MossRehab Aphasia Center Featured in WHYY in Segment on Language

Recently, public radio station WHYY broadcast a segment taking a deep look at different aspects of language. They interviewed experts to shed light on the process of language learning and what happens when a person’s ability to communicate is disrupted.

Aphasia is an acquired language impairment that commonly affects people after stroke. People with aphasia may have challenges in remembering and expressing words. More than two million Americans are affected by aphasia, and the MossRehab Aphasia Center is a world class center dedicated to meeting the long-term communication and psychosocial needs of people with aphasia.

In this radio segment, expert clinicians and scientists including MossRehab’s Karen R. Cohen, MSPA, CCC-SLP, and Sharon Antonucci, PhD, CCC-SLP, share their expertise.

You can listen to the full story on WHYY’s website.

A History of Pioneering Research and Clinical Care for People with Aphasia

Since opening its doors in 1996 as the third aphasia center in North America, MossRehab Aphasia Center has been a leader in aphasia rehabilitation. In recognition of National Aphasia Awareness Month, we are pleased to highlight the exceptional contributions of the Center.

The MossRehab Aphasia Center has been a pioneer in developing and implementing programs to address the long term communication and psychosocial needs of those living with aphasia (Fink & Schwarz, 2000). An early adopter of the Life Participation Approach to Aphasia (Chapey et al., 2001), the work of the Center has always been guided by several foundational principles:

  • Recovery from aphasia involves a life-long process of re-education, adaptation, and support.
  • Under the right conditions, people with aphasia can continue to recover even years after the onset of aphasia.
  • Participating in social, recreational, and educational activities reduces isolation and helps people with aphasia and their families make psychosocial adjustments.
  • Individuals with aphasia and their families can play an important role in increasing public awareness of aphasia.

Through the collaboration of founding directors, Myrna Schwartz, PhD (research director), and Ruth Fink, MA, CCC-SLP (clinical director), the Center has always been a place in which the convergence of scholarly and clinical innovation is the norm, a trajectory that continues today.

Through the integration of the Aphasia Activities Center, the Advanced Clinical Therapy Program, and ongoing aphasia rehabilitation research, the Center supports the continuum of communication needs of people with aphasia and their families. Access to cutting edge treatment has been brought into the homes and communities of those with aphasia, through early adoption of technology and through ‘outside the box’ approaches to targeting the psychosocial consequences of aphasia.  

Aphasia Activities Center

Social interaction facilitates rehabilitation. The Activities Center provides a variety of opportunities for engagement and conversation, activities that are therapeutic and life-enhancing. Group activities including Constance Sheerr-Kittner Conversation Cafés, Talking Book Club, and Reta’s Games Groups provide not only for practicing communication, but perhaps even more critically, for building friendships. Computer lab, technology workshops, and online resources such as the Aphasia Center Blog and library of video resources expand the reach of the Center beyond the space and provide additional ways for members to reach out into their communities.

The Advanced Clinical Therapy (ACT) Program

ACT is a specialized outpatient program bringing up-to-the-minute aphasia rehabilitation research into a clinical setting. Clinicians use this cutting edge research and computer technology to design a program for each individual that emphasizes effective home practice routines using computers whenever possible.

Aphasia Rehabilitation Research: Innovative Treatments

Scientific and clinical collaborations at the MossRehab Aphasia Center have facilitated the development of novel treatments, informed by cognitive neuropsychology and psycholinguistics, as well as by a person-centered approach to rehabilitation.

  • MossTalk Words 2® is an evidence-based computer-assisted treatment program developed to strengthen understanding and production of single words for individuals with aphasia.
  • Mapping Therapy (Schwartz et al., 1994) is a treatment for agrammatism that targets the ability to link grammatical constituents (subject, object) with thematic roles (agent, theme) to facilitate  comprehension and production of language at the sentence level.
  • The Persons with Aphasia Training Dogs (PATD) Program is a treatment designed to target the psychosocial consequences of aphasia by training participants in positive reinforcement dog training techniques that harness new skill learning and the advantages of human-animal interactions.

The Center has always maintained a commitment not only to developing the highest quality programs, but also to providing community leadership.

