2020; 
Durham et al., 2014; Fasoli et al., 2002; Mückel & Mehrholz, 2014). The remaining studies in the 
stroke population, however, have found no difference between internal and external foci (Kal et al., 
2019; Kim et al., 2017). Most of these studies examined the effect of attentional focus during 
practice but did not include retention testing, thus the effects on motor learning have not been 
assessed. In addition, these studies have not examined the effects of focus of attention on functional 
movements such as sit to stand. 
Statement of the Problem 
Impairments following stroke often lead to functional limitations such as difficulty 
performing a sit to stand transfer, which may affect independence in other activities of daily living.  
Individuals following stroke often perform sit to stand transfers less efficiently than individuals 
without stroke.  This inefficiency is due in part to asymmetry between the unaffected and affected 
lower extremity.  Training people to use the affected side more may increase efficiency of their 
movement and decrease fall risk.  The type of instruction and feedback, specifically focus of 
attention instruction, may impact how well people following stroke learn to use the affected side 
more during sit to stand transfers. At this time, the effect of focus of attention instruction and 
feedback on the increased use of the affected side during sit to stand in individuals post stroke is 
unknown. 

 
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Purpose 
The purpose of this study is to fill some of the gaps in the literature by examining the effects 
of focus of attention on performance and learning of sit to stand in individuals post chronic stroke. 
This study will investigate whether an internal or external focus of attention can lead to improved 
use of the affected lower extremity during the sit to stand transition, while maintaining an upright 
trunk position.  
Research Questions 
The following research questions will be addressed in this study: 
1. 
Does an internal or external focus lead to an increased weight shift towards the 
affected side and upright trunk alignment during sit to stand training? 
2. 
Does an internal or external focus lead to greater learning of increased weight shift 
towards the affected side and upright trunk alignment during a sit to stand task in 
which learning will be evaluated using a retention test? Retention will refer to the 
ability to perform the sit to stand task without explicit instruction five minutes and 
one hour after practice.  
3. 
Does an internal or external focus lead to greater learning of increased weight shift 
towards the affected side and upright trunk alignment during a sit to stand task in 
which learning will be evaluated using a transfer test? Transfer of learning will be 
evaluated by exploring the effects of sit to stand training on gait symmetry.  
Research Hypotheses 
The following hypotheses will be addressed in this study: 
1. An external focus of attention will lead to a significantly greater weight shift towards the 
affected side during a sit to stand task than an internal focus of attention. 
2. An external focus will lead to significantly more vertical trunk position during a sit to stand 
task than an internal focus of attention. 

 
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3. An external focus of attention will lead to a greater retention of weight shift towards the 
affected side during a sit to stand task than an internal focus of attention. 
4. An external focus will lead to a greater retention of a more vertical trunk position during a 
sit to stand task than an internal focus of attention. 
5. An external focus of attention will lead to a greater task transfer of weight shift towards 
the affected side during gait than an internal focus of attention. 
Operational definitions 
The following operational definitions apply to this study:  
• 
Focus of attention: refers to where an individual places their attention when performing a 
motor task (McNevin et al., 2000). 
• 
Internal focus of attention: refers to focusing on one’s body movements when performing a 
motor task (Wulf et al., 1998). 
• 
External focus of attention: indicates focusing on the effects the body has on the 
environment, such as an outcome or target (Wulf et al., 1998). 
• 
Sit to stand task or training: will include the transition from sitting to standing and from 
standing back to sitting.  
• 
Asymmetric weight distribution: will be defined as overutilization of one leg compared to 
the other during sit to stand or gait, resulting in a difference in applied force between legs. 
There is a tendency of individuals post stroke to use the unaffected side more during the sit 
to stand transition(Cheng et al., 1998).  
• 
Lateral trunk deviation: will be determined by the amount an individual side bends or 
angles their torso to the side as captured by an inertial measurement unit placed on the 
superior aspect of the sternum directly below the sternal notch. The angle captured will be 
the movement around the anterior/posterior axis in the frontal plane.  

 
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• 
Force through the involved side: will be determined by measuring force through the 
affected lower extremity divided by the amount of force through both lower extremities 
using the Tekscan HR Pressure Mat. During each set the average percentage will be 
calculated. 
• 
Gait symmetry: will be determined by  percent of affected stance time divided by  percent of 
unaffected stance time ( percent of affected stance time/ percent of unaffected stance time).  
• 
use of the paretic lower extremity during stance phase of gait by using the equation paretic 
stance (percent of gait cycle)/nonparetic stance (percent of gait cycle) (Patterson et al., 
2008). Using this equation numbers close to and above one will reflect a longer stance time 
on the affected side compared to the unaffected side.  
• 
Motor performance: will be defined by how much force is being put through the affected 
lower extremity and the amount of lateral trunk deviation that occurs during the sit to stand 
transition. Less lateral trunk deviation and more force through the involved lower 
extremity will be a positive outcome for motor performance.  
• 
Motor learning: is defined as the ‘acquisition  and/or modification of skilled action’ 
(Shumway-Cook, 2017). In this study, motor learning will be defined as the ability for an 
individual to continue performing a motor task once the instructions are removed and the 
ability to carry over increased use of the affected lower extremity to a different task. It will 
be measured by a retention task done one hour after training and during a transfer task by 
assessing the effect of sit to stand training on the increased stance time of the affected side 
during gait.  
• 
Retention:  is defined as the ‘persistence of the performance’ after the acquisition or 
practice phase (Schmidt et al., 2019). In this study, retention will be defined as the amount 
of force through the affected lower extremity and upright trunk position that is maintained 

 
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during sit to stands once the specific instructions for internal or external focus of attention 
are removed five minutes post and one hour post training.  
• 
Transfer of a motor task: is the application of a learned skill to a new task (Müssgens & 
Ullén, 2015). During this study transfer of motor learning will be determined by whether sit 
to stand training affects use of the affected side during gait as measured by the GAITRite. 
Use of the affected side will be determined by  percent of affected stance time divided by  
percent of unaffected stance time ( percent of affected stance time/ percent of unaffected 
stance time).  
Assumptions 
The following assumptions will be applied to this study: 
• 
All participants are putting forth their best effort. 
• 
People in each focus group, internal and external, will use the focus instructions they 
receive during the task.  
• 
Individuals will understand and follow the instructions accurately. 
• 
Sample participants being tested are representative of people post stroke.  
• 
All individuals have been accurately diagnosed with a stroke.  
• 
The Tekscan HR Pressure Mat will accurately measure force through the lower extremities.  
• 
The Delsys IMU will accurately measure lateral trunk lean in the frontal plane.  
• 
The GAITRite will accurately measure affected and unaffected stance percentage during 
gait. 
Limitations 
The following limitations apply to the current study: 
• 
All participants will be from western North Carolina, potentially limiting  the 
generalizability to people from different areas of the country. 

 
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• 
Training will only involve one task so this may not carry over to other tasks such as bed 
mobility.  
• 
Participants will only receive one training session for each type of focus of attention 
instruction.  
• 
Individuals with neglect are excluded so the generalizability to individuals with perceptual 
disorders is limited.  
• 
All participants are able to stand without physical assistance and therefore function at a 
higher level, potentially limiting generalizability to individuals who function at lower levels.  
• 
Individuals who are unable to follow three step commands or have other neurologic 
diagnoses limiting their ability to perform the task are excluded, limiting generalizability to 
individuals with more cognitive involvement.   
• 
Targets are located anterolateral to patients on the affected side during the external focus 
intervention so participants with visual field cuts will have to turn their heads or have 
limited ability to see the targets.  
Clinical significance of the study  
Results of this study will increase understanding of what type of instructions and feedback 
should be used with individuals post stroke, specifically what type of focus of attention, internal or 
external is more effective. This study will help explicitly look at the effect of focus of attention on 
the increased use of the affected lower extremity during sit to stand training. Upon successful 
completion of this project the best type of focus of attention, internal or external, for training 
someone to use their affected lower extremity more during sit to stand training may be determined. 

