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

Abstract

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. 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. The study design involved direct nonparticipation observation of physical therapy treatment sessions. 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. 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. 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. 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.