  • Aphasia rehabilitation research evidence has been disseminated to scientific and consumer communities through more than 40 peer-reviewed publications and presentations based on work at the Center.
  • As a founding member center of Aphasia Access and a member of the Aphasia Resource Collaboration Hub, the Center participates in local, national, and international education and advocacy efforts with healthcare professionals and community advocates around the world.

The clinicians, scientists, community advocates, donors, and most importantly, the members of the MossRehab Aphasia Center have contributed substantially for 25 years to research and rehabilitation.  We look forward to continuing this innovation and person-centered service with the goal of supporting individuals and families in living well with aphasia.

Interview with MRRI Postdoctoral Fellow Abhijeet Patra

Abhijeet Patra, PhD, joined Moss Rehabilitation Research Institute (MRRI) as a postdoctoral fellow at the end of 2018. During his time at MRRI, he has conducted exceptional research in the Language and Learning Laboratory. As Dr. Patra prepares to wrap up his postdoctoral training and begin his new position at Manchester Metropolitan University, we were pleased to have an opportunity to speak with him about his career and his experiences at MRRI.

1. How did you first get interested in science and rehabilitation research?

I remember that when I was in high school, I went to visit a relative who was undergoing treatment in a rehabilitation hospital. After completing high school, I explored different career options, but I was not really sure which direction to go. However, I think my experience that day in the hospital made me lean more towards a career in rehabilitation. Especially, after seeing the dedication of the clinicians working in that rehabilitation hospital, I wanted to have a career where I could help people after injury and improve their quality of life. After completing a clinical undergraduate degree in speech-language therapy and audiology, I decided to pursue a master’s degree in cognitive science. During my master’s degree, I gained further knowledge about the relationship between brain and behavior and how brain injury or stroke can impact that relationship. Once I completed my master’s degree, I decided to pursue a PhD to further continue my research in the rehabilitation field. I received my PhD from the University of Reading, UK in 2018, and I am glad that my PhD research work involved patients from the same region (Kolkata, India) where I started my career as a clinician.      

2. Why did you choose to come to MRRI for a postdoctoral fellowship?

Throughout my academic career, I have read multiple impactful research articles written by MRRI scientists and that’s why MRRI was always on the top of my list. After completing my PhD, I was looking for research opportunities which would be more translational, and I came across the work of Erica Middleton, PhD (my current postdoctoral mentor). I started reading her papers and was fascinated by her simple yet powerful approach to rehabilitation. One day, I decided to write an email to Dr. Middleton. I discussed my research interests and my background with her, and that’s how it all started.

3. What has it been like working at MRRI?

I believe that my decision to come to MRRI has been one of the best decisions in my life. From day one, I have continued learning new and valuable things. All the scientists, research assistants, and staff at MRRI are wonderful, and they are always there to help. There is a very supportive and vibrant work culture at MRRI, and I feel that my postdoctoral mentors, lab members, and all the MRRI people are like my family.

4. What are some of the key questions you are focusing on in your research?

My postdoctoral work has focused mainly on three key areas: 1) how to improve naming impairments in people with aphasia using psychological learning principles, 2) understanding the changes in brain waves when an individual with aphasia produces common naming errors (e.g., saying cat instead of dog) and how that understanding may lead to better understanding of such impairment, and 3) understanding the relationship between sentence comprehension and cognitive control (e.g., inhibiting prepotent responses, working memory) in healthy adults and people with aphasia.

5. What have been some of the findings of your work?

In one of our studies, we found that people with aphasia make more naming errors when we asked them to name common everyday objects which belong to the same semantic category (e.g., dog, cat, elephant) versus objects from multiple semantic categories (e.g., dog, table, orange). However, one day later, that performance was reversed such that greater effort during training provided greater learning opportunities and led to better performance in future. During COVID-19 last year, we ran a web-based study on healthy young adults where participants read sentences word-by-word and also performed various cognitive control tasks. Our results provide evidence to support that cognitive control modulates sentence processing in healthy adults. We are currently writing the report to submit to a journal, and we also have plans to replicate these findings. These are only a few of the findings from my work, and I am looking forward to analyzing the results of a variety of other studies in the pipeline.