 
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Methods 
Impairments following stroke often lead to functional limitations such as difficulty 
performing a sit to stand transition.  Patients following stroke often perform sit to stand transfers 
less effectively than individuals without stroke, due in part to asymmetry between both lower 
extremities, with reduced use of the affected lower extremity. Training people to use the affected 
side more may increase efficiency of their movement and decrease fall risk.  The type of instruction 
and feedback, using an internal or external focus of attention, may impact how much individuals 
post stroke use their affected lower extremity during sit to stand transitions. Individuals post 
stroke have a variety of changes, including loss of automatic processes, so they may respond 
differently than healthy adults to focus of attention instruction and feedback. Therefore, the first 
purpose of this study is to determine which type of focus of attention, internal or external, 
instruction and feedback will lead to an improved sit to stand performance indexed by increased 
use of the affected lower extremity and a more vertical trunk alignment during sit to stand training. 
The second  purpose is to determine whether the effects of attentional focus on sit to stand 
performance will be maintained once cuing is removed. The third purpose of this study is to explore 
whether or not the instruction to increase the use of the affected lower extremity during sit to stand 
training transfer to impact gait symmetry. This chapter describes the study design, participants, 
instrumentation, study procedures, and statistical analysis used to explore these goals. 
Research Design 
This study will be a randomized cross over study. Individuals will be randomized into either 
an internal or external focus condition for the first week of the study and be crossed over to the 
other condition in the second week. Participants will be provided instruction and feedback 
consistent with one type of focus of attention while they perform a training session. The training 
session will consist of four sets of sit to stand trials with progressive difficulty by lowering seat 
heights. One week later, participants will return and perform the same training activities using the 

 
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opposite focus of attention. Each training session will be the same length to ensure participants 
receive the same training experience across conditions. This study will received IRB approval 
through Western Carolina University, Texas Woman’s University and HCA Healthcare. 
Setting 
Data collection will take place in three settings with similar environments for testing, two 
instructional sites at Western Carolina University and a local inpatient rehabilitation hospital. Data 
collection conducted in the Western Carolina University instructional sites will be in quiet 
instructional rooms with high-low mat tables. Data collection conducted in the local inpatient 
rehabilitation hospital will be in a treatment room with a high-low mat table, and initial screening 
will be conducted in the therapy gym. All equipment is portable to allow for the same equipment to 
be used for data collection in the multiple sites including the hospital setting. 
Participants 
This study will include 16 participants post stroke <6 months, at least 18 years of age, of 
any gender, race, or ethnic group. Participants will be excluded from this study if they are unable to 
stand unassisted from a standard height, 20” chair, with or without upper extremity assistance. 
Individuals who are unable to ambulate 20 feet without physical assistance or have moderate to 
severely impaired cognition with a score of <10/30 on the Montreal Cognitive Assessment (MOCA) 
will also be excluded. In addition, individuals who have contraversive pushing with >1 according to 
the Scale for Contraversive Pushing Scale or neglect as evidenced by <44/54 on the Star 
Cancellation Test will be excluded. Lastly, individuals with any orthopedic or other neurologic 
conditions that impact their ability to transition from sit to stand will be excluded from the study.  
Participants will be recruited via word of mouth and advertisements in areas of 
inpatient/outpatient clinics, and local health centers as well as social media. Participants will also 
be recruited from a local inpatient rehabilitation hospital. Clinicians at this facility will assist in 
identifying potential candidates. 

 
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Power analysis 
A power analysis (G*Power) based on pilot data indicated at least 12 participants would be 
sufficient to detect a moderate effect size (f = 0.37) to compare training effects, using a mixed model 
repeated measures analysis of variance (ANOVA), within factors (alpha level of 0.05, beta of 0.80, 2 
conditions, 4 measurements, r = 0.50), with a nonsphericity correction  of 1. A second power 
analysis (G*Power) based on pilot data to determine number of participants needed to discover if 
changes were maintained at one hour post training showed 10 participants needed to detect a 
moderate effect size (f = 0.49), using a mixed model repeated measures analysis of variance 
(ANOVA), within factors (alpha level of 0.05, beta of 0.80, 2 conditions, 3 measurements, r = 0.50), 
with a nonsphericity correction  of 1. With an estimated attrition rate of 25 percent based on 
previous data collection in this inpatient rehabilitation setting, 16 participants will be recruited to 
participate in this study. 
Instrumentation 
 
Four instruments will be used in this study. An inertial measurement unit (IMU) sensor and 
a HR pressure mat will be used to quantify sit-to-stand performance. A GAITRite system will be 
used to determine if sit to stand training transferred to the increased use of the affected lower 
extremity during gait. A survey will be administered at the end of the study to examine participant’s 
compliance with the focus of attention instructions. 
IMU sensors  
A 27 X 37 X 13 mm Delsys Trigno Avanti inertial measurement unit (IMU) will be used to 
collect position data in relation to the x, y, and z axis in the sagittal, frontal, and horizontal planes, 
respectively. These sensors have nine built-in inertial measurement units that collect acceleration, 
rotation, and earth magnetic field (compass) information. The sensor is able to estimate orientation 
in space using the data from the 9 IMU channels (Delsys, 2021). One IMU will be placed on the 
superior aspect of the sternum directly below the sternal notch to capture vertical trunk alignment 

 
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throughout sit to stand and stand to sit. This unit will collect orientation data at a sampling rate of 
222 Hz. The IMU data in the frontal plane around the y-axis will be used to determine how far the 
participant is leaning side to side with their trunk during the sit to stand transition. Numbers will 
be converted so positive values will indicate the individual is leaning or side bending towards the 
affected side. Normal movement during sit to stand is a neutral trunk position in the frontal plane 
so lower values indicating a vertical trunk position will be the targeted outcome.  
HR Pressure mat  
Force symmetry under the feet will be measured using a 61.26 X 58.72 cm pedobarograph 
with a 48.8 X 44.7 cm active sensing area during the sit to stand transition. The mat has 3.9 
sensels/cm2 with a 185 Hz sampling rate (Matscan, 2021). The mat will be calibrated prior to the 
start of each participant session and will be placed under both feet during the sit to stand task. The 
force data measured from the affected foot will be divided by the sum of the force data measured 
from below bilateral feet (force affected/(force affected + force unaffected)).  This computation will 
determine the percent of force through the affected lower extremity during the task. The average 
proportion of force will be taken throughout the three repetitions of sit to stand during baseline, 5 
minutes post training, and 1 hour post training, as well as in the four sets of ten repetitions during 
training. This instrument has been used in previous similar studies, one of which looked at 
symmetry during sit to stand in individuals post acute stroke (Britton et al., 2008; Rogers et al., 
2020; Sun et al., 2015; Sun & Shea, 2016). This study found the instrument to be reliable and 
successful in determining significant differences in affected lower extremity use.  
GAITRite  
A 20’X 4’ GAITRite will be used to analyze spatial temporal aspects of gait. The GAITRite mat is an 
electronic walkway which uses pressure activated sensors to map out foot placement during gait 
using a quadrilateral blocking system. The walkway is made up of sensor pads, each of which has 
2,304 sensors arranged in 48X48 grids. The mat has a spatial resolution of 1.27 cm and a spatial 

 
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resolution accuracy of + 1.27 cm. The mat will be set at 120 Hz sampling rate (CIR Sytems, 2013). 
GAITRite software will be used to collect the typical gait parameters. Of interest in this study,  the 
stance phase of the gait cycle (in  percent) in both affected and unaffected lower extremities will be 
used.  Participants will use their usual assistive device during gait trials to best capture typical 
performance and any effect the training has on symmetry during gait.   
Post Training Survey 
A manipulation check survey will be given to each participant 5 minutes after all 
biomechanical data is collected in order to ascertain what participants were actually focused on 
during the sit to stand training. This survey was revised based on a previous study (Bell & Hardy, 
2009) and has been successfully implemented during the pilot study. Participants will be instructed 
to answer questions based on what they are thinking about during training. Questions on this 
survey will include four questions, “To what extent were you thinking about a target that is outside 
of your body?”, “To what extent were you thinking about how you move your body (e.g. shoulders, 
hips, trunk)?”, “To what extent were you thinking about something else?”, and “if you were thinking 
about something else, what was it?”. They will respond to the first three questions on a Likert scale 
from 1, not at all, to 5, very much so. The last question is an open ended question to gather 
descriptive information. This data will be used to determine if participants adhered to the specific 
focus of attention instructions during training.  
Star Cancellation Test 
 
The Star Cancellation Test will be used solely as a screening tool for this study. Individuals 
who score <44/54 will be excluded and considered to have neglect. The Star Cancellation Test 
(SCT) has excellent test retest reliability, ICC (1,1) = .89, 95 percent CI .83–.93 (p=.001) (Bailey et 
al., 2004), and good validity (74-76.4 percent) for identifying visuospatial neglect (Bailey et al., 
2000; Halligan et al., 1990; Marsh & Kersel, 1993). 
Fugl Meyer Motor Scale 

 
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The Fugl Meyer Lower Extremity scale will be used to describe the patient population. This 
measure has excellent intra (ICC, 0.99; 95 percent CI, 0.91–1.0) and interrater reliability (ICC, 0.91; 
95 percent CI, 0.69–0.97) (Sullivan et al., 2011).  The Fugl Meyer is also a valid and responsive 
measure (Mao et al., 2002). It has good concurrent, convergent, and predictive validity (p=0.86-
0.88) when comparing it to the Berg Balance Scale, and the Postural Assessment Scale for Stroke. IN 
addition, it has good construct validity when compared to the Action Research Arm Test and The 
Wolf Motor Function Test (p=0.42-0.76) (Hsieh et al., 2009). 
Montreal Cognitive Assessment 
 
