Examining the role of attention focus walking training on conscious motor processing during rehabilitation by older adults at risk of falling: A randomized controlled trial.

This study examined the impact of walking training with different attention focus instructions on real-time conscious motor processing and fall-related rehabilitation outcomes in older adults at risk of falling. A total of 102 community-dwelling older adults (mean age = 75.2 years, SD = 6.8 years) were randomly assigned to three groups: no attention focus walking group (NAFWG), external attention focus walking group (EAFWG), or internal attention focus walking group (IAFWG). All groups underwent 12 training sessions. Assessments were conducted at baseline, post-training, and six months later, measuring real-time conscious motor processing, functional balance and gait, balance ability, functional mobility, walking ability, trait conscious motor processing propensity, fear of falling, and recurrent falls. The EAFWG showed significant reduction on real-time conscious motor processing immediately after training (p = 0.015). No changes were observed for the IAFWG and NAFWG. All groups showed significant improvements in functional balance and gait (p < 0.001) and balance ability (p < 0.001) post-training. Implementing external focus instructions during walking training could be a feasible and beneficial strategy for reducing real-time conscious motor processing, which may improve walking performance and prevent falls in older adults. Further research is needed to examine the sustained benefits of these interventions and determine optimal training dosage for older adults with different risks of falling in fall prevention.

The use of mindfulness-based interventions in stroke rehabilitation: A scoping review.

PURPOSE/OBJECTIVE: There is emerging evidence for the use of mindfulness-based interventions (MBIs) to improve health outcomes in the context of stroke rehabilitation. This scoping review identified recently available evidence and possible research gaps regarding how MBIs affect psychological and physical rehabilitation outcomes in individuals poststroke. RESEARCH METHOD/DESIGN: Electronic searches were performed using the four major databases, CINAHL, MEDLINE, PsycINFO, and Web of Science. Sixteen studies out of a total of 404 relevant studies met the selection criteria for inclusion in this review. RESULTS: Our findings indicate diverse results on the benefits of MBIs in individuals poststroke across a range of rehabilitative outcomes. For instance, significant improvements in mental fatigue, cognition, and quality of life were observed for most of the studies while the outcomes for mood and physical functioning were mixed. CONCLUSIONS/IMPLICATIONS: The available evidence lends qualified support to the view that mindfulness has the potential to be a therapeutic intervention that offers health benefits to individuals poststroke. Yet, the diversity of results highlights the need for a more rigorous examination in further research. We also identified several knowledge gaps in mindfulness research in the stroke population, such as the limited amount of evidence for mindfulness-based cognitive therapy (MBCT), inadequate evaluations of physical outcomes, and the lack of methodologically robust trials. Further investigations are warranted to strengthen the evidence for the feasibility and effectiveness of MBIs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Attentional Focus Strategies to Improve Motor Performance in Older Adults: A Systematic Review.

Previous literature shows the beneficial effects of an external focus of attention on various sports skills in young adults. The objective of this systematic review is to evaluate the effects of external and internal focus of attention on motor performance in healthy older adults. The literature search was conducted in five electronic databases (PsycINFO, PubMed, SPORTDiscus, Scopus, and Web of Science). Eighteen studies that met the inclusion criteria were evaluated. Most of the motor tasks targeting older adults were related to postural control and gait. Over 60% of the included studies reported that the effect of an external focus was superior to that of an internal focus on motor performance in older adults. An external focus generally results in better motor performance than an internal focus among healthy older adults. However, the advantage of an external focus on locomotion may not be as significant as those illustrated in previous attentional focus studies. A challenging cognitive task may allow more automatic motor control than an external focus. Practitioners might provide clear instruction cues guiding performers to divert their attention away from their body and towards the movement effect for better performance, particularly in balancing tasks.

Does an Externally Focused Dual-task Mitigate Real-time Conscious Postural Control in Older Adults?