6. In terms of your research, what is the next step or something new you are excited to begin working on?

I am currently in the process of designing two electroencephalogram (EEG) experiments that I wanted to start last year but could not do due to COVID-19. I am looking forward to finally being able to get these studies going. In one of the experiments, I will look at the changes in brain activity during word production in people with aphasia. In the second, I will be examining the changes in brain activity during sentence processing in people with aphasia.

7. Thinking about the big picture, can you describe some of the impacts or potential impacts of your research?

During my PhD, I examined the characteristics of language breakdown in Bengali-English bilinguals with aphasia. Despite Bengali being the sixth most spoken language in the world, there were very few studies in the aphasia literature at that time when I started my PhD. I feel that through my PhD work I was able to contribute to broadening the sparse literature in this area. I have done some exciting research as a postdoc at MRRI, and I am still working on several projects. I think the output of my postdoctoral research will help the rehabilitation community better understand the relationship between cognitive control and language processing in aphasia and how to improve language impairments in those population.   

8. What experiences or skills from your fellowship at MRRI do you think will be most important as you transition into your first faculty position?

I have learned many skills during my fellowship at MRRI that I feel will be important in my future job position. However, I would say following are the top four in my list: 1) experience in writing grant proposals, 2) communicating research ideas and results to people outside my field, 3) how to manage a lab, and 4) how to successfully manage my time and work on multiple projects at the same time.

9. Can you share one of your favorite memories from your time at MRRI?

I think it will be my first lab/postdoctoral get together at my mentor Dr. Middleton’s place. I had a really good time with everyone there, but I would like to mention one particular experience from that day. For most of my life, I was afraid of dogs and would avoid them if I could. However, I was surprised to discover that I really liked Dr. Middleton’s dog when I had a chance to spend time with the dog at her house. After this enjoyable encounter, I have decided to get a dog for myself someday.

10. Outside of research, what are some of your favorite pastimes or interests?

I am a fan of cricket, a very popular sport in India that is not as well-known in the U.S. I enjoy watching cricket games as well as playing tournaments. I also love cooking and experimenting with different cuisines.

Dr. Sharon Antonucci Discusses Her Life and Research in a New Podcast Interview

MossRehab Aphasia Center Director Sharon M. Antonucci, PhD, CCC-SLP, was recently featured as a guest on an episode of the People Behind the Science podcast. During her interview, Dr. Antonucci had an opportunity to discuss an exciting new research project at the Aphasia Center that has been funded by the National Institutes of Health (NIH). The Persons with Aphasia Training Dogs (PATD) Program combines Dr. Antonucci’s research interests in finding innovative ways to improve rehabilitation for people with aphasia with her lifelong love of dogs. In her interview, Dr. Antonucci described how the program was developed and the unforgettable moment when she received the news that their NIH grant application was successful.

Dr. Antonucci also spoke with podcast host Marie McNeely, PhD, about her career path, the influential mentors who had a big impact on her, some of her favorite authors, memorable travel experiences in Italy, and more.

You can listen to the full audio interview on the People Behind the Science website.

MRRI Scientists to Present in Workshop on TMS Motor Mapping in Neurorehabilitation

Mapping the locations in the motor cortex that are involved in the performance of different movements has been an important tool in both rehabilitation research and clinical practice. Motor mapping using transcranial magnetic stimulation (TMS) can provide insights on how movements are controlled in individuals with and without neurological disease or damage. It can also play an important role in targeting neuromodulation during rehabilitation. Despite the utility and benefits of TMS motor mapping, researchers and clinicians have not reached consensus on the protocol that should be used, optimal methods for data analysis, and the interpretation of results.

Moss Rehabilitation Research Institute (MRRI) Director Dylan Edwards, PhD, is chair of an upcoming virtual workshop that will address these topics. The event will be hosted by the National Center of Neuromodulation for Rehabilitation (NCNM4R), an NIH Medical Rehabilitation Research Resource Network center at the Medical University of South Carolina.

In addition to Dr. Edwards, MRRI Institute Scientist Shailesh Kantak, PT, PhD, and MossRehab Physician Nathaniel Mayer, MD, will join leading international experts to present and discuss content on motor mapping. Presentations will cover the full spectrum from preclinical research in animal models to clinical applications in humans.