The Montreal Cognitive Assessment (MOCA) will be used as a screening tool and assist in 
describing the population being studied. Individuals who score <10/30 will be considered too 
cognitively impaired to follow the training instructions and will be excluded from the study. The 
MOCA has moderate to excellent interrater reliability in individuals post stroke, varying by item 
(Cumming et al., 2020). It also has excellent internal consistency (Chronbach’s alpha = 0.78) (Toglia 
et al., 2011) and excellent criterion validity with the Mini Mental State Exam (MMSE) (r= 0.79) and 
Cognitive Functional Independence Measure (FIM) (r = 0.67) (Toglia et al., 2011). 
Procedures 
Participant demographics and clinical information will be collected, including age, gender, 
weight, height, location of stroke, how long ago the stroke occurred, and fall history. All participants 
will consent to participation in this study. The Star Cancellation Test and Montreal Cognitive 
Assessment (MOCA) will be used to determine eligibility. Gait speed and the Fugl Meyer Motor 
Scale for the lower extremity, excluding reflexes, will also be completed to help describe the sample. 
Blood pressure, heart rate, and oxygen saturation, via a pulse oximeter, will be taken and a gait belt 
will be placed on the participant prior to the start of baseline measures. Temporospatial gait 
parameters will be collected using the GAITRite mat at baseline, 5 minutes after training, and 1 
hour after training. Temporospatial gait parameters will be averaged across four passes over the 

 
17 
GAITRite mat at each measurement session. Participants will be instructed to ‘walk past the end of 
the mat at your normal comfortable pace’. Gait speed will be recorded at baseline as part of the 
individuals’ baseline measurements.  
Participants will then be seated on a hi-lo table with their feet on the HR pressure mat for 
baseline assessment of sit to stand. Initial mat height will be determined by raising or lowering the 
mat table until the femur is parallel to the floor. In order to determine this, a level will be lined up 
from the greater trochanter to the lateral femoral condyle, while the fibula, from fibular head to 
lateral malleolus, is perpendicular to the floor. This initial mat position will be the height used 
during each reassessment at baseline, 5 minutes after training, and 1 hour post training. This height 
will also be used to decide the mat positions needed during training. After the initial mat height is 
achieved and recorded, an IMU marker will be placed on the superior third of the sternum directly 
inferior to the sternal notch.  
After the mat table height is set, participants will be asked to stand up and sit down to 
determine comfortable foot placement in relation to their knees. The toe of the affected lower 
extremity will be lined up with the toe of the unaffected side once they have achieved a comfortable 
foot placement. Tape marks will be placed in front of the toes and on the lateral edges of both feet 
as well as around the buttocks to allow for a standardized starting position for all assessment 
timepoints. For all data collection during baseline, 5 minutes post, and 1 hour post training, 
participants will be instructed to “please stand up three times at your normal speed without your 
arms if possible”. The average force under the affected foot and the average overall force beneath 
both feet during the sit to stand transition will be captured by the HR pressure mat. The maximal 
lateral trunk position will be captured throughout this transition by the IMU marker. If individuals 
need to use their upper extremities this should be recorded.  
After baseline data collection, participants will be randomized into either the internal or 
external focus condition. Initial group allocation will be determined by a random number generator 

 
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(https://www.random.org), blocks of 6 with a 1:1 ratio. Group assignment will be sealed in 
envelopes numbered for each participant by an independent researcher, who will otherwise not be 
involved in this research study. Group allocation envelops will be opened directly prior to 
acquisition trials so baseline assessors will be blinded to group assignment of participants. 
Participants will be blinded to initial group assignment throughout the entirety of the sessions.  
Training 
Prior to training, a demonstration of the task will be provided to the participants. Those in 
the external focus condition will be told, “as you stand up and as you sit down try to bring the 
targets together like this”. Those in the internal focus condition will be told, “as you stand up and as 
you sit down bring your right/left (R/L) shoulder and R/L hip as far to the R/L as possible.” 
Participants will be asked to perform one repetition with the question “can you show me?”. The 
demonstration is only provided before the first set but these same instructions will be given prior 
to the start of each successive set during training.   
During training trials, individuals will perform four sets of ten sit to stand repetitions. 
During the external focus condition, foam circles will be taped to the participant’s lateral shoulder 
and lateral hip. In order to define this distance, participant girth will be measured in a seated 
position, by measuring the distance between bilateral outer thighs, using greater trochanters as 
landmarks. When the individual is standing in midline targets will be placed half of this girth 
measurement plus 10 centimeters away from the lateral tip of their acromion and another target 
placed the same distance away from their greater trochanter.  
During training, participants will perform four sets of sit to stand transitions with the mat at 
progressively lower seat heights to increasingly challenge the participants, with instruction and 
feedback consistent with their condition allocation. The four sets will occur in the following 
sequences: 130 percent of the initial mat height determined at baseline assessment (see Table 1), 
120 percent, 110 percent and 100 percent. Each set will end after the tenth repetition or when the 

 
19 
participant reports a RPE rating of >15/20. If participants are unable to complete 10 repetitions, 
the number completed will be recorded for each trial. Two minute rest breaks will occur between 
each set or until the participant reports a rate of perceived exertion (RPE) of <12/20 on the Borg 
RPE scale. During training, one verbal correction will be given during each set after the 2nd, 4th, and 
7th trials, based on patient performance and condition allocation. See table 2. The feedback 
provided will be recorded.  
Immediately after the training, participants will take a 5 minute break followed by the post-
5 minute retention test in which instrumented sit to stand and gait will be administered. Following 
the retention test, individuals will complete a general health questionnaire. Approximately one 
hour after the training ends, 1-hour retention testing will be administered consisting of 3 
instrumented sit to stands and gait over the GAITRite. After the immediate long term data 
collection, the participants will complete the post manipulation questionnaire to determine what 
the participants were focusing on during training. 
One week later participants will return and complete the same protocol in the opposite 
attentional condition to which they were initially randomized. Each session should last 90 to 120 
minutes.  
Data Analysis 
Data will be analyzed using IBM SPSS version 28. Descriptive statistics for all demographic 
and clinical data will include means, standard deviations, and ranges for parameters of interest 
including age, height, weight, and time since stroke. Counts will be utilized for nominal data such as 
gender and side of stroke. Assumptions will be tested including the Kolmogorov-Smirnov test for 
Normality and Mauchley’s test for sphericity. Main effects for group, internal or external focus, and 
for time points, dependent on what hypothesis, will be tested. Interaction effects will also be 
explored, and post hoc analysis for simple effects will utilize the Bonferroni correction to look at 

 
20 
pairwise comparison, when indicated. For all tests, statistical significance will be set at p=.05 and 
partial 2 and Cohen’s D will be used to determine effect size as appropriate.  
 
The average force through the affected lower extremity divided by the average force 
beneath bilateral lower extremities will be calculated for all instrumented sit to stands including 
baseline, training, and post-training assessments. Participants maximal lateral trunk position will 
be analyzed using the IMU data that captures lateral bending around the y-axis.  
 
For Research Question 1, two repeated measures analysis of variance (ANOVA) will be 
conducted.  A 2 (focus of attention) X 4 (sets) repeated measures ANOVA will be utilized to explore 
if there were any differences between the use of the affected lower extremity with internal and 
external focus of attention during the four training sets. Main effects of sets and type of focus of 
attention will be examined. Simple effects will be analyzed using a Bonferroni correction, based on 
main or interaction effects. A second 2 (focus of attention) X 4 (sets) repeated measures ANOVA 
will also be used to determine if any significant main or interaction effects for group and sets for 
vertical trunk alignment existed. Simple effects will be analyzed based on main or interaction 
effects using a Bonferroni correction.  
 
For Research Question 2, two additional repeated measures ANOVAs will be conducted. A 2 
(focus of attention) X 3 (baseline, 5 minutes post, and 1 hour post) repeated measures ANOVA will 
determine if there were significant differences from baseline to 5 minutes post and 1 hour post 
training, in the amount of affected lower extremity use during sit to stand depending on type of 
focus used. Interaction and main effects for type of focus of attention and changes over time will be 
explored as well as simple effects, when indicated, using a Bonferroni correction. A 2 (focus of 
attention) X 3 (baseline, 5 minutes post, and 1 hour post) repeated measures ANOVA will also be 
used to look at vertical trunk alignment changes during baseline, 5 minutes post, and 1 hour post 
training, based on type of focus of attention used. Interaction and main effects will be explored 
further based on the results of the repeated measures ANOVA.  

 
21 
For Research Question 3, two more repeated measures ANOVAs will be utilized. A 2 (focus 
of attention) X 3 (baseline, 5 minutes post, and 1 hour post) repeated measures ANOVA will explore 
whether gait symmetry is affected by the focus of attention condition during sit to stand training. 
Use of the paretic lower extremity during stance phase of gait will be determined by paretic stance 
(percent of gait cycle)/nonparetic stance (percent of gait cycle) (Patterson et al., 2008). Again, 
interaction and main effects for type of focus of attention and changes over time will be explored as 
well as simple effects, when indicated, using a Bonferroni correction. 
 
