Effects of Combined vs. Sequential Attentional Focus Instructions on Upper Extremity Function in Subacute Stroke
Trial statusRecruiting
Trial phaseNot applicable
Trial typeInterventional
Biological sexAll
Age40-80
SponsorBahçeşehir University
About this trial
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 criteria
This trial does not accept healthy volunteersQualifiers
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).
Disqualifiers
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.
Trial design
Design model
Parallel
Treatments tested in this trial
Combined Focus of Attention Instructions
Other interventionParticipants 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.
Sequential Focus of Attention Instructions
Other interventionParticipants 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").
standart rehabilitation program
Other interventionAll 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.
Treatment groups
36 Participants
are divided into 3 treatment groupsGroup A: Combined Focus of Attention Group (CFAG)Experimental treatment 2 interventions
Group B: Sequential Focus of Attention Group (SFAG)Experimental treatment 2 interventions
Group C: Control GroupActive comparator 1 intervention
Trial outcomes
Primary outcomes
1
Fugl Meyer Assessment- Upper Extremity Subscore
The Fugl-Meyer Assessment for the Upper Extremity (FMA-UE) is a validated scale used to evaluate motor control, coordination, and functional performance of the affected arm in stroke patients. Scores range from 0 to 66, with higher scores indicating better motor function.
Time frame
baseline, four weeks after the baselineSecondary outcomes
1
Fugl-Meyer Assessment-Total Score
The Fugl-Meyer Assessment (FMA) is a validated scale widely used in stroke rehabilitation to evaluate upper extremity motor function, coordination, balance, and range of motion. Scores range from 0 to 66 for the upper extremity, with higher scores indicating better function; it allows classification of motor impairment as mild, moderate, or severe.
Time frame
baseline, four weeks after the baseline2
Action Research Arm Test
The Action Research Arm Test (ARAT) is a validated scale used to assess upper limb function, including grasp, grip, pinch, and gross movements. Scores range from 0 to 57, with higher scores indicating better function, helping identify specific deficits and guide rehabilitation planning.
Time frame
baseline, four weeks after the baseline3
Wolf Motor Function Test
The Wolf Motor Function Test (WMFT) is a validated tool used to assess upper extremity motor function in stroke patients, evaluating both movement quality and task completion time across functional and strength-based activities. Scores range from 0 to 75, with higher scores indicating better motor performance.
Time frame
baseline, four weeks after the baselineSponsors and contacts
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Source ClinicalTrials.gov