The Contemporary TMS Motor Mapping in Neurorehabilitation Workshop will be held on Friday, June 25th, 2021 from 10:00 am – 3:00 pm EDT. It will include a combination of pre-recorded presentations and live Q&A sessions held virtually via Zoom. For more information and to register to participate in the workshop, please visit the NCNM4R website.

MRRI scientists look forward to participating and sharing their expertise in this engaging international event.

Improving Neurorehabilitation by Incorporating Gaming Theory and Technologies

Moss Rehabilitation Research Institute (MRRI) scientists are at the forefront of research applying new technologies to developing therapeutic games for neurorehabilitation. MossRehab’s Accepting the Challenge blog recently published a three-part series on how research at MRRI and clinical care at MossRehab are leveraging therapeutic gaming to increase engagement and enhance rehabilitation. 

Part 1 of the series provides an overview of how theories from neural and behavioral science are being applied game design for optimizing rehabilitation outcomes. Part 2 translates these principles from the lab to the clinic and describes how therapeutic games are currently being used in clinical care at MossRehab. Read more in Part 3 about the ongoing research projects that MRRI Scientists are involved in to develop the therapeutic games of the future.

The third article features a number of current projects spanning several MRRI research laboratories. One of these is a collaborative effort involving Dylan Edwards, PhD, Laurel Buxbaum, PsyD, Aaron Wong, PhD, Shailesh Kantak, PT, PhD, and collaborators from other leading research institutions. They are developing a new therapeutic gaming system for motor recovery after stroke, called Mindpod Dolphin. Dr. Buxbaum also describes two projects that use virtual reality games for assessment and treatment. Dr. Edwards discusses his work on NeuroMotion, a portable gaming console from TRCare, Inc. This console is designed for patients who experienced a stroke to assist them in recovering upper extremity functions in their own homes. Dr. Rabinowitz describes how her work on mobile technology in brain injury rehabilitation is enhancing our ability to promote adherence to home therapy and goal attainment.  

These research projects demonstrate how MRRI scientists are using theory-driven research to develop novel rehabilitation approaches to help improve the lives of individuals with neurological disabilities.

Check out the whole series on MossRehab’s Accepting the Challenge blog.

Using Gestures and Brain Stimulation to Enhance Language in People with Stroke

What’s the word? Those tip-of-the-tongue moments, when a word is seemingly right there but just out of reach, can temporarily hinder our ability to communicate effectively. Everyone experiences word-finding challenges (called anomia) from time to time. However, for people who have aphasia, an acquired language disorder following stroke or brain injury, these word-finding challenges can be very frequent and disruptive, causing problems for everyday communication needs. Verbs present a particular challenge for the majority of people with aphasia. Verbs are vital because we need them to communicate about actions and events, and they are central to sentence structure and conveying relationships between subjects and objects. Without using verbs, language can sound telegraphic or robotic, and it becomes very hard to get a point across.

Gestures can help people retrieve words when they get stuck. Using a gesture to pantomime an action can convey a speaker’s intended message to others, and it can furthermore help the person produce the verb they want to say. Unfortunately, producing gestures can also be impaired following stroke, and many patients who have aphasia also have limb apraxia, a disorder that impairs skilled action and gesture production.

However, it is possible that simply watching someone else produce a gesture may help adults living with stroke to get those words off the tip of their tongues. This is possible when an observed gesture and intended verb share meaning, or semantics. Semantic knowledge consists of everything we know about the world, and it is stored in long-term memory. Semantics are distributed in a network of regions across the brain and can therefore be resilient to damage. Neurorehabilitation treatments that enhance semantic activation may therefore benefit many patients with different patterns of brain damage. Moss Rehabilitation Research Institute (MRRI) and University of Pennsylvania researchers Haley Dresang, PhD, Laurel Buxbaum, PsyD, and Roy Hamilton, MD, MS, are combining gesture observation with non-invasive brain stimulation to investigate whether enhanced activation of action knowledge (semantics) can facilitate verb production in patients with aphasia. This is the first study to implement a specific type of excitatory stimulation – intermittent theta-burst stimulation – on verb-production impairments, and also the first to combine brain stimulation with gesture-observation cues in aphasia. First, this research examines whether passive observation of gestures can help patients produce verbs. Second, this research compares the benefit of gestures on verb production in patients who have had a stroke that damaged the left anterior versus the left posterior parts of the brain. Third, Dr. Dresang and colleagues are also investigating whether applying non-invasive brain stimulation to increase activation in intact nodes of the semantic neural network will enhance the benefits that observing gestures may have on verb production. The researchers will apply a magnetic current that amplifies the activity of neurons in brain regions important for semantic processing, and they will assess whether patients are able to successfully name more verbs based on observed gestures while receiving this brain stimulation. This study will begin recruiting participants later this summer. This research advances scientific understanding of how the brain functions following injury. Furthermore, this work seeks to create a novel neurorehabilitation approach that will improve treatment success for a variety of stroke patients with language and/or motor impairments.