 

 
22 
References 
Abdullahi, A., Truijen, S., Umar, N. A., Useh, U., Egwuonwu, V. A., Van Criekinge, T., & Saeys, W. 
(2021). Effects of Lower Limb Constraint Induced Movement Therapy in People With Stroke: A 
Systematic Review and Meta-Analysis. Frontiers in Neurology, 12(March). 
https://doi.org/10.3389/fneur.2021.638904 
Alexander, N. B., Galecki, A. T., Nyquist, L. V., Hofmeyer, M. R., Grunawalt, J. C., Grenier, M. L., & 
Medell, J. L. (2000). Chair and bed rise performance in ADL-impaired congregate housing 
residents. Journal of the American Geriatrics Society, 48(5), 526–533. 
https://doi.org/10.1111/j.1532-5415.2000.tb04999.x 
Aloraini, S. M., Glazebrook, C. M., Pooyania, S., Sibley, K. M., Singer, J., & Passmore, S. (2020). An 
external focus of attention compared to an internal focus of attention improves anticipatory 
postural adjustments among people post-stroke. Gait and Posture, 82(2020), 100–105. 
https://doi.org/10.1016/j.gaitpost.2020.08.133 
Andersson, P., & Franzén, E. (2015). Effects of weight-shift training on walking ability, ambulation, 
and weight distribution in individuals with chronic stroke: A pilot study. Topics in Stroke 
Rehabilitation, 22(6), 437–443. https://doi.org/10.1179/1074935715Z.00000000052 
Awad, L. N., Palmer, J. A., Pohlig, R. T., Binder-Macleod, S. A., & Reisman, D. S. (2015). Walking speed 
and step length asymmetry modify the energy cost of walking after stroke. Neurorehabilitation 
and Neural Repair, 29(5), 416–423. https://doi.org/10.1177/1545968314552528 
Bailey, M. J., Riddoch, M., & Crome, P. (2000). Evaluation of a test battery for hemineglect in elderly 
stroke patients for use by therapists in clinical practice. NeuroRehabilitation, 14(3), 139–150. 
Bailey, M. J., Riddoch, M. J., & Crome, P. (2004). Test-retest stability of three tests for unilateral 
visual neglect in patients with stroke: Star Cancellation, Line Bisection, and the Baking Tray 
Task. Neuropsychological Rehabilitation, 14(4), 403–419. 
https://doi.org/10.1080/09602010343000282 

 
23 
Becker, K., & Smith, P. J. K. (2013). Age, task complexity, and sex as potential moderators of 
attentional focus effects. Perceptual and Motor Skills, 117(1), 130–144. 
https://doi.org/10.2466/23.25.PMS.117x14z3 
Bell, J. J., & Hardy, J. (2009). Effects of attentional focus on skilled performance in Golf. Journal of 
Applied Sport Psychology, 21(2), 163–177. https://doi.org/10.1080/10413200902795323 
Beyea, J., McGibbon, C. A., Sexton, A., Noble, J., & O’Connell, C. (2017). Convergent validity of a 
wearable sensor system for measuring sub-task performance during the timed up-and-go test. 
Sensors (Switzerland), 17(4), 1–18. https://doi.org/10.3390/s17040934 
Billinger, S., Guo, L. X., Pohl, P. S., & Kluding, P. M. (2010). Single limb exercise: Pilot study of 
physiological and functional responses to forced use of the hemiparetic lower extremity. 
Topics in Stroke Rehabilitation, 17(2), 128–139. https://doi.org/10.1310/tsr1702-128 
Borg, J., Mizzi, S., & Formosa, C. (2018). Peak pressure data and pressure-time integral in the 
contralateral limb in patients with diabetes and a trans-tibial prosthesis. Gait and Posture, 
64(2018), 55–58. https://doi.org/10.1016/j.gaitpost.2018.05.023 
Britton, E., Harris, N., & Turton, A. (2008). An exploratory randomized controlled trial of assisted 
practice for improving sit-to-stand in stroke patients in the hospital setting. Clinical 
Rehabilitation, 22(5), 458–468. https://doi.org/10.1177/0269215507084644 
Buckley, C., Micó-Amigo, M. E., Dunne-Willows, M., Godfrey, A., Hickey, A., Lord, S., Rochester, L., Din, 
S. Del, & Moore, S. A. (2020). Gait asymmetry post-stroke: Determining valid and reliable 
methods using a single accelerometer located on the trunk. Sensors (Switzerland), 20(1), 1–17. 
https://doi.org/10.3390/s20010037 
Cheng, P., Liaw, M., Wong, M., & Tang, F. (1998). The Sit-to-Stand Movement in Stroke Patients. 
Archives of Physical Medicine and Rehabilitation, 79, 1043–1046. 
Cheng, P. T., Liaw, M. Y., Wong, M. K., Tang, F. T., Lee, M. Y., & Lin, P. S. (1998). The sit-to-stand 
movement in stroke patients and its correlation with falling. Archives of Physical Medicine and 

 
24 
Rehabilitation, 79(9), 1043–1046. https://doi.org/10.1016/S0003-9993(98)90168-X 
Cheng, P. T., Wu, S. H., Liaw, M. Y., Wong, A. M. K., & Tang, F. T. (2001). Symmetrical body-weight 
distribution training in stroke patients and its effect on fall prevention. Archives of Physical 
Medicine and Rehabilitation, 82(12), 1650–1654. https://doi.org/10.1053/apmr.2001.26256 
Cho, K. H., Lee, H. J., & Lee, W. H. (2015). Test-retest reliability of the GAITRite walkway system for 
the spatio-temporal gait parameters while dual-tasking in post-stroke patients. Disability and 
Rehabilitation, 37(6), 512–516. https://doi.org/10.3109/09638288.2014.932445 
Chou, S. W., Wong, A. M. K., Leong, C. P., Hong, W. S., Tang, F. T., & Lin, T. H. (2003). Postural control 
during sit-to stand and gait in stroke patients. American Journal of Physical Medicine and 
Rehabilitation, 82(1), 42–47. https://doi.org/10.1097/00002060-200301000-00007 
CIR Sytems. (2013). GAITRite Electronic Walkway Technical Reference. Technical Reference (WI-02-
15), 1–50. 
Civelek, G. M., Atalay, A., & Turhan, N. (2015). Association of ideomotor apraxia with lesion site, 
etiology, neglect, and functional independence in patients with first ever stroke. Topics in 
Stroke Rehabilitation, 22(2), 94–101. https://doi.org/10.1179/1074935714Z.0000000027 
Connell, L. A., Lincoln, N. B., & Radford, K. A. (2008). Somatosensory impairment after stroke: 
Frequency of different deficits and their recovery. Clinical Rehabilitation, 22(8), 758–767. 
https://doi.org/10.1177/0269215508090674 
Cumming, T. B., Lowe, D., Linden, T., & Bernhardt, J. (2020). The AVERT MoCA Data: Scoring 
Reliability in a Large Multicenter Trial. Assessment, 27(5), 976–981. 
https://doi.org/10.1177/1073191118771516 
Dall, P. M., & Kerr, A. (2010). Frequency of the sit to stand task: An observational study of free-living 
adults. Applied Ergonomics, 41(1), 58–61. https://doi.org/10.1016/j.apergo.2009.04.005 
de Sousa, D. G., Harvey, L. A., Dorsch, S., Varettas, B., Jamieson, S., Murphy, A., & Giaccari, S. (2019). 
Two weeks of intensive sit-to-stand training in addition to usual care improves sit-to-stand 

 
25 
ability in people who are unable to stand up independently after stroke: a randomised trial. 
Journal of Physiotherapy, 65(3), 152–158. https://doi.org/10.1016/j.jphys.2019.05.007 
Delsys. (2021). Trigno Wireless Biofeedback System User’s Guide. 
Dhamoon, M. S., Moon, Y. P., Paik, M. C., Boden-Albala, B., Rundek, T., Sacco, R. L., & Elkind, M. S. V. 
(2010). Quality of life declines after first ischemic stroke: The Northern Manhattan Study. 
Neurology, 75(4), 328–334. https://doi.org/10.1212/WNL.0b013e3181ea9f03 
Dhamoon, Mandip S., Moon, Y. P., Paik, M. C., Sacco, R. L., & Elkind, M. S. V. (2012). Trajectory of 
functional decline before and after ischemic stroke: The northern manhattan study. Stroke, 
43(8), 2180–2184. https://doi.org/10.1161/STROKEAHA.112.658922 
Donkervoort, M., Dekker, J., Van Den Ende, E., Stehmann-Saris, J. C., & Deelman, B. G. (2000). 
Prevalence of apraxia among patients with a first left hemisphere stroke in rehabilitation 
centres and nursing homes. Clinical Rehabilitation, 14(2), 130–136. 
https://doi.org/10.1191/026921500668935800 
Duclos, C., Nadeau, S., & Lecours, J. (2008). Lateral trunk displacement and stability during sit-to-
stand transfer in relation to foot placement in patients with hemiparesis. Neurorehabilitation 
and Neural Repair, 22(6), 715–722. https://doi.org/10.1177/1545968308316000 
Durham, K. F., Sackley, C. M., Wright, C. C., Wing, A. M., Edwards, M. G., & Van Vliet, P. (2014). 
Attentional focus of feedback for improving performance of reach-to-grasp after stroke: A 
randomised crossover study. Physiotherapy (United Kingdom), 100(2), 108–115. 
https://doi.org/10.1016/j.physio.2013.03.004 
Durham, K., Vliet, P. M. Van, Badger, F., & Sackley, C. (2009). Use of information feedback and 
attentional focus of feedback in treating the person with a hemiplegic arm. Physiotherapy 
Research International, 14(2), 77–90. https://doi.org/10.1002/pri.431 
Engardt, M. (1994). Rising and sitting down in stroke patients. Auditory feedback and dynamic 
strength training to enhance symmetrical body weight distribution. Scandinavian Journal of 