OBJECTIVES: This study first examined whether real-time conscious postural control (reinvestment) and postural sway increase with different postural difficulties on a compliant surface among older adults. The second objective was to investigate the effect of an externally focused dual-task on real-time reinvestment and postural sway under a relatively challenging standing position. METHOD: Thirty-two community-dwelling older adults (mean age = 72.09, SD = 4.18 years) were recruited. Participants performed balance tasks in four standing positions in a randomized order on a balance foam pad. The four positions included wide-based standing on foam (WBF), narrow-based standing on foam (NBF), tandem-based standing on foam (TBF) and tandem-based standing on foam with an externally focused dual-task (TBFE). Throughout all the balance tasks, participants' real-time reinvestment and body sway were indicated by the Alpha2 T3-Fz Electroencephalogram (EEG) coherence and the total sway length (TSL), respectively. RESULTS AND DISCUSSION: Our results revealed no significant difference in real-time reinvestment among different standing positions while postural sway increased from WBF to NBF and reduced from NBF to TBF. We also demonstrated that when performing a relatively challenging standing task on a compliant surface, an externally focused dual-task (TBFE), compared to a baseline single task (TBF), can neither mitigate real-time reinvestment nor improve balance performance in community-dwelling older adults with good balance capability. Potential explanations and implications are discussed.

Effects of Single-Task, Dual-Task and Analogy Training during Gait Rehabilitation of Older Adults at Risk of Falling: A Randomized Controlled Trial.

It has been suggested that implicit motor learning via dual-task or analogy training during gait rehabilitation may yield better outcomes in older adults by reducing the propensity for the conscious processing of movements (movement-specific reinvestment). The current study investigated the immediate effects of single-task, dual-task, and analogy training on reinvestment propensity and fall-related rehabilitation outcomes among older adults at risk of falling. Seventy-one older adults were randomly allocated to the single-task (ST), dual-task (DT), or analogy (AG) training conditions and received 12 training sessions. We assessed the reinvestment propensity, functional gait and balance, functional mobility, balance ability, single-task and dual-task walking abilities, and fear of falling at baseline (before training) and immediately after training. Our findings revealed a lack of training effect on reinvestment propensity for all groups. However, all groups displayed significant improvements in functional gait and balance (p < 0.001), functional mobility (p = 0.02), and balance ability (p = 0.01) after training. AG appeared to be superior to DT and ST, as it was the only condition that resulted in significant improvements in both single-task and dual-task walking abilities (p < 0.001). Implementing movement analogies could be a feasible and useful gait rehabilitation strategy for fall prevention and wellbeing promotion among older adults.

Real-time conscious postural control is not affected when balancing on compliant surface by young adults.

Previous research has illustrated that real-time conscious postural control (i.e., reinvestment - shifting from movement automaticity to a more consciously controlled and monitoring of movement) increased with standing task difficulties among healthy older adults. However, such association has not been investigated in the younger population. This study attempted to examine real-time conscious postural control among healthy young adults when performing different standing tasks on a compliant (foam) surface. T3-Fz EEG (electroencephalography) coherence, indicative of real-time conscious postural control, was recorded during the standing tasks (i.e., wide base on foam (WBF), narrow base on foam (NBF) and tandem stance on foam (TAF)). Body sway was also recorded by a motion capture system. Participants' perceived difficulty on the different standing tasks was evaluated by the Visual Analogue Scale (VAS). Results revealed that while body sway and perceived difficulty increased significantly with task difficulties, T3-Fz EEG coherence did not differ among standing tasks. In addition, no differences of any measures were found between young adults with high and low trait reinvestment propensity. Our findings indicate that young adults do not pose higher real-time conscious postural control when task difficulty increases. We also add support to the existing literature; the between-group effect of trait reinvestment appears to be minimal in real-time.

Do attentional focus instructions affect real-time reinvestment during level-ground walking in older adults?

This study represents the first attempt in exploring whether attentional focus instructions could affect real-time reinvestment (conscious movement processing) in older adults during level-ground walking. Forty-five community-dwelling older adults were instructed to walk at a self-selected pace along a 6-m level-ground walkway under three randomized attentional focus conditions (i.e., Internal, External, and Control) for a total of fifteen trials (five trials for each condition). Electroencephalography (EEG) T3-Fz coherence was utilized as an objective measurement of real-time reinvestment during walking. The Chinese version of the Movement-Specific Reinvestment Scale (MSRS-C) was used to measure the trait reinvestment propensity. Results revealed that the EEG T3-Fz coherence did not differ among the three conditions. The EEG T3-Fz coherence at the Control condition was not correlated with the scores of the MSRS-C. Our findings suggest that the measurement of trait reinvestment propensity (MSRS-C) may not be sensitive enough to reflect real-time reinvestment. Moreover, attentional focus instructions do not affect real-time reinvestment during level-ground walking, possibly due to the low level of motor task difficulty in level-ground walking for healthy older adults. Future studies should investigate this influential issue with a more challenging walking task.

Visual-related training to improve balance and walking ability in older adults: A systematic review.