Understanding Spatial Navigation Challenges After Stroke

Erica Barhorst-Cates Headshot

To find the offices at Moss Rehabilitation Research Institute (MRRI), take the elevator to thethird floor. Once you exit the elevator, turn left, then right down the first hallway, then left through the conference room. Turn right, then left, and the office is the third door on your right. Got that? Okay, now head back to the elevator the way you came. Make sure not to bump into any of the obstacles in your way, and make sure you still pay attention to what the research assistant is saying as you go.

Spatial navigation, or the way we find our way around an indoor or outdoor space while remembering important landmarks or routes, is a complicated activity that many of us take for granted. It requires attention, memory, language, and, often, physical requirements such as the ability to walk or control a wheelchair. Spatial navigation involves various brain regions, including the temporal and parietal lobes. Even many neurotypical individuals have difficulty with navigation; some of us forget where the exit is in the local Target or have no idea which way is north.

Stroke can make the act of spatial navigation even more challenging, because lesions in different parts of the brain can impair different aspects of navigation. MRRI researchers Drs. Erica Barhorst-Cates, PhD, Aaron Wong, PhD, and Laurel Buxbaum, PsyD, are conducting research to better understand how stroke can affect navigation abilities, and in what situations. While one individual might have an excellent “mental map” of the environment, she may have difficulty walking and become distracted by the need to avoid an obstacle in the environment. This distraction may make her temporarily forget where she is, thus affecting her navigation ability. Another individual may walk normally but have impaired working memory ability, thus making it hard for him to remember a list of directions. Depending on where an individual’s stroke occurred in the brain, different abilities might be affected. There is no one-size-fits-all navigation impairment.

In their ongoing study funded by the Albert Einstein Society, Dr. Barhorst-Cates and colleagues are asking participants with stroke and a group of neurotypical participants to navigate around the MRRI building and learn the location of “landmarks” in the hallways. Much of the prior research on navigation after stroke has used computer based virtual reality tasks, where participants are seated and stationary. The task used in this study is more similar to how navigation occurs in the real world, thus allowing the researchers to more accurately understand the various challenges. They are testing participants’ memory for the object locations and the traveled routes using a series of measures that they have adapted for use for individuals with stroke. In addition to this navigation task, participants also complete a series of tests aimed at understanding their physical and mental abilities. The researchers have currently run 30 participants through the study out of our goal sample size of 55. We hope to use the results from these tests to understand more about which types of patients might be affected in terms of their navigation abilities.

Ultimately, the results from this study may help inform development of therapies to improve navigation abilities for individuals who suffer a stroke. In the meantime, which way is south?

Interview with Dr. Shailesh Kantak on the People Behind the Scientist Podcast

Dr. Kantak's headshot

In a new episode of the People Behind the Science podcast, Shailesh Kantak, PT, PhD, discusses his career, ongoing research on bimanual coordination after stroke, and his interests outside of science. Over the years, Dr. Kantak has been dedicated to trying to better understand why some patients recover well from brain injury, and others do not. This curiosity is what drove him to pursue a career in research, and it continues to motivate him in his work today.

During his interview, Dr. Kantak also shares exciting news about a novel framework he developed with colleagues to help clinicians analyze movement and factors that may contribute to movement deficits, memorable lab traditions he has experienced, advice for aspiring scientists, and more. Dr. Kantak is Director of the Neuroplasticity and Motor Behavior Laboratory at MRRI.

You can find the full interview on the People Behind the Science website.

