Essential Role of Social Context and Self-Efficacy in Daily Paretic Arm/Hand Use After Stroke: An Ecological Momentary Assessment Study With Accelerometry.

OBJECTIVE: To determine the momentary effect of social-cognitive factors, in addition to motor capability, on post-stroke paretic arm/hand use in the natural environment. DESIGN: A 5-day observational study in which participants were sent 6 Ecological Momentary Assessment (EMA) prompts/day. SETTING: Participants' daily environment. PARTICIPANTS: Community-dwelling, chronic stroke survivors with right-dominant, mild-moderate upper extremity paresis (N=30). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Time duration of bimanual and unimanual paretic arm/hand use indexed by accelerometry; social-cognitive factors (social context, self-efficacy, mood) captured by EMA; motor capability of the paretic limb measured by Fugl-Meyer Upper Extremity Motor Assessment (FM). RESULTS: After accounting for participants' motor capability, we found that momentary social context (alone or not) and self-efficacy significantly predicted post-stroke paretic arm/hand use behavior in the natural environment. When participants were not alone, paretic arm/hand movement increased both with and without the less-paretic limb (bimanual and unimanual movements, P=.018 and P<.001, respectively). Importantly, participants were more likely to use their paretic arm/hand (unimanually) if they had greater self-efficacy for limb use (P=.042). EMA repeated-measures provide a real-time approach that captures the natural dynamic ebb and flow of social-cognitive factors and their effect on daily arm/hand use. We also observed that people with greater motor impairments (FM<50.6) increase unimanual paretic arm/hand movements when they are not alone, regardless of motor capability. CONCLUSIONS: In addition to motor capability, stroke survivors' momentary social context and self-efficacy play a role in paretic arm/hand use behavior. Our findings suggest the development of personalized rehabilitative interventions which target these factors to promote daily paretic arm/hand use. This study highlights the benefits of EMA to provide real-time information to unravel the complexities of the biopsychosocial (ie, motor capability and social-cognitive factors) interface in post-stroke upper extremity recovery.

Expectancy and affective response to challenging balance practice conditions in individuals with Parkinson's disease.

Psychological states can influence motor performance and learning. In Parkinson's disease (PD), placebo effects or expectancies for pharmacological treatment benefits are not uncommon, but little is known about whether self-efficacy, beliefs about personal performance capabilities, may play a role in this population. To address this question, we investigated whether experimental manipulations designed to enhance self-efficacy would benefit motor performance and learning in PD. A motor learning paradigm was utilized to determine the short-term (i.e., practice) and longer-term (i.e., retention) impact of self-efficacy enhancement when 44 individuals with PD (Hoehn and Yahr stage I-III) acquired a challenging balance skill. Using stratified randomization by Hoehn and Yahr stage, participants were assigned to a control group or one of two investigational groups: (a) an expectancy-relevant statement that encouraged an incremental mindset in which the balance skill, though initially challenging, was acquirable with practice (incremental theory group, IT), and (b) the expectancy-relevant statement in combination with a criterion for successful performance (incremental theory plus success criteria group, IT + SC). All groups improved their balance performance, but contrary to expectations, investigational groups did not outperform the control group at practice or retention. Unexpectedly, the IT + SC group reported greater nervousness than the control and IT groups, suggesting that the employed success criteria may have induced performance-related anxiety. Regression analyses revealed that self-efficacy increase from initial practice predicted performance at the end of practice and at retention. These findings highlight the potential contribution of psychological factors on motor function and rehabilitation in individuals with PD.

Choices enhance punching performance of competitive kickboxers.

While self-controlled practice has been shown to enhance motor learning with various populations and novel tasks, it remains unclear if such effects would be found with athletes completing familiar tasks. Study 1 used a single case-study design with a world-champion kickboxer. We investigated whether giving the athlete a choice over the order of punches would affect punching velocity and impact force. Separated by 1 min of rest, the athlete completed 2 rounds of 12 single, maximal effort punches (lead straight, rear straight, lead hook and rear hook) delivered to a punching integrator in a counterbalanced order over six testing days. In one round the punches were delivered in a predetermined order while in the second round the order was self-selected by the athlete. In the choice condition, the world champion punched with greater velocities (6-11 %) and impact forces (5-10 %). In Study 2, the same testing procedures were repeated with 13 amateur male kickboxers over 2 testing days. Similar to Study 1, the athletes punched with significantly greater velocities (6 %, p < 0.05) and normalised impact forces (2 %, p < 0.05) in the choice condition. These findings complement research on autonomy support in motor learning by demonstrating immediate advantages in force production and velocity with experienced athletes.

Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial.

IMPORTANCE: Clinical trials suggest that higher doses of task-oriented training are superior to current clinical practice for patients with stroke with upper extremity motor deficits. OBJECTIVE: To compare the efficacy of a structured, task-oriented motor training program vs usual and customary occupational therapy (UCC) during stroke rehabilitation. DESIGN, SETTING, AND PARTICIPANTS: Phase 3, pragmatic, single-blind randomized trial among 361 participants with moderate motor impairment recruited from 7 US hospitals over 44 months, treated in the outpatient setting from June 2009 to March 2014. INTERVENTIONS: Structured, task-oriented upper extremity training (Accelerated Skill Acquisition Program [ASAP]; n = 119); dose-equivalent occupational therapy (DEUCC; n = 120); or monitoring-only occupational therapy (UCC; n = 122). The DEUCC group was prescribed 30 one-hour sessions over 10 weeks; the UCC group was only monitored, without specification of dose. MAIN OUTCOMES AND MEASURES: The primary outcome was 12-month change in log-transformed Wolf Motor Function Test time score (WMFT, consisting of a mean of 15 timed arm movements and hand dexterity tasks). Secondary outcomes were change in WMFT time score (minimal clinically important difference [MCID] = 19 seconds) and proportion of patients improving ≥25 points on the Stroke Impact Scale (SIS) hand function score (MCID = 17.8 points). RESULTS: Among the 361 randomized patients (mean age, 60.7 years; 56% men; 42% African American; mean time since stroke onset, 46 days), 304 (84%) completed the 12-month primary outcome assessment; in intention-to-treat analysis, mean group change scores (log WMFT, baseline to 12 months) were, for the ASAP group, 2.2 to 1.4 (difference, 0.82); DEUCC group, 2.0 to 1.2 (difference, 0.84); and UCC group, 2.1 to 1.4 (difference, 0.75), with no significant between-group differences (ASAP vs DEUCC: 0.14; 95% CI, -0.05 to 0.33; P = .16; ASAP vs UCC: -0.01; 95% CI, -0.22 to 0.21; P = .94; and DEUCC vs UCC: -0.14; 95% CI, -0.32 to 0.05; P = .15). Secondary outcomes for the ASAP group were WMFT change score, -8.8 seconds, and improved SIS, 73%; DEUCC group, WMFT, -8.1 seconds, and SIS, 72%; and UCC group, WMFT, -7.2 seconds, and SIS, 69%, with no significant pairwise between-group differences (ASAP vs DEUCC: WMFT, 1.8 seconds; 95% CI, -0.8 to 4.5 seconds; P = .18; improved SIS, 1%; 95% CI, -12% to 13%; P = .54; ASAP vs UCC: WMFT, -0.6 seconds, 95% CI, -3.8 to 2.6 seconds; P = .72; improved SIS, 4%; 95% CI, -9% to 16%; P = .48; and DEUCC vs UCC: WMFT, -2.1 seconds; 95% CI, -4.5 to 0.3 seconds; P = .08; improved SIS, 3%; 95% CI, -9% to 15%; P = .22). A total of 168 serious adverse events occurred in 109 participants, resulting in 8 patients withdrawing from the study. CONCLUSIONS AND RELEVANCE: Among patients with motor stroke and primarily moderate upper extremity impairment, use of a structured, task-oriented rehabilitation program did not significantly improve motor function or recovery beyond either an equivalent or a lower dose of UCC upper extremity rehabilitation. These findings do not support superiority of this program among patients with motor stroke and primarily moderate upper extremity impairment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00871715.

Additive benefits of external focus and enhanced performance expectancy for motor learning.

