Effects of Combined vs. Sequential Attentional Focus Instructions on Upper Extremity Function in Subacute Stroke
The Effect of Combined Versus Sequential Attentional Focus Instructions on Upper Extremity Function in Subacute Stroke Patients: An Assessor-Blinded Randomized Controlled Trial
Bahçeşehir University
36 participants
Jan 2, 2025
INTERVENTIONAL
Conditions
Summary
Stroke is a leading cause of long-term disability, and upper extremity impairments-affecting about 80% of survivors-limit functional reach, grasp, and manipulation more severely than lower limb deficits. Despite partial recovery of walking ability, meaningful functional use of the paretic arm remains limited. Conventional rehabilitation often lacks sufficient intensity, task specificity, and motor learning principles, highlighting the need for more effective approaches. The subacute phase of stroke (up to 6 months post-onset) represents a period of heightened neuroplasticity and strong rehabilitation potential. During this time, integrating cognitive and motor training-such as attentional focus strategies-has gained attention. External focus enhances movement efficiency through motor automaticity, whereas internal focus supports early motor control. Evidence suggests that combining these strategies may optimize recovery, yet their relative effectiveness in stroke rehabilitation remains unclear. Two main instructional approaches exist: combined attentional focus (internal and external cues delivered within the same session) and sequential attentional focus (internal focus first, followed by external focus as control improves). While both show therapeutic promise, comparative data in stroke populations are lacking. This study aims to compare combined versus sequential attentional focus instructions in improving upper extremity function in subacute stroke. We hypothesize that a combined approach-starting with internal focus early, then integrating external focus-will yield superior motor improvements.
Eligibility
Inclusion Criteria8
- Age 40-80 years at enrollment (Kwakkel et al., 1996; Coupar et al., 2012).
- Stroke diagnosed by a neurologist between 1 week and 6 months before enrollment (Langhorne et al., 2020; Bernhardt et al., 2017).
- Medically stable, as confirmed by a neurologist, with controlled and non-fluctuating vital signs (Stinear et al., 2020; Powers et al., 2019; Winstein et al., 2016).
- Sufficient cognitive function to follow instructions, sustain attention, and actively participate in rehabilitation, as judged by the treating therapist (Stinear et al., 2020; Boyd et al., 2018).
- Brunnstrom stage 2-5 in the affected upper limb (Brunnstrom, 1970; Langhorne et al., 2020).
- Individuals with a Modified Ashworth Scale (MAS) score \<3: Participants were required to have a MAS score of less than 3 in both the upper and lower extremities to ensure that spasticity remained at a manageable level and to allow safe participation in upper-limb motor rehabilitation (Pandyan et al., 2005; Li \& Francisco, 2015; Ada et al., 2020).
- Preserved corticospinal tract integrity, confirmed by a positive Motor Evoked Potential (MEP) response (Stinear et al., 2017; Byblow et al., 2015; Stinear et al., 2020).
- Moderate to severe upper-extremity motor impairment, determined by Fugl-Meyer Assessment (FMA) scores of 0-47 (0-19 severe, 20-47 moderate) (Fugl-Meyer et al., 1975).
Exclusion Criteria6
- Spasticity level: Individuals with a Modified Ashworth Scale (MAS) score ≥3 in either the upper or lower extremities were excluded, as marked hypertonicity and severe spastic contractions could negatively affect proximal stabilization and movement strategies, thereby interfering with upper-limb task performance (Pandyan et al., 2005).
- Fractures: Participants with a current or recent fracture on the affected side of the body were excluded from the study.
- Botulinum toxin injections: Individuals who had received Botulinum Toxin (Botox) injections within the previous three months were excluded due to the potential effects of the intervention on muscle tone and motor performance.
- Communication disorders: Participants with motor or global aphasia, or other communication impairments that could interfere with understanding instructions or performing the required tasks, were excluded.
- Concurrent rehabilitation: Individuals who were concurrently receiving rehabilitation treatment at another facility were excluded to prevent potential confounding effects from parallel interventions (Winstein et al., 2016).
- Non-adherence to treatment sessions: Participants who failed to attend all required treatment sessions were excluded to ensure consistency and fidelity of the intervention protocol (Winstein et al., 2016).
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Interventions
Participants perform task-specific upper extremity exercises while receiving simultaneous internal and external attentional focus cues, directing attention both to body movements (internal focus) and movement effects on the environment (external focus). This combined approach aims to enhance motor control, movement efficiency, and functional performance.
Participants perform task-specific upper extremity exercises with internal attentional focus cues during the first two weeks (focusing on body movements, e.g., "feel your shoulder moving"), followed by external attentional focus cues during the next two weeks (focusing on movement effects, e.g., "focus on the target and guide your hand to touch it").
All participants receive a standardized, evidence-based rehabilitation program targeting upper extremity range of motion, motor control, coordination, and functional performance. Sessions are conducted five times per week in the clinic and twice per week at home, each lasting 45 minutes, over four weeks.
Locations(1)
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NCT07289308