Combined versus sequential attentional focus instructions for upper limb recovery after subacute stroke

The Effect of Combined Versus Sequential Attentional Focus Instructions on Upper Extremity Function in Subacute Stroke Patients: An Assessor-Blinded Randomized Controlled Trial

This trial will test whether using combined or sequential attentional focus instructions during rehab helps people aged 40–80 in the subacute phase of stroke improve movement and everyday use of their affected arm.

Quick facts

• Phase: Not applicable
• Study type: Interventional
• Enrollment: 36 (estimated)
• Ages: 40 Years to 80 Years
• Sex: All
• Sponsor: Bahçeşehir University (Academic / other)
• Locations: 1 site (Istanbul)
• Trial ID: NCT07289308 on ClinicalTrials.gov

What this trial studies

The trial compares three approaches: combined external and internal attentional focus instructions, sequential use of internal then external focus, and a standard rehabilitation program delivered in the subacute window (1 week to 6 months post-stroke). Participants who meet motor and cognitive criteria will receive standardized upper-extremity training while therapists deliver specific verbal cues that emphasize either body-focused (internal) or effect-focused (external) attention, or combinations/sequencing of both. Outcomes include impairment and functional measures such as the Fugl-Meyer Assessment, Wolf Motor Function Test, and Action Research Arm Test measured before and after the intervention and at follow-up. The aim is to see if integrating motor learning–based attentional focus strategies produces greater functional recovery than standard instruction alone.

Who should consider this trial

Good fit: Ideal candidates are medically stable adults aged 40–80 who are 1 week to 6 months post-stroke, have Brunnstrom stage 2–5 in the affected arm, Modified Ashworth Scale <3, and sufficient cognition to follow therapy instructions.

Not a fit: Patients with severe cognitive deficits, high spasticity (MAS ≥3), very mild or very severe paralysis outside Brunnstrom stages 2–5, or who cannot attend the Istanbul sites are unlikely to benefit from this protocol.

Why it matters

Potential benefit: If successful, these instruction strategies could make routine rehab sessions more effective and help patients regain more usable arm function for daily activities.

How similar studies have performed: Motor-learning research has shown external focus often improves movement automaticity and small post-stroke trials report benefits from attentional focus cues, but direct comparisons of combined versus sequential approaches remain relatively untested in larger stroke populations.

Eligibility criteria

Inclusion Criteria:

1. Age 40-80 years at enrollment (Kwakkel et al., 1996; Coupar et al., 2012).
2. Stroke diagnosed by a neurologist between 1 week and 6 months before enrollment (Langhorne et al., 2020; Bernhardt et al., 2017).
3. 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).
4. 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).
5. Brunnstrom stage 2-5 in the affected upper limb (Brunnstrom, 1970; Langhorne et al., 2020).
6. Individuals with a Modified Ashworth Scale (MAS) score \<3: Participants were required to have a MAS score of less than 3 in both the upper and lower extremities to ensure that spasticity remained at a manageable level and to allow safe participation in upper-limb motor rehabilitation (Pandyan et al., 2005; Li \& Francisco, 2015; Ada et al., 2020).
7. Preserved corticospinal tract integrity, confirmed by a positive Motor Evoked Potential (MEP) response (Stinear et al., 2017; Byblow et al., 2015; Stinear et al., 2020).
8. Moderate to severe upper-extremity motor impairment, determined by Fugl-Meyer Assessment (FMA) scores of 0-47 (0-19 severe, 20-47 moderate) (Fugl-Meyer et al., 1975).

Exclusion Criteria:

* 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.
* Concurrent rehabilitation: Individuals who were concurrently receiving rehabilitation treatment at another facility were excluded to prevent potential confounding effects from parallel interventions (Winstein et al., 2016).
* Non-adherence to treatment sessions: Participants who failed to attend all required treatment sessions were excluded to ensure consistency and fidelity of the intervention protocol (Winstein et al., 2016).

Where this trial is running

Istanbul

• Neur-On Clinic, İstinye University, Bahcesehir Liv Hospital Stroke Center — Istanbul, Turkey (Türkiye) (Recruiting)

Study contacts

• Principal investigator: Emirhan Kocer, PT — Bahcesehir University, Graduate Education Institute
• Study coordinator: Pelin Pisirici, PT, PhD

Conditions Stroke; Upper Extremity Dysfunction; Cue, Threat; Wolf Motor Function Test; Motor Learning; Functional Recovery; Fugl-Meyer Assessment; Action Research Arm Test