The authors examined the individual and combined influences of 2 factors that have been shown to benefit motor learning: an external focus of attention and enhanced performance expectancies. Another purpose of this study was to gain further insight into the mechanisms underlying these variables. In a factorial design, participants learning a novel motor skill (i.e., throwing with the non-dominant arm) were or were not given external focus instructions, and were or were not provided bogus positive social-comparative feedback to enhance their expectancies. This resulted in 4 groups: external focus, enhanced expectancy, external focus/enhanced expectancy and control. External focus instructions and enhanced expectancies had additive benefits for learning: the external focus/enhanced expectancy group demonstrated the greatest throwing accuracy on both retention and transfer tests, while the accuracy scores of the external focus and enhanced expectancy groups were lower, but higher than those of the control group. Furthermore, self-efficacy was increased by both external focus and enhanced expectancy, and predicted retention and transfer performance. Positive affect was heightened in the enhanced expectancy and external focus/enhanced expectancy groups after practice and predicted transfer performance. The findings suggest that the learning benefits of an external focus and enhanced expectancies mediate learning through partially different mechanisms.

Infusing motor learning research into neurorehabilitation practice: a historical perspective with case exemplar from the accelerated skill acquisition program.

UNLABELLED: : This special interest article provides a historical framework with a contemporary case example that traces the infusion of the science of motor learning into neurorehabilitation practice. The revolution in neuroscience provided the first evidence for learning-dependent neuroplasticity and presaged the role of motor learning as critical for restorative therapies after stroke. The scientific underpinnings of motor learning have continued to evolve from a dominance of cognitive or information processing perspectives to a blend with neural science and contemporary social-cognitive psychological science. Furthermore, advances in the science of behavior change have contributed insights into influences on sustainable and generalizable gains in motor skills and associated behaviors, including physical activity and other recovery-promoting habits. For neurorehabilitation, these insights have tremendous relevance for the therapist-patient interactions and relationships. We describe a principle-based intervention for neurorehabilitation termed the Accelerated Skill Acquisition Program that we developed. This approach emphasizes integration from a broad set of scientific lines of inquiry including the contemporary fields of motor learning, neuroscience, and the psychological science of behavior change. Three overlapping essential elements-skill acquisition, impairment mitigation, and motivational enhancements-are integrated. VIDEO ABSTRACT AVAILABLE: (See Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A71) for more insights from the authors.

Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE): a randomized controlled trial protocol.

BACKGROUND: Residual disability after stroke is substantial; 65% of patients at 6 months are unable to incorporate the impaired upper extremity into daily activities. Task-oriented training programs are rapidly being adopted into clinical practice. In the absence of any consensus on the essential elements or dose of task-specific training, an urgent need exists for a well-designed trial to determine the effectiveness of a specific multidimensional task-based program governed by a comprehensive set of evidence-based principles. The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) Stroke Initiative is a parallel group, three-arm, single blind, superiority randomized controlled trial of a theoretically-defensible, upper extremity rehabilitation program provided in the outpatient setting.The primary objective of ICARE is to determine if there is a greater improvement in arm and hand recovery one year after randomization in participants receiving a structured training program termed Accelerated Skill Acquisition Program (ASAP), compared to participants receiving usual and customary therapy of an equivalent dose (DEUCC). Two secondary objectives are to compare ASAP to a true (active monitoring only) usual and customary (UCC) therapy group and to compare DEUCC and UCC. METHODS/DESIGN: Following baseline assessment, participants are randomized by site, stratified for stroke duration and motor severity. 360 adults will be randomized, 14 to 106 days following ischemic or hemorrhagic stroke onset, with mild to moderate upper extremity impairment, recruited at sites in Atlanta, Los Angeles and Washington, D.C. The Wolf Motor Function Test (WMFT) time score is the primary outcome at 1 year post-randomization. The Stroke Impact Scale (SIS) hand domain is a secondary outcome measure.The design includes concealed allocation during recruitment, screening and baseline, blinded outcome assessment and intention to treat analyses. Our primary hypothesis is that the improvement in log-transformed WMFT time will be greater for the ASAP than the DEUCC group. This pre-planned hypothesis will be tested at a significance level of 0.05. DISCUSSION: ICARE will test whether ASAP is superior to the same number of hours of usual therapy. Pre-specified secondary analyses will test whether 30 hours of usual therapy is superior to current usual and customary therapy not controlled for dose. TRIAL REGISTRATION: www.ClinicalTrials.gov Identifier: NCT00871715

Discriminant validity of a new measure of self-efficacy for reaching movements after stroke-induced hemiparesis.

