PT Critically Appraised Topics

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Critically Appraised Topic

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Clinical Scenario

The patient who led me to pursue this question is a 79 year-old female with a diagnosis of an acute exacerbation of congestive heart failure who ambulates short distances with a front-wheeled walker (FWW) at baseline. Medical treatment to date has included intravenous Lasix for three days, daily weighing, implementation of a ‘cardiac diet’, and daily physical therapy. The patient was also instructed to ambulate three times per day with nursing and to sit up in a recliner chair three times per day for at least 1-hour each, preferably during meals. Problems identified include deconditioning due to illness, gait deviation, impaired balance and decreased activity tolerance. When I saw her one day after hospital admission, she required moderate assistance for transfers and minimal assistance during ambulation with verbal cues required to maintain posture, take larger strides, and widen her base of support. During ambulation with this patient, I noticed that I was being inconsistent with my focus of attention during verbal cues, switching between internal focus (e.g., “try and make your steps larger”) and external focus (e.g., “look up at that exit sign down the hall when you walk”). Both types of verbal cues seemed somewhat effective, although the external focus seemed to have a longer-lasting effect during treatment than the internal focus, which the patient seemed to easily forget.

Clinical Question

Is an external focus of attention more effective than an internal focus of attention when providing older adults with verbal cues for ambulation with an assistive device in the acute care setting?

Clinical Bottom Line

Based on the results of the two studies by Chiviacowsky et al., and Wulf et al., it is beneficial to provide healthy adults an external focus of attention, and that focus should be specific to the task goal of the individual. Chiviacowsky and colleagues found that the type of focus of attention (i.e., internal focus on self or external focus on a platform) showed no difference on motor performance during the practice or acquisition phase of a skill in which participants were asked to maintain balance on a teeter-totter like device called a stabilometer. However, the external focus group showed statistically significant improvements over the internal focus group at the retention test the following day, indicating better motor learning. Wulf and colleagues found that not only does focus of attention (internal versus external) impact the amount of excursion and frequency of adjustments during a balance task in which participants were asked to balance on an inflated rubber disc over a force place while simultaneously holding a pole horizontal, but so does the task to which that attention is directed (the pole versus the disc). When participants were asked to use an external focus of attention, their frequency of adjustments increased and total excursion decreased in the task to which their attention was directed. The authors proposed that the increased frequency of adjustments (as measured by mean power frequency of either the force plate vector adjustments or the excursion of the pole) and decreased total excursion (as measured by root mean square error of the force plate vector adjustments or the excursion of the pole) demonstrated that an individual was using more automatic control processes to maintain balance and less voluntary self-adjustments. Although both studies had a PEDro score of 5/10, they varied greatly in internal validity threats. The Chiviacowsky et al. study lacked blinding of the investigators, which was a minor threat. The Wulf et al. study not only lacked the blinding of investigators, it also had insufficient number and duration of trials to yield good reliability1, and had a very poor analysis and interpretation of the data making the article difficult to follow. Both studies were laboratory based and used healthy adult populations, making the results difficult to extrapolate to a broader population. Both study designs could have benefited from using a less healthy adult population subset, such as adults with stable, compensated, congestive heart failure as these adults may present more like those in the acute care setting. While the stabilometer used in both studies yields very accurate quantitative data, it would be helpful to use an outcome measure that is easily accessible to a clinician such as the Berg Balance Scale. Both studies analyzed balance, but balance is only one component of gait that is addressed during ambulatory training in the acute care setting. Many other components of gait would need to be addressed in order to fully answer my clinical question such as motor planning, muscular strength, and neurological coordination. Further research in this area may help to decrease the overall cost of healthcare by providing individuals with the most effective form of verbal cues, which could decrease the total number of treatment sessions and potentially shorten the length of hospital stay by increasing motor learning and not simply motor performance.