 
26 
Rehabilitation Medicine, 31, 1–57. 
Engardt, M., & Olsson, E. (1992). Body weight-bearing while rising and sitting down in patients with 
stroke. Scandinavian Journal of Rehabilitation Medicine, 24(2), 67–74. 
Fasoli, S. E., Trombly, C. A., Tickle-Degnen, L., & Verfaellie, M. H. (2002). Effect of Instructions on 
Functional Reach in Persons With and Without Cerebrovascular Accident. American Journal of 
Occupational Therapy, 56(4), 380–390. 
Felius, R. A. W., Geerars, M., Bruijn, S. M., van Dieën, J. H., Wouda, N. C., & Punt, M. (2022). Reliability 
of IMU-Based Gait Assessment in Clinical Stroke Rehabilitation. Sensors, 22(3), 62–68. 
https://doi.org/10.3390/s22030908 
Ghahramani, M., Stirling, D., & Naghdy, F. (2020). The sit to stand to sit postural transition 
variability in the five time sit to stand test in older people with different fall histories. Gait and 
Posture, 81(September 2019), 191–196. https://doi.org/10.1016/j.gaitpost.2020.07.073 
Gillain, S., Boutaayamou, M., Schwartz, C., Brüls, O., Bruyère, O., Croisier, J. L., Salmon, E., Reginster, J. 
Y., Garraux, G., & Petermans, J. (2019). Using supervised learning machine algorithm to 
identify future fallers based on gait patterns: A two-year longitudinal study. Experimental 
Gerontology, 127(May). https://doi.org/10.1016/j.exger.2019.110730 
Girotra, T., Lekoubou, A., Bishu, K. G., & Ovbiagele, B. (2020). A contemporary and comprehensive 
analysis of the costs of stroke in the United States. Journal of the Neurological Sciences, 
410(June 2019), 116643. https://doi.org/10.1016/j.jns.2019.116643 
Gittins, M., Lugo-Palacios, D., Vail, A., Bowen, A., Paley, L., Bray, B., & Tyson, S. (2021). Stroke 
impairment categories: A new way to classify the effects of stroke based on stroke-related 
impairments. Clinical Rehabilitation, 35(3), 446–458. 
https://doi.org/10.1177/0269215520966473 
Granger, CV, Markello SJ, Graham JE, Deutsch A, O. K. (2009). The Uniform Data System for Medical 
Rehabilitation. American Journal of Physical Medicine & Rehabilitation, 88(12), 961–972. 

 
27 
Guralnik, J. M., Ferrucci, L., Simonsick, E. M., Salive, M. E., & Wallace, R. B. (1995). Lower-Extremity 
Function in Persons over the Age of 70 Years as a Predictor of Subsequent Disability. New 
England Journal of Medicine, 332(9), 556–562. 
https://doi.org/10.1056/nejm199503023320902 
Halligan, P., Wilson, B., & Cockburn, J. (1990). A short screening test for visual neglect in stroke 
patients. International Disability Studies, 12(3), 95–99. 
https://doi.org/https://doi.org/10.3109/03790799009166260 
Hammer, A. M., & Lindmark, B. (2009). Effects of forced use on arm function in the subacute phase 
after stroke: A randomized, clinical pilot study. Physical Therapy, 89(6), 526–539. 
https://doi.org/10.2522/ptj.20080017 
Han, J., Kim, Y., & Kim, K. (2015). Effects of foot position of the nonparetic side during sit-to-stand 
training on postural balance in patients with stroke. Journal of Physical Therapy Science, 27(8), 
2625–2627. https://doi.org/10.1589/jpts.27.2625 
Hanawa, H., Hirata, K., Miyazawa, T., Kubota, K., Yokoyama, M., Matsumoto, Y., Fujino, T., & 
Kanemura, N. (2021). Classification of abnormal muscle synergies during sit-to-stand motion 
in individuals with acute stroke. Measurement: Sensors, 16. 
https://doi.org/10.1016/j.measen.2021.100055 
Hirschfeld, H., Thorsteinsdottir, M., & Olsson, E. (1999). Coordinated ground forces exerted by 
buttocks and feet are adequately programmed for weight transfer during sit-to-stand. Journal 
of Neurophysiology, 82(6), 3021–3029. https://doi.org/10.1152/jn.1999.82.6.3021 
Hodt-Billington, C., Helbostad, J. L., & Moe-Nilssen, R. (2008). Should trunk movement or footfall 
parameters quantify gait asymmetry in chronic stroke patients? Gait and Posture, 27(4), 552–
558. https://doi.org/10.1016/j.gaitpost.2007.07.015 
Hsieh, Y. W., Wu, C. Y., Lin, K. C., Chang, Y. F., Chen, C. L., & Liu, J. Sen. (2009). Responsiveness and 
validity of three outcome measures of motor function after stroke rehabilitation. Stroke, 40(4), 

 
28 
1386–1391. https://doi.org/10.1161/STROKEAHA.108.530584 
Hsu, C. J., Kim, J., Roth, E. J., Rymer, W. Z., & Wu, M. (2017). Forced use of the paretic leg induced by a 
constraint force applied to the nonparetic leg in individuals poststroke during walking. 
Neurorehabilitation and Neural Repair, 31(12), 1042–1052. 
https://doi.org/10.1177/1545968317740972 
Hsu, W., Sugiarto, T., Liao, Y., Lin, Y., Yang, F., Hueng, D., Sun, C., & Chou, K. (2021). Can trunk 
acceleration differentiate stroke patient gait patterns using time- and frequency-domain 
features? Applied Sciences, 11(1541), 1–14. 
Hyatt, A., Greene, L., Lopez, J., Parker, A. M., Suwak, M., & Waugh, E. (2020). Shift your learning: Does 
focus of attention strategies impact motor learning in adults post-acute stroke? American 
Physical Therapy Association Combined Sections Meeting (Neurology: Stroke SIG Section). 
Hyatt, A., McPherson, S., Franco, V., Bowen, H., Foil, R., Kao, E., & Linton, T. (2018). Impact of 
external vs internal focus of attention strategies on seated lateral excursion measures in adults 
with chronic stroke and healthy adults. American Physical Therapy Association Combined 
Sections Meeting (Neurology: Stroke SIG Section). 
Hyatt, A., McPherson, S., Wilson, E., Pollard, H., Correll, W., Kirkland, E., Puchel, H., & Tresslar, N. 
(2019). Impact of focus of attention strategies on performance and learning of seated trunk 
control in the acute stroke population. American Physical Therapy Association Combined 
Sections Meeting (Neurology: Stroke SIG Section). 
Janssen, W. G. M., Bussmann, H. B. J., & Stam, H. J. (2002). Determinants of the sit-to-stand 
movement: A review. Physical Therapy, 82(9), 866–879. https://doi.org/10.1093/ptj/82.9.866 
Johnson, L., Burridge, J. H., & Demain, S. H. (2013). Internal and external focus of attention during 
gait re-education: An observational study of physical therapist practice in stroke 
rehabilitation. Physical Therapy, 93(7), 957–966. https://doi.org/10.2522/ptj.20120300 
Jørgensen, L., Engstad, T., & Jacobsen, B. K. (2002). Higher incidence of falls in long-term stroke 

 
29 
survivors than in population controls: Depressive symptoms predict falls after stroke. Stroke, 
33(2), 542–547. https://doi.org/10.1161/hs0202.102375 
Kakebeeke, T., Knols, R., & de Bruin, E. (2013). Should rehabilitation specialists use external focus 
instructions when motor learning is fostered? A systematic review. Sports, 1(2), 37–54. 
https://doi.org/10.3390/sports1020037 
Kal, E. C., Van Der Kamp, J., & Houdijk, H. (2013). External attentional focus enhances movement 
automatization: A comprehensive test of the constrained action hypothesis. Human Movement 
Science, 32(4), 527–539. https://doi.org/10.1016/j.humov.2013.04.001 
Kal, E. C., Van Der Kamp, J., Houdijk, H., Groet, E., Van Bennekom, C. A. M., & Scherder, E. J. A. (2015). 
Stay focused! The effects of internal and external focus of attention on movement automaticity 
in patients with stroke. PLoS ONE, 10(8), 1–18. 
https://doi.org/10.1371/journal.pone.0136917 
Kal, E., Winters, M., Van Kamp, J. Der, Houdijk, H., Groet, E., Bennekom, C., & Scherder, E. (2016). Is 
implicit motor learning preserved after stroke? A systematic review with meta-analysis. PLoS 
ONE, 11(12), 1–24. https://doi.org/10.1371/journal.pone.0166376 
Kal, Elmar, Houdijk, H., van der Kamp, J., Verhoef, M., Prosée, R., Groet, E., Winters, M., van 
Bennekom, C., & Scherder, E. (2019). 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. Clinical Rehabilitation, 33(2), 207–221. 
https://doi.org/10.1177/0269215518795243 
Kal, Elmar, Prosée, R., Winters, M., & Van Der Kamp, J. (2018). Does implicit motor learning lead to 
greater automatization of motor skills compared to explicit motor learning? A systematic 
review. PLoS ONE, 13(9), 1–26. https://doi.org/10.1371/journal.pone.0203591 
Katzan, I. L. (2013). Epidemiology of stroke. Handbook of Clinical Nutrition and Stroke, 3–14. 
https://doi.org/10.1007/978-1-62703-380-0_1 