Evidence has emerged about the use of visual-related training as an intervention to improve mobility that could implicate fall prevention in the older population. The objective of this systematic review was to investigate whether visual-related interventions are effective in improving balance and walking ability in healthy older adults. An electronic database search was conducted using Pubmed, Embase, CINAHL Plus, Web of Science, PsycINFO, and SportDiscus. Seventeen studies out of a total of 3297 studies were identified in this review that met the inclusion criteria of (1) adopting a longitudinal design with at least one control comparison group, (2) targeting healthy older adults (age 60 or above), (3) primary focus targeting visual element, and (4) the primary outcome(s) were measures indicating walking and/or balance ability. Our results indicated that visual-related training generally led to improvements in balance and walking ability in healthy older adults. It seems necessary that visual-related training should at least involve mobility-related movement component(s), or form a part of a multi-component training to achieve a beneficial effect on balance and walking. The effectiveness and feasibility of these visual-related training in clinical practice for rehabilitation has been discussed and needs to be investigated in future studies. (197/200).

Conscious Control of Gait Increases with Task Difficulty and Can Be Mitigated by External Focus Instruction.

Objectives: We aimed to address whether increased task difficulty is sufficient to induce heightened conscious control and influence gait performance in older adults through the manipulations of either task difficulty or attentional focus. Method: Fifty older adults, split into high- (HR) and low-reinvestor (LR) groups, performed a walking task on a 7.4 m straight walkway in two conditions: firm level-ground surface (GW) and foam surface (FW). They subsequently performed the same walking task under two attentional focus conditions: Internal focus (IF) and External focus (EF). Electroencephalography (EEG) T3-Fz and T4-Fz coherences were used to indicate real-time conscious motor control and visual-spatial control, respectively. Results: We observed significantly higher T3-Fz and T4-Fz coherences under FW compared to GW. HR reduced their gait speed at a greater extent than LR under FW. Significantly lower T3-Fz coherence and faster gait were demonstrated under EF compared to IF. LR walked slower under IF compared to Baseline while gait speed of HR did not differ. Discussion: Visual-spatial and conscious movement processing increase as a function of task difficulty during gait. Our findings also advocate the use of external focus instructions in clinical settings, with the potential to reduce conscious control and promote movement automaticity, even in relatively complex gait tasks.

Strategies for Teachers to Promote Physical Activity in Early Childhood Education Settings-A Scoping Review.

Recent evidence has emphasized the importance of the early childhood years for developing lifelong physical activity patterns. As such, evidence-informed programs that create opportunities for young children to engage in physical activity are needed and education settings present an important context. This review aimed to identify strategies that are implemented by teachers to promote physical activity in early childhood education and care settings. This is a scoping review that followed the framework proposed by the Joanna Briggs Institute. Searches were conducted using the databases of PubMed, SCOPUS, PsycINFO, SPORT Discus, ERIC and Web of Science for publications up to September 2020. From a total of 8974 articles, 19 were deemed eligible. Ten types of strategies, performed by teachers with the intention to improve physical activity-related primary outcomes, were identified. Physical activity promotion by teachers in early childhood settings is recommended to take a multi-strategy approach, in conjunction with professional development training opportunities and continuous follow-up support for teachers. Future work is warranted to fill the evidence gap in other regions (e.g., Asia, Africa and South America) and strengthen the evidence base to establish best practice standards.

The role of reinvestment in conservative gait in older adults.

Previous research suggests that reinvestment (i.e. conscious control of movements) is associated with inefficient information processing and compromised movement strategies in older adults during walking. We examined whether reinvestment propensity is associated with conservative gait behaviour in older adults. Trait Reinvestment propensity was measured using the Movement Specific Reinvestment Scale (Chinese version) (MSRS-C). Thirty-eight older adults were categorized into 'Low Reinvestor Group' (LRG) (MSRS-C < 27) and another 38 were categorized into 'High Reinvestor Group' (HRG) (MSRS-C > 38). There were no significant differences in physical and cognitive abilities between groups. Participants were asked to walk along a 6-m straight level-ground walkway at a self-selected pace under conditions of no instruction (Baseline), instruction related to self-focus on body movements (BI), and instruction related to the external environment (EI). No significant difference was found in gait behaviour between LRG and HRG at Baseline. However, significant changes, indicative of conservative gait patterns, were found in LRG when given instructions that prompted them to consciously control their body movements. No changes were observed in HRG under external-related instructions that are assumed to reduce conscious motor processing and improve motor performance. Our findings contradict previous views on the association between trait reinvestment propensity and compromised motor performance in older adults, which potentially reduces justification for reducing trait reinvestment propensity in older adults. We also suggest that MSRS is insensitive to reflect the degree of conscious control during gait tasks. Our findings also implicate the potential detrimental effect of applying inward-focus-related instructions in healthcare rehabilitation settings.