STUDY DESIGN: Case-control study. INTRODUCTION: After stroke, difficulties in motor control mediate spontaneous paretic arm use in real life. Along with the obvious motor impairments, self-efficacy has been shown to be an important modifier for physical function. However, a self-efficacy measure for arm reaching is lacking. The aim of this study was to develop such a measure and to examine its validity. METHODS: Fifteen participants with hemiparesis and ten control participants were recruited. A measure of reaching self-efficacy (RSE) was developed using a two-dimensional center-out target array. RESULTS: For the control group, RSE was significantly correlated with target distance (r = -0.657) and location (r = -0.545), respectively. Additionally, average RSE was lower for the non-dominant than the dominant hand (p < 0.001). More importantly, for the stroke group, RSE was significantly correlated with target distance (r = -0.603) and location (r = -0.378), respectively. Finally, average RSE was lower for the paretic than the non-paretic hand (p < 0.001). CONCLUSIONS: These results demonstrate robust discriminant validity for this new measure of reaching self-efficacy. LEVEL OF EVIDENCE: 3b.

Enhanced expectancies improve movement efficiency in runners.

We followed up on recent findings demonstrating that enhancing performers' expectancies can improve their performance. Specifically, we examined whether providing experienced runners with positive feedback regarding their movement efficiency would increase running efficiency. Two groups of experienced runners ran on a treadmill at 75% of their maximum oxygen consumption (VO(2max)) for 10 min. One group (enhanced expectancy) was provided with (fabricated) feedback about the efficiency of their running style every 2 min. A control group was not given feedback. Oxygen consumption decreased in the enhanced expectancy group across measurement times (every 2 min for 10 min), but remained the same in the control group. In addition, performance perceptions changed only in the enhanced expectancy group, indicating a perception of greater ease of running and reduced fatigue when assessed after compared with before running. Finally, positive affect increased from a pre- to a post-test in the enhanced expectancy group, in contrast to the control group. Our findings show that enhanced expectancies can have a positive effect on movement efficiency and running experience. They add to the accumulating evidence for the social-cognitive-affective-motor nature of motor performance.

Different Patterns of Neural Activity Characterize Motor Skill Performance During Acquisition and Retention.

Motor performance and learning have distinct behavioral and neural signatures and can be uniquely modulated by various informational and motivational factors. Contemporary frameworks describe four different motor learning mechanisms mapped onto specific neural regions which are key for motor skill acquisition: error-based learning (cerebellum), reinforcement learning (basal ganglia), cognitive strategies (prefrontal cortex), and use-dependent learning (motor cortex). However, little is known about the neural circuits engaged during skill acquisition that are modulated specifically by practice-based performance improvement and those that predict recall performance. Based on previous work, we hypothesize that brain activity during practice in primary motor cortex and basal ganglia (1) is associated with trial-by-trial practice performance and (2) is predictive of immediate recall performance. Leveraging the contemporary framework, we use a well-known task paradigm that primarily relies upon cognitive strategy, reinforcement, and use-based learning mechanisms to test our hypotheses. Forty neurotypical young adults were asked to practice a pinch force tracking task. Participants received performance feedback after each trial during practice. We used whole brain analysis of functional magnetic resonance imaging (fMRI) and behavioral performance measures (i.e., time-on-target and self-efficacy) during the practice phase to determine which brain activation patterns are (1) associated with trial-by-trial tracking performance and (2) predictive of immediate no-feedback retention performance. We observed brain activations in the frontal orbital cortex, putamen, amygdala, and insula correlated with tracking performance improvement during practice. In contrast, a different set of performance-related activated regions were observed that were associated with immediate retention performance that included the primary motor cortex, superior frontal gyrus, somatosensory cortex, angular gyrus, and parietal gyrus. Our findings demonstrate that improved practice performance and recall of a sensorimotor skill are correlated with distinct neural activity patterns during acquisition, drawing on different motor learning mechanisms during encoding. While motor performance improvements depend on both cortical and subcortical regions, motor skill recall depends primarily on prefrontal and motor cortices. We discuss possible interpretations for why our hypothesis regarding basal ganglia activity and retention performance was not supported. Understanding the different neural mechanisms engaged in motor performance and learning may inform novel interventions to enhance motor skill learning.

Mechanisms of the contextual interference effect in individuals poststroke.