 
30 
Kerr, A., Clark, A., & Pomeroy, V. M. (2019). Neuromechanical differences between successful and 
failed sit-to-stand movements and response to rehabilitation early after stroke. 
Neurorehabilitation and Neural Repair, 33(5), 395–403. 
https://doi.org/10.1177/1545968319846119 
Kerr, K., White, J., Barr, D., & Mollan, R. (1997). Analysis of the sit-stand-sit cycle in normal subjects 
movement. Clinical Biomechanics 14(4), 236–245. 
Khemlani, M. M., Carr, J. H., & Crosbie, W. J. (1999). Muscle synergies and joint linkages in sit-to-
stand under two initial foot positions. Clinical Biomechanics, 14(4), 236–246. 
https://doi.org/10.1016/S0268-0033(98)00072-2 
Kim, G. J., Hinojosa, J., Rao, A. K., Batavia, M., & O’Dell, M. W. (2017). Randomized trial on the effects 
of attentional focus on motor training of the upper extremity using robotics with individuals 
after chronic stroke. Archives of Physical Medicine and Rehabilitation, 98(10), 1924–1931. 
https://doi.org/10.1016/j.apmr.2017.06.005 
Kim, J. M., Je, H. D., & Kim, H. D. (2017). Effects of pelvic compression belts on the kinematics and 
kinetics of the lower extremities during sit-to-stand maneuvers. Journal of Physical Therapy 
Science, 29(8), 1311–1317. https://doi.org/10.1589/jpts.29.1311 
Kotake, T., Miura, T., & Kajiwara, T. (1993). An Analysis of Sit-to-Stand Movements. Archives of 
Physical Medicine and Rehabilitation, 74(October), 1095–1099. 
Kyrozis, A., Potagas, C., Ghika, A., Tsimpouris, P. K., Virvidaki, E. S., & Vemmos, K. N. (2009). 
Incidence and predictors of post-stroke aphasia: The Arcadia Stroke Registry. European 
Journal of Neurology, 16(6), 733–739. https://doi.org/10.1111/j.1468-1331.2009.02580.x 
Lawrence, G. P., Gottwald, V. M., Khan, M. A., & Kramer, R. S. S. (2012). The movement kinematics 
and learning strategies associated with adopting different foci of attention during both 
acquisition and anxious performance. Frontiers in Psychology, 3(468), 1–11. 
https://doi.org/10.3389/fpsyg.2012.00468 

 
31 
LeBrasseur, N. K., Sayers, S. P., Ouellette, M. M., & Fielding, R. A. (2006). Muscle impairments and 
behavioral factors mediate functional limitations and disability following stroke. Physical 
Therapy, 86(10), 1342–1350. https://doi.org/10.2522/ptj.20050162 
Lecours, J., Nadeau, S., Gravel, D., & Teixera-Salmela, L. (2008). Interactions between foot placement, 
trunk frontal position, weight-bearing and knee moment asymmetry at seat-off during rising 
from a chair in healthy controls and persons with hemiparesis. Journal of Rehabilitation 
Medicine, 40(3), 200–207. https://doi.org/10.2340/16501977-0155 
Lee, M. Y., Wong, M. K., Tang, F. T., Cheng, P. T., & Lin, P. S. (1997). Comparison of balance responses 
and motor patterns during sit-to-stand task with functional mobility in stroke patients. 
American Journal of Physical Medicine and Rehabilitation, 76(5), 401–410. 
https://doi.org/10.1097/00002060-199709000-00011 
Lee, T. H., Choi, J. D., & Lee, N. G. (2015). Activation timing patterns of the abdominal and leg 
muscles during the sit-to-stand movement in individuals with chronic hemiparetic stroke. 
Journal of Physical Therapy Science, 27(11), 3593–3595. https://doi.org/10.1589/jpts.27.3593 
Levine, D. A., Galecki, A. T., Langa, K. M., Unverzagt, F., Kabeto, M., Giordani, B., & Wadley, V. (2015). 
Trajectory of Cognitive Decline after Incident Stroke. JAMA, 314(1), 41–51. 
https://doi.org/10.1001/jama.2015.6968 
Lewek, M. D., Bradley, C. E., Wutzke, C. J., & Zinder, S. M. (2014). The relationship between 
spatiotemporal gait asymmetry and balance in individuals with chronic stroke. Journal of 
Applied Biomechanics, 30(1), 31–36. https://doi.org/10.1123/jab.2012-0208 
Liepert, J., Uhde, I., Gräf, S., Leidner, O., & Weiller, C. (2001). Motor cortex plasticity during forced-
use therapy in stroke patients: A preliminary study. Journal of Neurology, 248(4), 315–321. 
https://doi.org/10.1007/s004150170207 
Liu, M., Chen, J., Fan, W., Mu, J., Zhang, J., Wang, L., Zhuang, J., & Ni, C. (2016). Effects of modified sit-
to-stand training on balance control in hemiplegic stroke patients: A randomized controlled 

 
32 
trial. Clinical Rehabilitation, 30(7), 627–636. https://doi.org/10.1177/0269215515600505 
Livingston-Thomas, J. M., McGuire, E. P., Doucette, T. A., & Tasker, R. A. (2014). Voluntary forced use 
of the impaired limb following stroke facilitates functional recovery in the rat. Behavioural 
Brain Research, 261, 210–219. https://doi.org/10.1016/j.bbr.2013.12.032 
Lomaglio, M. J., & Eng, J. J. (2005). Muscle strength and weight-bearing symmetry relate to sit-to-
stand performance in individuals with stroke. Gait and Posture, 22(2), 126–131. 
https://doi.org/10.1016/j.gaitpost.2004.08.002 
Lopez, A. D., Mathers, C. D., Ezzati, M., Jamison, D. T., & Murray, C. J. (2006). Global and regional 
burden of disease and risk factors, 2001: Systematic analysis of population health data. Lancet, 
367(9524), 1747–1757. https://doi.org/10.1016/S0140-6736(06)68770-9 
Lundy-Ekman, L. (2018). Neuroscience - Fundamentals for Rehabilitation (5th ed.). Elsevier. 
Mao, H. F., Hsueh, I. P., Tang, P. F., Sheu, C. F., & Hsieh, C. L. (2002). Analysis and comparison of the 
psychometric properties of three balance measures for stroke patients. Stroke, 33(4), 1022–
1027. https://doi.org/10.1161/01.STR.0000012516.63191.C5 
Mao, Y. R., Wu, X. Q., Li Zhao, J., Lo, W. L. A., Chen, L., Ding, M. H., Xu, Z. Q., Bian, R. H., Huang, D. F., & 
Li, L. (2018). The crucial changes of sit-to-stand phases in subacute stroke survivors identified 
by movement decomposition analysis. Frontiers in Neurology, 9(185), 1–8. 
https://doi.org/10.3389/fneur.2018.00185 
Marsh, N. V., & Kersel, D. A. (1993). Screening tests for visual neglect following stroke. 
Neuropsychological Rehabilitation, 3(3), 245–257. 
https://doi.org/10.1080/09602019308401439 
Masters, R., & Maxwell, J. (2008). The theory of reinvestment. International Review of Sport and 
Exercise Psychology, 1(2), 160–183. https://doi.org/10.1080/17509840802287218 
Masters, R. S. W. (1992). Knowledge, knerves and know-how: The role of explicit versus implicit 
knowledge in the breakdown of a complex motor skill under pressure. British Journal of 

 
33 
Psychology, 83, 343–358. 
Matscan, F. (2021). Footmat TM user manual 7.1x. 
McEwen, S. E., Huijbregts, M. P. J., Ryan, J. D., & Polatajko, H. J. (2009). Cognitive strategy use to 
enhance motor skill acquisition post-stroke: A critical review. Brain Injury, 23(4), 263–277. 
https://doi.org/10.1080/02699050902788493 
McNevin, N. H., Wulf, G., & Carlson, C. (2000). Effects of attentional focus, self-control, and dyad 
training on motor learning: Implications for physical rehabilitation. Physical Therapy, 80(4), 
373–385. https://doi.org/10.1093/ptj/80.4.373 
Monger, C., Carr, J. H., & Fowler, V. (2002). Evaluation of a home-based: Exercise and training 
programme to improve sit-to-stand in patients with chronic stroke. Clinical Rehabilitation, 
16(4), 361–367. https://doi.org/10.1191/0269215502cr506oa 
Mückel, S., & Mehrholz, J. (2014). Immediate effects of two attention strategies on trunk control on 
patients after stroke. A randomized controlled pilot trial. Clinical Rehabilitation, 28(7), 632–
636. https://doi.org/10.1177/0269215513513963 
Müssgens, D. M., & Ullén, F. (2015). Transfer in motor sequence learning: Effects of practice 
schedule and sequence context. Frontiers in Human Neuroscience, 9(642), 1–13. 
https://doi.org/10.3389/fnhum.2015.00642 
Nandikolla, V. K., Bochen, R., Meza, S., & Garcia, A. (2017). Experimental gait analysis to study stress 
distribution of the human foot. Journal of Medical Engineering, 2017, 1–13. 
https://doi.org/10.1155/2017/3432074 
Nyberg, L., & Gustafson, Y. (1995). Patient falls in stroke rehabilitation: A challenge to rehabilitation 
strategies. Stroke, 26(5), 838–842. https://doi.org/10.1161/01.STR.26.5.838 
O’Sullivan, S. B., Schmitz, T. J., & Fulk, G. (2019). Physical rehabilitation. F.A. Davis Co. 
Olney, S. J., & Richards, C. (1996). Hemiparetic gait following stroke. Part I: Characteristics. Gait and 
Posture, 4(2), 136–148. https://doi.org/10.1016/0966-6362(96)01063-6 

