The Effects of Attentional Focus on Arm Training in Stroke

Study Overview
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Brief Summary
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This study compares the effects of an internal versus an external focus of attention on motor training of the affected arm for individuals with stroke. Participants were randomly assigned to either the internal or external focus treatment groups and received 12 sessions of arm training.

Detailed Description
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Participants were randomized to one of two treatment groups and received upper arm reaching training on the InMotion 2 shoulder robot (12 hourly sessions over four weeks). The external focus group received instructions specifically to pay attention to the task goal--hitting targets on the video game, while the internal focus group was instructed to pay attention to the movement of their arm motions (video game monitor was turned off). Both groups practiced the same arm reaching pattern and were matched for level of arm impairment and training dosage.

Official Title
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A Randomized Control Trial on the Effects of Attentional Focus on Motor Training of the Upper Extremity Using Robotics With Individuals After Chronic Stroke

Conditions
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Stroke

Intervention / Treatment
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* Behavioral: upper arm training on the InMotion 2 shoulder robot


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: diagnosis of stroke > 6 months moderate to severe arm impairment intact visual scanning and spatial orientation of the affected arm functional cognitive status medically stable Exclusion Criteria: concurrent occupational or physical therapy for the arm joint contractures at the wrist, forearm, elbow, or shoulder moderate to severe spasticity at the elbow or shoulder presence of other neurological conditions botulinum toxin injection in the affected arm < 3 months prior score of 0/5 on manual muscle test at the elbow or shoulder

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: External Focus (EF)<br>Participants received arm training using the InMotion2 robot under external focus practice conditions and instructions. Participants practiced arm reaching by playing a simple video game. EF instructions: Focus on moving the yellow ball on the screen in a smooth, straight line at a constant speed; Move the yellow ball toward the blinking red/orange light; and Hit the center of the target and try not to overshoot the target | Behavioral: upper arm training on the InMotion 2 shoulder robot<br>* Both groups practiced shoulder and elbow exercises on a robotic arm device under an external focus or internal focus practice condition. Practiced arm reaching in a clock-like design to facilitate horizontal shoulder flexion, extension, abduction, adduction. 12 sessions--3 times a week for 4 weeks<br>|
| Experimental: Internal Focus (IF)<br>Participants received arm training using the InMotion2 robot without the video game interface. Participants were instructed to think about how they were moving their arm while completing the arm training tasks. IF instructions: think about how you're moving your arm; push your arm away from you; pull your arm toward you; move your arm to the right/left | Behavioral: upper arm training on the InMotion 2 shoulder robot<br>* Both groups practiced shoulder and elbow exercises on a robotic arm device under an external focus or internal focus practice condition. Practiced arm reaching in a clock-like design to facilitate horizontal shoulder flexion, extension, abduction, adduction. 12 sessions--3 times a week for 4 weeks<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in coordination at the shoulder and elbow measured by joint independence after arm training assessed start of training, discharge and at follow up. | kinematic measure of coordination between the shoulder and elbow joint | baseline, 4 weeks, 8 weeks | 
| Change in quality of arm motion measured by smoothness at the start of arm training, at 4week, and 8 weeks. | kinematic assessment of arm motion measured by average velocity decided by maximum velocity | baseline, 4 weeks, 8 weeks | 
| Change in motor impairment of the arm measured by Fugl-Meyer Assessment (FMA) at the start of training, discharge, and follow up. | performance based assessment of underlying motor impairment of the affected shoulder, elbow, hand after stroke | baseline, 4 weeks, 8 weeks | 
| Change in motor impairment and functional ability of the arm measured by the Wolf Motor Function Test (WMFT) at start of training, discharge, and follow up. | performance based assessment of underlying motor impairment and function of the affected arm after stroke | baseline, 4 weeks, 8 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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attentional focus, upper extremity, hemiparesis, stroke