Gait Stability in Older Adults During Level-Ground Walking: The Attentional Focus Approach.

OBJECTIVES: The objective of this study was to investigate the effect of attentional focus instructions on gait stability during level-ground walking among older adults. METHODS: We recruited 140 community-dwelling older adults (mean age = 70.3 years, SD = 4.7 years) from elderly community centers in Hong Kong. The experiment included assessments on participant's characteristics and walking trials. During walking trials, each participant was invited to walk at a self-selected pace along a 6-m walkway. Internal focus instructions (Internal condition), external focus instructions (External condition), or no instruction (Control condition) were given in a randomized order for three trials per condition, giving a total of nine walking trials. Spatial and temporal gait parameters were measured. RESULTS: Results showed significantly higher body sway and variability of swing and stance time under Internal condition relative to External and Control conditions. Moreover, reduced velocity and shorter steps were demonstrated under Internal condition relative to External and Control conditions. DISCUSSION: External focus instructions did not improve gait stability in older adults when compared to Control condition. Internal focus instructions appear to compromise gait stability. Future research should investigate if walking instructions that refer to body movements explicitly compromise gait rehabilitation for older adults in clinical settings.

The role of attentional focus on walking efficiency among older fallers and non-fallers.

BACKGROUND: This study evaluated the effect of attentional focus instructions on movement efficiency during a level-ground walking task in older adults with and without a history of falls. METHODS: One hundred and thirty-four community-dwelling older adults were categorised into older fallers (OF) (n = 37) and older non-fallers (ONF) (n = 97). Each participant was instructed to walk at a self-selected pace along a 6 m walkway under three attentional focus conditions (i.e. internal, goal-directed and control) for a total of nine trials. Average muscle activity indices of lower limb co-contractions were measured using surface electromyography. RESULTS: Both shank and thigh muscle co-contractions were higher in OF than in ONF in all three conditions. OF also demonstrated higher shank muscle co-contraction under the internal relative to the goal-directed condition, with no such change observed in ONF. CONCLUSION: Despite no significant between-group differences in functional balance and balance confidence, relative walking inefficiencies were observed in OF compared with ONF. This finding demonstrates the debilitating consequences of falling that can occur with relative independence from various physiological or psychological factors that are commonly associated with falling and used to rationalise behavioural change. We also provide evidence that OF are more susceptible to conditions that provoke them to allocate attention internally. Therefore, in clinical contexts (e.g. gait rehabilitation), verbal instructions that refer to body movements (internal focus) might serve to compromise movement efficiency in older adults with a history of falls. Such changes will, theoretically, lessen the ability to react efficiently to changing environments experienced in daily life.

Revisiting the Relationship Between Internal Focus and Balance Control in Young and Older Adults.

Research highlights the detrimental effect that directing too much conscious attention toward movement can have on postural control. While this concept has received support from many studies, recent evidence demonstrates that this principle does not always translate to aging clinical populations. Given the increasing clinical interest in this topic, the current study evaluated if the original notion (that an internal focus results in compromised balance performance) is upheld in young and older adults during a challenging balance task where we are able to objectively corroborate changes in attentional focus; using an electroencephalography (EEG) method previously identified as an objective indicator of conscious movement control. This method assesses the neural coherence, or "communication," between T3 (verbal-analytical) and Fz (motor-planning) regions of the brain. Thirty-nine young and 40 older adults performed a challenging balance task while holding a 2-meter pole under two randomized conditions: Baseline and Internal focus of attention (directing attention internally toward movement production). Results showed that young adults demonstrated increased EEG T3-Fz coherence in conjunction with increased sway path during the Internal focus condition. However, no significant differences were observed in older adults between conditions for any measure. The current study provides supporting evidence for the detrimental effect that adopting an Internal focus can have on postural control-especially in populations able to govern these processes in a relatively "automatic" manner (e.g., young adults). However, this work illustrates that such observations may not readily translate between populations and are not robust to age-related changes. Further work is necessary to examine mechanisms underlying this clear translational issue.