 
34 
Orrell, A.J., Masters, R. S. W., & Eves, F. F. (2009). Following stroke. Neurorehabilitation and Neural 
Repair, 23(2), 177–183. 
Orrell, Alison J., Eves, F. F., & Masters, R. S. W. (2006). Motor learning of a dynamic balancing task 
after stroke: Implicit implications for stroke rehabilitation. Physical Therapy, 86(3), 369–380. 
https://doi.org/10.1093/ptj/86.3.369 
Patterson, K. K., Parafianowicz, I., Danells, C. J., Closson, V., Verrier, M. C., Staines, W. R., Black, S. E., & 
McIlroy, W. E. (2008). Gait asymmetry in community-ambulating stroke survivors. Archives of 
Physical Medicine and Rehabilitation, 89(2), 304–310. 
https://doi.org/10.1016/j.apmr.2007.08.142 
Poolton, J. M., Maxwell, J. P., Masters, R. S. W., & Raab, M. (2006). Benefits of an external focus of 
attention: Common coding or conscious processing? Journal of Sports Sciences, 24(1), 89–99. 
https://doi.org/10.1080/02640410500130854 
Prinz, W. (1997). Perception and action planning. European Journal of Cognitive Psychology, 9(2), 
129–154. https://doi.org/10.1080/713752551 
Ptak, R., Bourgeois, A., Cavelti, S., Doganci, N., Schnider, A., & Iannotti, G. R. (2020). Discrete patterns 
of cross-hemispheric functional connectivity underlie impairments of spatial cognition after 
stroke. Journal of Neuroscience, 40(34), 6638–6648. 
https://doi.org/10.1523/JNEUROSCI.0625-20.2020 
Qu, H. L., Zhao, M., Zhao, S. S., Xiao, T., Song, C. G., Cao, Y. P., Jolkkonen, J., & Zhao, C. S. (2015). Forced 
limb-use enhanced neurogenesis and behavioral recovery after stroke in the aged rats. 
Neuroscience, 286, 316–324. https://doi.org/10.1016/j.neuroscience.2014.11.040 
Qu, H., Zhao, M., Zhao, S., Xiao, T., Tang, X., Zhao, D., Jolkkonen, J., & Zhao, C. (2014). Forced limb-use 
enhances brain plasticity through the cAMP/PKA/CREB signal transduction pathway after 
stroke in adult rats. Restorative Neurology and Neuroscience, 32(5), 597–609. 
https://doi.org/10.3233/RNN-130374 

 
35 
Riley, P. O., Krebs, D. E., & Popat, R. A. (1997). Biomechanical analysis of failed sit-to-stand. IEEE 
Transactions on Rehabilitation Engineering, 5(4), 353–359. 
https://doi.org/10.1109/86.650289 
Rogers, A., Morrison, S. C., Gorst, T., Paton, J., Freeman, J., Marsden, J., & Cramp, M. C. (2020). 
Repeatability of plantar pressure assessment during barefoot walking in people with stroke. 
Journal of Foot and Ankle Research, 13(1), 1–7. https://doi.org/10.1186/s13047-020-00407-x 
Schenkman, M., Berger, R. A., Riley, P. O., Mann, R. W., & Hodge, W. A. (1990). Whole-body 
movements during rising to standing from sitting. Physical Therapy, 70(10), 638–651. 
https://doi.org/10.1093/ptj/70.10.638 
Schmidt, R., Lee, T., Winstein, C., Wulf, G., & Zelaznik, H. (2019). Motor Contorl and Learning (6th 
Edition). 
Seo, J. W., Kim, S. G., Kim, J. Il, Ku, B., Kim, K., Lee, S., & Kim, J. U. (2020). Principal characteristics of 
affected and unaffected side trunk movement and gait event parameters during hemiplegic 
stroke gait with IMU sensor. Sensors (Switzerland), 20(24), 1–10. 
https://doi.org/10.3390/s20247338 
Shumway-Cook, A., & Woollacott, M. H. (2017). Motor Control: Translating Research to Clinical 
Practice (5th Editio). 
Silva, A., Sousa, A. S. P., Pinheiro, R., Ferraz, J., Tavares, J. M. R. S., Santos, R., & Sousa, F. (2013). 
Activation timing of soleus and tibialis anterior muscles during sit-to-stand and stand-to-sit in 
post-stroke vs. healthy subjects. Somatosensory and Motor Research, 30(1), 48–55. 
https://doi.org/10.3109/08990220.2012.754755 
Soangra, R., & Lockhart, T. E. (2012). A comparative study for performance evaluation of sit-to-
stand task with body worn sensor and existing laboratory methods. Biomedical Sciences 
Instrumentation, 48(March), 22–24. 
Sullivan, K. J., Tilson, J. K., Cen, S. Y., Rose, D. K., Hershberg, J., Correa, A., Gallichio, J., McLeod, M., 

 
36 
Moore, C., Wu, S. S., & Duncan, P. W. (2011). Fugl-meyer assessment of sensorimotor function 
after stroke: Standardized training procedure for clinical practice and clinical trials. Stroke, 
42(2), 427–432. https://doi.org/10.1161/STROKEAHA.110.592766 
Sun, R., Guerra, R., & Shea, J. B. (2015). The posterior shift anticipatory postural adjustment in 
choice reaction step initiation. Gait and Posture, 41(4), 894–898. 
https://doi.org/10.1016/j.gaitpost.2015.03.010 
Sun, R., & Shea, J. B. (2016). Probing attention prioritization during dual-task step initiation: a novel 
method. Experimental Brain Research, 234(4), 1047–1056. https://doi.org/10.1007/s00221-
015-4534-z 
Tekscan, Inc. (n.d.). Retrieved September 3, 2022, from https://www.tekscan.com/products-
solutions/systems/hr-mat 
Toglia, J., Fitzgerald, K. A., O’Dell, M. W., Mastrogiovanni, A. R., & Lin, C. D. (2011). The Mini-Mental 
State Examination and Montreal Cognitive Assessment in persons with mild subacute stroke: 
Relationship to functional outcome. Archives of Physical Medicine and Rehabilitation, 92(5), 
792–798. https://doi.org/10.1016/j.apmr.2010.12.034 
Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Alonso, A., Beaton, A. Z., Bittencourt, M. S., Boehme, A. K., 
Buxton, A. E., Carson, A. P., Commodore-Mensah, Y., Elkind, M. S. V., Evenson, K. R., Eze-Nliam, 
C., Ferguson, J. F., Generoso, G., Ho, J. E., Kalani, R., Khan, S. S., Kissela, B. M., … Martin, S. S. 
(2022). Heart disease and stroke statistics—2022 Update: A report from the American Heart 
Association. Circulation, 145(8). https://doi.org/10.1161/cir.0000000000001052 
Tung, F. L., Yang, Y. R., Lee, C. C., & Wang, R. Y. (2010). Balance outcomes after additional sit-to-
stand training in subjects with stroke: A randomized controlled trial. Clinical Rehabilitation, 
24(6), 533–542. https://doi.org/10.1177/0269215509360751 
Van Bladel, A., Onursal Kilinç, Ö., De Ridder, R., & Kılınç, M. (2021). Trunk and lower extremity 
biomechanics during sit-to-stand activity after stroke: A systematic review. Gait & Posture, 

