Johnson L1,2, Burridge J2, Demain S2
1Royal Bournemouth Hospital, Bournemouth, United Kingdom, 2University of Southampton, Southampton, United Kingdom
Background: This project forms the initial phase of a programme of research investigating the impact of an Implicit Learning Approach in acute stroke rehabilitation (IMPS Study).
The process of functional recovery following stroke is underpinned by the concept of motor learning. Instructions and feedback are known to play an important role in this learning process. Evidence in sport has consistently shown the benefits of instructions that promote an external focus of attention (EFOA); leading to greater movement automaticity, and improved learning. However, observational studies in stroke have shown that therapists use frequent internally focussed instructions during rehabilitation, and that they find it challenging to adapt their approach to create an EFOA. It is possible that impairments of movement, cognition and language mean that attentional focus is even more important in this group. This requires evaluation.
During this initial phase of the IMPS study, we have developed interventional guidance, which will provide examples for how common therapy exercises can be adapted to promote an EFOA.
Purpose: To produce definitions and validated descriptors of the content of an Implicit Learning Approach, for use in acute stroke rehabilitation.
Methods: We used a Delphi Approach to develop and refine externally focussed exercise examples. This was achieved through a series of online surveys, which were be completed by a multi-professional expert panel.
Within each survey, embedded videos of common exercises were shown. The expert panel were asked to comment on the likely focus of attention of the performer; what instructions would be used to promote an EFOA; and how the task set up could be modified to promote an EFOA.
Where there was >80% agreement regarding FOA, the exercise was included in the final intervention manual. Where there was not agreement, the exercise and instruction was modified based on participants feedback, and was included in the next round of the survey.
Results: A panel of 16 individuals, with a range of expertise and professional backgrounds in the field of motor learning and/or stroke rehabilitation, were invited to take part. Four rounds of survey were used, gaining consensus on a set of exercises designed to facilitate the recovery of sit to stand, stepping and gait.
Conclusion(s): Commonly used rehabilitation exercises can be adapted to promote an EFOA; by altering the therapist's use of instructions and/or altering the task set up. The Delphi approach was an effective method to generate treatment ideas, and to gain consensus on a set of exercise examples that promote the patient to have an EFOA. A range of experts from different professional backgrounds, including physiotherapy, sports science and psychology, contributed to this process.
Implications: The intervention developed through this study is now being tested in a pilot Cluster Randomised Controlled Trial, comparing an Implicit Learning Approach to standard care in the acute phase post stroke.
Keywords: stroke, motor learning, focus of attention
Funding acknowledgements: This project is funded through the National Institute of Health Research (NIHR), UK
The process of functional recovery following stroke is underpinned by the concept of motor learning. Instructions and feedback are known to play an important role in this learning process. Evidence in sport has consistently shown the benefits of instructions that promote an external focus of attention (EFOA); leading to greater movement automaticity, and improved learning. However, observational studies in stroke have shown that therapists use frequent internally focussed instructions during rehabilitation, and that they find it challenging to adapt their approach to create an EFOA. It is possible that impairments of movement, cognition and language mean that attentional focus is even more important in this group. This requires evaluation.
During this initial phase of the IMPS study, we have developed interventional guidance, which will provide examples for how common therapy exercises can be adapted to promote an EFOA.
Purpose: To produce definitions and validated descriptors of the content of an Implicit Learning Approach, for use in acute stroke rehabilitation.
Methods: We used a Delphi Approach to develop and refine externally focussed exercise examples. This was achieved through a series of online surveys, which were be completed by a multi-professional expert panel.
Within each survey, embedded videos of common exercises were shown. The expert panel were asked to comment on the likely focus of attention of the performer; what instructions would be used to promote an EFOA; and how the task set up could be modified to promote an EFOA.
Where there was >80% agreement regarding FOA, the exercise was included in the final intervention manual. Where there was not agreement, the exercise and instruction was modified based on participants feedback, and was included in the next round of the survey.
Results: A panel of 16 individuals, with a range of expertise and professional backgrounds in the field of motor learning and/or stroke rehabilitation, were invited to take part. Four rounds of survey were used, gaining consensus on a set of exercises designed to facilitate the recovery of sit to stand, stepping and gait.
Conclusion(s): Commonly used rehabilitation exercises can be adapted to promote an EFOA; by altering the therapist's use of instructions and/or altering the task set up. The Delphi approach was an effective method to generate treatment ideas, and to gain consensus on a set of exercise examples that promote the patient to have an EFOA. A range of experts from different professional backgrounds, including physiotherapy, sports science and psychology, contributed to this process.
Implications: The intervention developed through this study is now being tested in a pilot Cluster Randomised Controlled Trial, comparing an Implicit Learning Approach to standard care in the acute phase post stroke.
Keywords: stroke, motor learning, focus of attention
Funding acknowledgements: This project is funded through the National Institute of Health Research (NIHR), UK
Topic: Neurology: stroke
Ethics approval required: Yes
Institution: University of Southampton
Ethics committee: Ethics and Research Governance Online (ERGO)
Ethics number: 42008
All authors, affiliations and abstracts have been published as submitted.
