{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,21]],"date-time":"2026-02-21T01:38:49Z","timestamp":1771637929145,"version":"3.50.1"},"reference-count":45,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2022,7,7]],"date-time":"2022-07-07T00:00:00Z","timestamp":1657152000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100009633","name":"Eunice Kennedy Shriver National Institute of Child Health and Human Development","doi-asserted-by":"publisher","award":["1K01HD091449"],"award-info":[{"award-number":["1K01HD091449"]}],"id":[{"id":"10.13039\/100009633","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Encompass Health Corporation","award":["2018 therapy grant"],"award-info":[{"award-number":["2018 therapy grant"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Objective<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>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\u201321 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\u2019 age, time since amputation, and perceived mobility were associated with the proportion of attentional focus statements they received.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>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).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>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\u2019 body movements and not externally on the movement effects.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec005\">\n<jats:title>Impact statement<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0262977","type":"journal-article","created":{"date-parts":[[2022,7,7]],"date-time":"2022-07-07T17:34:28Z","timestamp":1657215268000},"page":"e0262977","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":7,"title":["Direction of attentional focus in prosthetic training: Current practice and potential for improving motor learning in individuals with lower limb loss"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0398-8256","authenticated-orcid":true,"given":"Szu-Ping","family":"Lee","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander","family":"Bonczyk","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria Katrina","family":"Dimapilis","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Partridge","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Samantha","family":"Ruiz","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lung-Chang","family":"Chien","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrew","family":"Sawers","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2022,7,7]]},"reference":[{"issue":"3","key":"pone.0262977.ref001","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1016\/j.apmr.2007.11.005","article-title":"Estimating the prevalence of limb loss in the United States: 2005 to 2050","volume":"89","author":"K Ziegler-Graham","year":"2008","journal-title":"Archives of physical medicine and rehabilitation"},{"issue":"1","key":"pone.0262977.ref002","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1016\/j.pmr.2013.09.007","article-title":"Impact of limb loss in the United States.","volume":"25","author":"TP Sheehan","year":"2014","journal-title":"Physical medicine and rehabilitation clinics of North America"},{"issue":"11","key":"pone.0262977.ref003","doi-asserted-by":"crossref","first-page":"782","DOI":"10.1097\/PHM.0000000000000967","article-title":"Mobility Analysis of AmpuTees II: Comorbidities and Mobility in Lower Limb Prosthesis Users.","volume":"97","author":"SR Wurdeman","year":"2018","journal-title":"American journal of physical medicine & rehabilitation \/ Association of Academic Physiatrists"},{"issue":"9","key":"pone.0262977.ref004","doi-asserted-by":"crossref","first-page":"820","DOI":"10.1097\/PHM.0000000000001213","article-title":"Clinical Practice Guidelines for the Rehabilitation of Lower Limb Amputation An Update from the Department of Veterans Affairs and Department of Defense.","volume":"98","author":"JB Webster","year":"2019","journal-title":"Am J Phys Med Rehab"},{"issue":"5","key":"pone.0262977.ref005","doi-asserted-by":"crossref","first-page":"1382","DOI":"10.3758\/s13423-015-0999-9","article-title":"Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning","volume":"23","author":"G Wulf","year":"2016","journal-title":"Psychon Bull Rev"},{"issue":"10","key":"pone.0262977.ref006","doi-asserted-by":"crossref","first-page":"1431","DOI":"10.1682\/JRRD.2011.12.0235","article-title":"Beyond componentry: How principles of motor learning can enhance locomotor rehabilitation of individuals with lower limb loss\u2014a review","volume":"49","author":"A Sawers","year":"2012","journal-title":"Journal of rehabilitation research and development"},{"key":"pone.0262977.ref007","article-title":"A scoping review of the application of motor learning principles to optimize myoelectric prosthetic hand control","author":"JVV Parr","year":"2021","journal-title":"Prosthetics and orthotics international."},{"issue":"5","key":"pone.0262977.ref008","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1093\/ptj\/pzaa008","article-title":"Effectiveness of an Evidence-Based Amputee Rehabilitation Program: A Pilot Randomized Controlled Trial","volume":"100","author":"R Gailey","year":"2020","journal-title":"Physical therapy."},{"issue":"1","key":"pone.0262977.ref009","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1080\/1750984X.2012.723728","article-title":"Attentional focus and motor learning: a review of 15 years","volume":"6","author":"G. 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