Although intermixing different motor learning tasks via random schedules enhances long-term retention compared with "blocked" schedules, the mechanism underlying this contextual interference effect has been unclear. Furthermore, previous studies have reported inconclusive results in individuals poststroke. We instructed participants to learn to produce three grip force patterns in either random or blocked schedules and measured the contextual interference effect by long-term forgetting: the change in performance between immediate and 24-h posttests. Nondisabled participants exhibited the contextual interference effect: no forgetting in the random condition but forgetting in the blocked condition. Participants at least 3 mo poststroke exhibited no forgetting in the random condition but marginal forgetting in the blocked condition. However, in participants poststroke, the integrity of visuospatial working memory modulated long-term retention after blocked schedule training: participants with poor visuospatial working memory exhibited little forgetting at 24 h. These counterintuitive results were predicted by a computational model of motor memory that contains a common fast process and multiple slow processes, which are competitively updated by motor errors. In blocked schedules, the fast process quickly improved performance, therefore reducing error-driven update of the slow processes and thus poor long-term retention. In random schedules, interferences in the fast process led to slower change in performance, therefore increasing error-driven update of slow processes and thus good long-term retention. Increased forgetting rates in the fast process, as would be expected in individuals with visuospatial working memory deficits, led to small updates of the fast process during blocked schedules and thus better long-term retention.

Superiority of external attentional focus for motor performance and learning: Systematic reviews and meta-analyses.

Considerable literature on the role of attentional focus in motor performance and learning has accumulated for over two decades. We report the results of comprehensive meta-analyses that address the impact of an external focus (EF, on intended movement effects) versus internal focus (IF, on movements of body parts) of attention on the performance and learning of motor skills. Values of effect sizes (ES) from 73 studies with 1,824 participants and 40 studies with 1,274 participants were used for examining the effects of EF versus IF on behavioral outcomes of motor performance and learning (separately for retention and transfer phases) respectively. The EF condition was more effective than the IF condition for performance, Hedges' g value = 0.264 (95% CI [0.217, 0.310]), retention learning, Hedges' g value = 0.583 (95% CI [0.425, 0.741]), and transfer learning, Hedges' g value = 0.584 (95% CI [0.325, 0.842]). Multivariable metaregression analyses on behavioral measures further indicated that neither age group, health status, or skill level, nor their two-way interactions, moderated the ES differences between EF and IF in performance, retention, and transfer models (all p > .100). A secondary analysis on 12 studies with 216 participants that examined the effects of EF versus IF on electromyographic outcomes of motor performance also indicated that EF was associated with more efficient neuromuscular processing, Hedges' g value = 0.833 (95% CI [0.453, 1.213]). From nine studies with 272 participants, performance measured by behavioral outcomes was found to be more effective when a more distal, rather than proximal, EF was used, Hedges' g value = 0.224 (95% CI [0.019, 0.429]). Overall, the meta-analytic results are consistent with prior narrative reviews and indicate that an external focus is superior to an internal focus whether considering tests of motor performance or learning, and regardless of age, health condition, and level of skill expertise. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Novel Combination of Accelerometry and Ecological Momentary Assessment for Post-Stroke Paretic Arm/Hand Use: Feasibility and Validity.

Use of the paretic arm and hand is a key indicator of recovery and reintegration after stroke. A sound methodology is essential to comprehensively identify the possible factors impacting daily arm/hand use behavior. We combined ecological momentary assessment (EMA), a prompt methodology capturing real-time psycho-contextual factors, with accelerometry to investigate arm/hand behavior in the natural environment. Our aims were to determine (1) feasibility and (2) measurement validity of the combined methodology. We monitored 30 right-dominant, mild-moderately motor impaired chronic stroke survivors over 5 days (6 EMA prompts/day with accelerometers on each wrist). We observed high adherence for accelerometer wearing time (80.3%), EMA prompt response (84.6%), and generally positive user feedback upon exit interview. The customized prompt schedule and the self-triggered prompt option may have improved adherence. There was no evidence of EMA response bias nor immediate measurement reactivity. An unexpected small but significant increase in paretic arm/hand use was observed over days (12-14 min), which may be the accumulated effect of prompting that provided a reminder to choose the paretic limb. Further research that uses this combined methodology is needed to develop targeted interventions that effectively change behavior and enable reintegration post-stroke.

Motor skill learning and performance: a review of influential factors.

