Direction of attentional focus in prosthetic training: Current practice and potential for improving motor learning in individuals with lower limb loss.

OBJECTIVE: Adopting an external focus of attention has been shown to benefit motor performance and learning. However, the potential of optimizing attentional focus for improving prosthetic motor skills in lower limb prosthesis (LLP) users has not been examined. In this study, we investigated the frequency and direction of attentional focus embedded in the verbal instructions in a clinical prosthetic training setting. METHODS: Twenty-one adult LLP users (8 female, 13 male; 85% at K3 level; mean age = 50.5) were recruited from prosthetic clinics in the Southern Nevada region. Verbal interactions between LLP users and their prosthetists (mean experience = 10 years, range = 4-21 years) during prosthetic training were recorded. Recordings were analyzed to categorize the direction of attentional focus embedded in the instructional and feedback statements as internal, external, mixed, or unfocused. We also explored whether LLP users' age, time since amputation, and perceived mobility were associated with the proportion of attentional focus statements they received. RESULTS: We recorded a total of 20 training sessions, yielding 904 statements of instruction from 338 minutes of training. Overall, one verbal interaction occurred every 22.1 seconds. Among the statements, 64% were internal, 9% external, 3% mixed, and 25% unfocused. Regression analysis revealed that female, older, and higher functioning LLP users were significantly more likely to receive internally-focused instructions (p = 0.006, 0.035, and 0.024, respectively). CONCLUSIONS: Our results demonstrated that verbal instructions and feedback are frequently provided to LLP users during prosthetic training. Most verbal interactions are focused internally on the LLP users' body movements and not externally on the movement effects. IMPACT STATEMENT: While more research is needed to explore how motor learning principles may be applied to improve LLP user outcomes, clinicians should consider adopting the best available scientific evidence during treatment. Overreliance on internally-focused instructions as observed in the current study may hinder prosthetic skill learning.

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.