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Cited by 132Stroke Rehabilitation and RecoverySport Psychology and PerformanceSports and Physical Education Research

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

Johnson, Louise, Burridge, Jane H., Demain, Sara H.·2013·Physical Therapy
DOI 10.2522/ptj.20120300
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Abstract

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

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  • Instructors predominantly use approaches that involve selecting tasks, describing how movements should be performed, giving corrective feedback, and instructions referring to body movement coordination.

    “In a typical scenario, the instructor (e.g., coach, physical therapist, music teacher) selects the tasks to be practiced, describes how movements should be performed, gives corrective feedback, and instructions that refer to the coordination of body movements.”

    From Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning (2016) · cites this paper as Johnson et al., 2013

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Authors
Johnson, L., Burridge, J. H., & Demain, S. H.
Affiliations
  • Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (GB)
  • University of Southampton (GB)
Corresponding author
Johnson, Louise
ORCID
Venue
Physical Therapy
Publisher
Oxford University Press (OUP)
Published
2013-07-01
Volume
93
Issue
7
Pages
957-966
ISSN
  • 0031-9023 (ISSN-L)
  • 1538-6724
DOI
10.2522/ptj.20120300
OpenAlex
W2113547133
Cited by
132
References
52
Citations by year
2026: 3 · 2025: 10 · 2024: 16 · 2023: 13 · 2022: 9 · 2021: 18 · 2020: 12 · 2019: 13 · 2018: 11 · 2017: 9 · 2016: 13 · 2015: 3 · 2014: 2
FWCI
6.40
Type
journal article
Language
en
Open access
closed
Locations
  • Physical Therapy (publishedVersion)
  • PubMed (publishedVersion)
  • ePrints Soton (University of Southampton) (submittedVersion)
Funders
National Institute for Health and Care Research (PDF-2011-04-016)
Topics
  • Health Sciences › Medicine › Rehabilitation › Stroke Rehabilitation and Recovery
  • Social Sciences › Psychology › Developmental and Educational Psychology › Sport Psychology and Performance
  • Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Sports and Physical Education Research
Keywords
internal focus, external attention, gait rehabilitation, stroke rehabilitation, hemiplegia, verbal feedback, motor skill learning, automaticity
MeSH terms
Stroke Rehabilitation, Adult, Aged, Aged, 80 and over, Attention, Feedback, Female, Hemiplegia, Humans, Male, Middle Aged, Nonverbal Communication, Professional-Patient Relations, Teaching, Verbal Behavior, Video Recording, Observation, Gait Disorders, Neurologic, Stroke, Physical Therapy Modalities

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