OBJECTIVES: Findings from the contemporary psychological and movement science literature that appear to have implications for medical training are reviewed. Specifically, the review focuses on four factors that have been shown to enhance the learning of motor skills: observational practice; the learner's focus of attention; feedback, and self-controlled practice. OBSERVATIONAL PRACTICE: Observation of others, particularly when it is combined with physical practice, can make important contributions to learning. This includes dyad practice (i.e. practice in pairs), which is not only cost-effective, but can also enhance learning. FOCUS OF ATTENTION: Studies examining the role of the performer's focus of attention have consistently demonstrated that instructions inducing an external focus (directed at the movement effect) are more effective than those promoting an internal focus (directed at the performer's body movements). An external focus facilitates automaticity in motor control and promotes movement efficiency. FEEDBACK: Feedback not only has an informational function, but also has motivational properties that have an important influence on learning. For example, feedback after successful trials and social-comparative (normative) feedback indicating better than average performance have been shown to have a beneficial effect on learning. SELF-CONTROLLED PRACTICE: Self-controlled practice, including feedback and model demonstrations controlled by the learner, has been found to be more effective than externally controlled practice conditions. CONCLUSIONS: All factors reviewed in this article appear to have both informational and motivational influences on learning. The findings seem to reflect general learning principles and are assumed to have relatively broad applicability. Therefore, the consideration of these factors in designing procedures for medical training has the potential to enhance the effectiveness and efficiency of training.

Choose your words wisely: Optimizing impacts on standardized performance testing.

BACKGROUND: The OPTIMAL theory of motor learning identifies motivational (enhanced expectancies, EE, and autonomy support, AS) and attentional (an external attentional focus, EF) factors that affect motor performance and learning [1]. One implication of this theory is that standardized clinical and laboratory assessments of physical capacity and motor performance that do not incorporate optimizing conditions may underestimate true maximal capabilities. The influence of "optimized" conditions on a clinical-applied test of balance control was examined with healthy participants. Given the motor performance benefits of optimized conditions predicted by the OPTIMAL theory, it was hypothesized that providing participants with information that induced EE, provided them with AS, and promoted their use of EF would reduce balance errors and postural sway. METHODS: We used as an exemplar assessment, the Balance Error Scoring System (BESS), and center-of-pressure (COP) velocity measurements of postural sway. Participants performed under two different conditions, separated by two days: an optimized (EE, AS, and EF) condition and a control ("neutral") condition, with sample-wide order counterbalancing. In each condition, participants performed three stances (double-leg, single-leg, and tandem) on two support surfaces (firm and foam). Stance order was participant-determined in the optimized condition and, for the control condition, yoked to a participant in the optimized condition. RESULTS: Participants committed fewer balance errors in the optimized condition than in the control condition (p < .001) and their resultant COP velocity in the optimized condition was lower than that in the control condition (p = .004). BESS scores were correlated with resultant COP velocity (r = .593, p < .001). SIGNIFICANCE: Our results demonstrated the impact of implementing optimized, as opposed to "neutral" control, conditions for better insight into balance capabilities in normal and challenging situations. Practitioners' roles in mediating test situations and using subtle wording to promote optimized performance may have consequential impacts on motor assessment outcomes.

Conceptions of ability affect motor learning.

The authors examined the effects of induced conceptions of ability on motor learning. Participants in 3 groups practiced a balance task after receiving instructions suggesting that the task would reflect an inherent ability (IA group), represent an acquirable skill (AS group), or no ability-related instructions (control group). Across 2 days of practice, the AS and IA groups showed greater improvement in performance compared with the control group. For the retention test on Day 3, the AS group tended to demonstrate generally more effective balance performance than the control group and increasingly greater effectiveness compared with the IA group. Moreover, AS group participants made higher-frequency (reflexive) movement adjustments than participants of the other 2 groups, indicating a greater automaticity in the control of their movements. Thus, learning was enhanced by instructions portraying the task as a learnable skill, rather than revealing a fixed inherent capacity or no instructions (control group).

Self-efficacy and Reach Performance in Individuals With Mild Motor Impairment Due to Stroke.