 
37 
90(1), 280. https://doi.org/10.1016/j.gaitpost.2021.09.145 
Vaughan-Graham, J., Patterson, K., Brooks, D., Zabjek, K., & Cott, C. (2019). Transitions sit to stand 
and stand to sit in persons post-stroke: Path of centre of mass, pelvic and limb loading – A pilot 
study. Clinical Biomechanics, 61(November 2018), 22–30. 
https://doi.org/10.1016/j.clinbiomech.2018.11.004 
Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, 
A. M., Chang, A. R., Cheng, S., Delling, F. N., Djousse, L., Elkind, M. S. V., Ferguson, J. F., Fornage, 
M., Khan, S. S., Kissela, B. M., Knutson, K. L., Kwan, T. W., Lackland, D. T., … Heard, D. G. (2020). 
Heart disease and stroke statistics—2020 update: A report from the American Heart 
Association. In Circulation. https://doi.org/10.1161/CIR.0000000000000757 
Ward, A. B. (2012). A literature review of the pathophysiology and onset of post-stroke spasticity. 
European Journal of Neurology, 19(1), 21–27. https://doi.org/10.1111/j.1468-
1331.2011.03448.x 
Weiss, S. M., Reber, A. S., & Owen, D. R. (2008). The locus of focus: The effect of switching from a 
preferred to a non-preferred focus of attention. Journal of Sports Sciences, 26(10), 1049–1057. 
https://doi.org/10.1080/02640410802098874 
Wong, J. S., Jasani, H., Poon, V., Inness, E. L., McIlroy, W. E., & Mansfield, A. (2014). Inter- and intra-
rater reliability of the GAITRite system among individuals with sub-acute stroke. Gait and 
Posture, 40(1), 259–261. https://doi.org/10.1016/j.gaitpost.2014.02.007 
Woodford, H., & Price, C. (2007). EMG biofeedback for the recovery of motor function after stroke. 
Cochrane Database of Systematic Reviews, 2. 
https://doi.org/10.1002/14651858.CD004585.pub2 
Wu, M., Hsu, C. J., & Kim, J. (2019). Forced use of paretic leg induced by constraining the non-paretic 
leg leads to motor learning in individuals post-stroke. Experimental Brain Research, 237(10), 
2691–2703. https://doi.org/10.1007/s00221-019-05624-w 

 
38 
Wulf, G. (2013). Attentional focus and motor learning: A review of 15 years. International Review of 
Sport and Exercise Psychology, 6(1), 77–104. https://doi.org/10.1080/1750984X.2012.723728 
Wulf, G., Höß, M., & Prinz, W. (1998). Instructions for motor learning: Differential effects of internal 
versus external focus of attention. Journal of Motor Behavior, 30(2), 169–179. 
https://doi.org/10.1080/00222899809601334 
Wulf, G., McNevin, N., & Shea, C. H. (2001). The automaticity of complex motor skill learning as a 
function of attentional focus. The Quarterly Journal of Experimental Psychology A, 54(4), 1143–
1154. https://doi.org/10.1080/02724980143000118 
Wulf, G., Shea, C., & Park, J. H. (2001). Attention and motor performance: Preferences for and 
advantages of an external focus. Research Quarterly for Exercise and Sport, 72(4), 335–344. 
https://doi.org/10.1080/02701367.2001.10608970 
Yoshida, K., An, Q., Yozu, A., Chiba, R., Takakusaki, K., Yamakawa, H., Tamura, Y., Yamashita, A., & 
Asama, H. (2019). Visual and vestibular inputs affect muscle synergies responsible for body 
extension and stabilization in sit-to-stand motion. Frontiers in Neuroscience, 13(JAN), 1–12. 
https://doi.org/10.3389/fnins.2018.01042 
Yu, W. H., Liu, W. Y., Wong, A. M. K., Wang, T. C., Li, Y. C., & Lien, H. Y. (2015). Effect of forced use of 
the lower extremity on gait performance and mobility of post-acute stroke patients. Journal of 
Physical Therapy Science, 27(2), 421–425. https://doi.org/10.1589/jpts.27.421 
Zhao, C., Zhao, S., Guan, M., Cheng, X., Wang, H., Liu, C., Zhong, S., Zhou, Z., & Liang, Y. (2020). Forced 
forelimb use following stroke enhances oligodendrogenesis and functional recovery in the rat. 
Brain Research, 1746(January), 147016. https://doi.org/10.1016/j.brainres.2020.147016 
Zinn, S., Bosworth, H. B., Hoenig, H. M., & Swartzwelder, H. S. (2007). Executive function deficits in 
acute stroke. Archives of Physical Medicine and Rehabilitation, 88(2), 173–180. 
https://doi.org/10.1016/j.apmr.2006.11.015 
 

 
39 
WESTERN CAROLINA UNIVERSITY (WCU) 
CONSENT TO PARTICIPATE IN RESEARCH 
 
Title: The Effect of Focus of Attention on Motor Performance and Learning During a Sit to 
Stand Task in Individuals Post-Stroke 
 
Principle Investigator: Ashley Watamura, PT, DPT, PhD, NCS………………..awhyatt@wcu.edu  
717-682-9710 
 
Co-Investigators: Elijah Albright, SPT, Hannah Bernier, SPT, Erica Massaro Heinricy, SPT, 
Acacia Houle, SPT, Isabelle Lytle, SPT, Shauna Mignella, SPT, Maxwell Tinkley, SPT, Lauren 
Santangelo, SPT 
 
Study Summary and Key Information 
 
I, ____________________________________, agree to be in a study led by Dr. Ashley Watamura, 
Assistant Clinical Professor. This study looks at the best way to help people learn how to 
stand up and sit down. 
 
What Will You Do?  
 
First, we will check your thinking, memory, and attention. We will also test the strength 
and feeling in your weaker leg. In this study, you will practice standing up and sitting down. 
You will do four sets of ten sit-to-stands. You will also get tips to improve. This study is 
safe, but it may feel hard depending on your strength. 
 
Who Can Join?  
 
You can join if you had a mild or moderate stroke more than six months ago and can stand 
and walk without help. You cannot join if you had a severe stroke, have trouble paying 
attention to your weak side, cannot follow many instructions, or have other health 
problems that make standing up hard. 
 
Why Are We Doing This Study?  
 
We want to find the best way to teach people who have had a stroke how to stand up and 
sit down. 
 
What Will Happen?  
 
This study will take place at a Western Carolina University location. A licensed physical 
therapist or faculty member will be with you. You will take some tests, including a thinking 
test. We will check your blood pressure, heart rate, and oxygen levels. You will sit on a table 
with a mat under your feet to measure how you stand up. A small marker will be placed on 
your chest to track your movements. You will stand up, sit down, and walk 80 feet on a 
special mat. 

 
40 
Treatment 1: You will be randomly given one of two types of instructions. You will be 
shown how to stand up, then you will do four sets of ten sit-to-stands. You will rest as 
needed. After five minutes and after one hour, you will stand up and sit down three more 
times and walk on the mat four times. Then, you will complete a survey. 
Break: After the first treatment, you will come back one week later for Phase 2. 
Treatment 2: One week later, you will get the second type of instruction and repeat the 
same steps. 
 
How Long Will It Take? 
 
• 
The first tests will take 30-60 minutes. 
• 
Training will take another 30-60 minutes. 
• 
You will rest for one hour, then do a five-to-ten-minute activity. 
• 
The total time will be under three hours. 
• 
You will return one week later for another session, which will take less than two 
hours. 
 
Risks and Safety:  
 
You may feel tired or sore, but you will get rest breaks. We will check your blood pressure 
and heart rate. You will wear a safety belt, and someone will be with you to help if needed. 
We will do our best to keep you safe. If anything goes wrong, tell us right away. 
 
Emergency Care: 
 
• 
Call 911 or extension 8911 (if on the Cullowhee campus) if you need emergency 
care. Tell the doctors you are in a research study and give them the Principal 
Investigator’s name. Bring a copy of this consent form. 
• 
If you do NOT need emergency care but feel sick or hurt, call Dr. Ashley Watamura 
at 717-682-9710 as soon as possible. Go to your regular doctor if needed and let 
them know you are in this study. Bring a copy of this consent form. 
Western Carolina University will not cover medical costs if you get hurt. Your insurance 
may not pay for costs related to research. You should check with your insurance company. 
 
Possible Benefits:  
 
You may not see a difference, but this study could help others in the future. You might get 
stronger and improve how you sit, stand, and walk. 
 
Privacy:  
 
We will keep your information private, but we cannot promise complete privacy. Only the 
research team and those who fund or check the study may see your information. If required 
by law, we may have to share your information. Your name will not be in reports or 
articles. 

 
41 
We will collect information through interviews and surveys. It will be stored in a locked 
office at Western Carolina University. Your name will be kept separate from your data in a 
secure file. 
 
When We Must Share Information:  
 
We must report to authorities if: 
1. We believe a child, elderly person, or disabled person is being abused or neglected. 
2. You make a serious threat to hurt yourself or others. 
 
Future Use of Your Information:  
 
Your personal details may be removed from your data, and the data could be used for 
future research without your additional consent. However, there is still a small chance 
someone could identify you. 
 
Voluntary:  
 
Joining this study is your choice. You will not be paid for participating. You can leave at any 
time, and your information will stay private. 
 
Cost:  
 
You will not have to pay anything to be in this study. The Department of Physical Therapy 
at Western Carolina University covers all costs. 
 
Questions? 
 
• 
If you have questions about the study, contact Dr. Ashley Watamura at 717-682-
9710 or awhyatt@email.wcu.edu. 
• 
If you have concerns about your rights as a participant, contact the Western 
Carolina University Institutional Review Board at 828-227-7212 or irb@wcu.edu. 
 
Consent:  
 
I am at least 18 years old, have read this form, and had the chance to ask questions. I agree 
to be in this study. 
 
Participant’s signature: _________________________________________________________ Date: ___________ 
 
Investigator’s signature: ________________________________________________________ Date: ___________ 
 
A researcher can read this form to you and act as a witness if needed. You will get a copy of 
this form. 
If you want to receive study results, tell us where to send them: Email: 
_____________________________________ Address: ____________________________________________