Background and Purpose—: Neurophysiological models of rehabilitation and recovery suggest that a large volume of specific practice is required to induce the neuroplastic changes that underlie behavioral recovery. The primary objective of this meta-analysis was to explore the relationship between time scheduled for therapy and improvement in motor therapy for adults after stroke by (1) comparing high doses to low doses and (2) using metaregression to quantify the dose–response relationship further. Methods—: Databases were searched to find randomized controlled trials that were not dosage matched for total time scheduled for therapy. Regression models were used to predict improvement during therapy as a function of total time scheduled for therapy and years after stroke. Results—: Overall, treatment groups receiving more therapy improved beyond control groups that received less ( g =0.35; 95% confidence interval, 0.26–0.45). Furthermore, increased time scheduled for therapy was a significant predictor of increased improvement by itself and when controlling for linear and quadratic effects of time after stroke. Conclusions—: There is a positive relationship between the time scheduled for therapy and therapy outcomes. These data suggest that large doses of therapy lead to clinically meaningful improvements, controlling for time after stroke. Currently, trials report time scheduled for therapy as a measure of therapy dose. Preferable measures of dose would be active time in therapy or repetitions of an exercise.

The objective of this analysis was to systematically review the evidence for virtual reality (VR) therapy in an adult post-stroke population in both custom built virtual environments (VE) and commercially available gaming systems (CG). MEDLINE, CINAHL, EMBASE, ERIC, PSYCInfo, DARE, PEDro, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were systematically searched from the earliest available date until April 4, 2013. Controlled trials that compared VR to conventional therapy were included. Population criteria included adults (>18) post-stroke, excluding children, cerebral palsy, and other neurological disorders. Included studies were reported in English. Quality of studies was assessed with the Physiotherapy Evidence Database Scale (PEDro). Twenty-six studies met the inclusion criteria. For body function outcomes, there was a significant benefit of VR therapy compared to conventional therapy controls, G = 0.48, 95% CI = [0.27, 0.70], and no significant difference between VE and CG interventions (P = 0.38). For activity outcomes, there was a significant benefit of VR therapy, G = 0.58, 95% CI = [0.32, 0.85], and no significant difference between VE and CG interventions (P = 0.66). For participation outcomes, the overall effect size was G = 0.56, 95% CI = [0.02, 1.10]. All participation outcomes came from VE studies. VR rehabilitation moderately improves outcomes compared to conventional therapy in adults post-stroke. Current CG interventions have been too few and too small to assess potential benefits of CG. Future research in this area should aim to clearly define conventional therapy, report on participation measures, consider motivational components of therapy, and investigate commercially available systems in larger RCTs. Prospero CRD42013004338

Research on the focus of attention has begun exploring the physiological changes that underlie the difference between internal and external foci of attention. However, previous electromyography studies have used dynamic tasks, making it difficult to interpret electrophysiological data. The authors analyzed how the focus of attention affects a subject's ability to perform an isometric force production task (focus was directed either at the force platform or the muscles responsible for force production). Subjects received practice without attentional focus instructions and then completed blocks of trials with an external and internal attentional focus separately. An external focus led to significantly less error overall and reduced surface electromyography activity with lower median power frequencies in the antagonist muscle, but attentional focus had no effects on the agonist muscle. Thus, an external focus of attention led to more efficient motor unit recruitment patterns (reduced cocontraction) and improved performance. Posttest surveys revealed subjects were aware of their improved performance with an external focus.

Research on the focus of attention (FOA) in motor control has found a consistent advantage for focusing externally (on the effects of one's actions) compared to focusing internally (on one's body mechanics). However, most of this work has concentrated on movement outcomes, leaving open the question of how external attention changes the movement itself. Somewhat paradoxically, recent research has found that external attention also increases trial-by-trial movement variability. To explain these findings, we propose a theory of attention in motor control, grounded in optimal control theory, wherein variability is minimized along attended aspects of the movement. Internal attention thus reduces variability in individual bodily dimensions (positions and velocities of effectors), whereas external attention minimizes variability in the task outcome. Because the goal of a task defines a dimension in the movement space that is generally oblique to bodily dimensions, external attention should increase correlations among bodily dimensions while allowing their individual variances to grow. The current experiment tests these predictions in a dart-throwing task. External FOA led to more accurate performance and increased variability in the motion of the throwing arm, concomitant with stronger correlations among bodily dimensions (shoulder, elbow, and wrist positions and velocities) in a manner consistent with the task kinematics. These findings indicate a shift in the control policy of the motor system, consistent with the proposed theory. These results suggest an important role of attention as a control parameter in the regulation of the motor system, and more broadly illustrate the importance of cognitive mechanisms in motor behavior.