BACKGROUND: Persistent deficits in arm function are common after stroke. An improved understanding of the factors that contribute to the performance of skilled arm movements is needed. One such factor may be self-efficacy (SE). OBJECTIVE: To determine the level of SE for skilled, goal-directed reach actions in individuals with mild motor impairment after stroke and whether SE for reach performance correlated with actual reach performance. METHODS: A total of 20 individuals with chronic stroke (months poststroke: mean 58.1 ± 38.8) and mild motor impairment (upper-extremity Fugl-Meyer [FM] motor score: mean 53.2, range 39 to 66) and 6 age-matched controls reached to targets presented in 2 directions (ipsilateral, contralateral). Prior to each block (24 reach trials), individuals rated their confidence on reaching to targets accurately and quickly on a scale that ranged from 0 ( not very confident) to 10 ( very confident). RESULTS: Overall reach performance was slower and less accurate in the more-affected arm compared with both the less-affected arm and controls. SE for both reach speed and reach accuracy was lower for the more-affected arm compared with the less-affected arm. For reaches with the more-affected arm, SE for reach speed and age significantly predicted movement time to ipsilateral targets ( R2 = 0.352), whereas SE for reach accuracy and FM motor score significantly predicted end point error to contralateral targets ( R2 = 0.291). CONCLUSIONS: SE relates to measures of reach control and may serve as a target for interventions to improve proximal arm control after stroke.

Practice variability promotes an external focus of attention and enhances motor skill learning.

Variability in practice has been shown to enhance motor skill learning. Benefits of practice variability have been attributed to motor schema formation (variable versus constant practice), or more effortful information processing (random versus blocked practice). We hypothesized that, among other mechanisms, greater practice variability might promote an external focus of attention on the intended movement effect, while less variability would be more conducive to a less effective internal focus on body movements. In Experiment 1, the learning of a throwing task was enhanced by variable versus constant practice, and variable group participants reported focusing more on the distance to the target (external focus), while constant group participants focused more on their posture (internal focus). In Experiment 2, golf putting was learned more effectively with a random compared with a blocked practice schedule. Furthermore, random group learners reported using a more effective distal external focus (i.e., distance to the target) to a greater extent, whereas blocked group participants used a less effective proximal focus (i.e., putter) more often. While attentional focus was assessed through questionnaires in the first two experiments, learners in Experiment 3 were asked to report their current attentional focus at any time during practice. Again, the learning of a throwing task was more effective after random relative to blocked practice. Also, random practice learners reported using more external focus cues, while in blocked practice participants used more internal focus cues. The findings suggest that the attentional foci induced by different practice schedules might be at least partially responsible for the learning differences.

Onward and upward: Optimizing motor performance.

In the OPTIMAL theory of motor learning (Wulf & Lewthwaite, 2016), three factors are postulated to facilitate motor performance and learning: Enhanced expectancies (EE) for performance, autonomy support (AS), and an external focus (EF) of attention. We examined whether EE, AS, and EF would have immediate performance benefits and whether implementing these factors consecutively would lead to incremental performance increases. Participants were assigned to the optimized or control groups and performed a maximal jump. After the first trial block (baseline), optimized group participants were provided different conditions on each of the following 3 blocks: (a) Positive social-comparative feedback (EE); (b) choice of figure on the ground from which to jump (AS); and (c) instructions to focus on a marker on their waist (EF). The order of conditions was counterbalanced. Control group participants performed all 4 blocks under the same (control) condition. The optimized group outperformed the control group on Blocks 2-4. Moreover, their jump height increased with each addition of another variable, whereas it did not change across blocks in the control group. Thus, EE, AS, and EF had additive or incremental benefits for performance. The findings corroborate the importance of key variables in the OPTIMAL theory for motor performance.

Triple play: Additive contributions of enhanced expectancies, autonomy support, and external attentional focus to motor learning.

In the OPTIMAL theory of motor learning [Wulf, G., & Lewthwaite, R. (2016). Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychonomic Bulletin & Review, 23, 1382-1414], 3 factors are postulated to facilitate learning: enhanced expectancies (EE) for performance, autonomy support (AS), and an external focus (EF) of attention. In 3 recent studies, combinations of 2 of these variables resulted in superior learning relative to the presence of only 1 variable, or none. We examined whether the combination of all 3 factors would enhance learning relative to combinations of 2 factors. Our design included EE-AS, EE-EF, AS-EF, and AS-EE-EF groups. Participants threw balls at a target with their non-dominant arm. In the EE conditions, they received positive social-comparative feedback. In the AS conditions, they were allowed to throw with their dominant arm on trial blocks chosen by them. In the EF conditions, participants were asked to focus on the target. On a delayed retention test, the AS-EE-EF group outperformed all other groups. The findings provide evidence that enhanced expectancies, autonomy support, and an external focus can contribute in an additive fashion to optimize motor learning.