Dr. Cory Potts Aims To Get a Grasp on Cognition and Action

Figure 1. A research assistant performs the bimanual arm choice task. In each trial, participants use their choice of one or both arms to touch virtual targets (green circles) with the cursor(s) (black dots). The arrangements of targets are varied to examine differences in limb choice.

The ability to plan and perform movements is typically taken for granted in healthy people. Actions feel as though they happen automatically while individuals attend to other ‘higher level’ matters, like how to reply to an email or what to eat for dinner. But the ease with which movements usually occur masks the rich cognitive mechanisms that underlie even the most basic actions. When movement planning is disrupted due to stroke or injury, the profound consequences to health and wellbeing that can follow reveal the critical importance and daunting complexity of these processes. Research projects conducted by Moss Rehabilitation Research Institute (MRRI) scientists Cory Potts, PhD, Laurel Buxbaum, PsyD, Shailesh Kantak, PT, PhD, and Aaron Wong, PhD, are focused on understanding interactions between cognition and action with the broader goal of gaining insight into how to help individuals with disordered movement.

Following a stroke, 80% of individuals show reduced ability and use of one arm. Most daily activities involve bimanual action, or the coordinated use of both arms. Thus, the reduced use of one arm can severely impact survivors’ independence and quality of life. While previous research has examined use of the affected or the unaffected arm during unimanual action (movement with one arm), virtually nothing is known about how stroke survivors choose between using one or both arms for daily tasks. In a new research project, Drs. Potts, Buxbaum, and Kantak will investigate, for the first time, task-related and clinical variables that influence the use of one or both arms in individuals with chronic stroke (Fig. 1). These MRRI scientists hope that the insights gained from this work can guide the development of rehabilitative strategies that ultimately promote use of the affected arm.

The clinical importance of this work is highlighted by research suggesting that the use and ability of the weaker arm is improved during bimanual action in stroke survivors. Important daily activities such as cooking, bathing, and performing housework can be performed more effectively using both arms together compared to either arm alone. Additionally, research recording patients’ arm movement in their daily lives has suggested that use of the weaker arm happens almost exclusively during bimanual action, when the weaker arm can be used together with the unaffected arm. These findings suggest important and clinically relevant differences in the control and mechanisms that underlie bimanual compared to unimanual action.

In related work, Drs. Potts and Kantak are examining the planning and coordination of bimanual actions in stroke patients. Efficient movement planning involves adjusting for the physical properties of objects. Here, researchers tested how well stroke patients and adults without stroke (controls) could adjust for changes in an object’s weight. In the experiment, participants lifted a box that was initially unweighted. After a few lifts, unbeknownst to the participant, weight was added to the box. Drs. Potts and Kantak were interested in how the additional weight would affect forthcoming movements. The results suggested interesting planning differences between control participants and stroke survivors. After feeling the increased weight of the box, neurotypical controls incorporated the information into the forthcoming movement plan, scaling the force applied to the box before liftoff. Stroke patients, on the other hand, showed a more reactive pattern, adjusting the force applied to the box throughout the movement. These results illustrate how differences in low-level features of movement—the physical forces applied to an object—can offer a window of insight into changes in movement planning following stroke. Additionally, pinpointing the differences between movement planning in healthy individuals and stroke survivors may inform training strategies to improve movement capacity.

A final line of work is aimed at understanding issues with gesture imitation in apraxia—a disorder of intentional action most commonly associated with left hemisphere stroke. Individuals with apraxia often show difficulties imitating gestures. Imagine that a coach is showing a player how to throw a ball through gesture. There are two strategies the player might take to reproduce the gesture. The player could recreate the pathway of the coach’s hand through space. Alternatively, the player could recreate the position of the coach’s hand relative to other arm joints—where the hand is located in relation to the elbow, for example. Researchers at MRRI are testing whether the latter strategy—replicating specific joint positions—is especially difficult for individuals with apraxia. The foundation for this hypothesis is that a common site of damage in apraxia, the left parietal lobe, plays an important role in the ability to store and update the position of the body.

To test this hypothesis, Drs. Potts, Buxbaum, and Wong asked age-matched controls and individuals with left-hemisphere stroke to imitate meaningless gestures. To encourage participants to attend to their joint positions, the scientists distorted some of the gestures such that successful imitation required unnatural arm joint positions. Imagine, for example, that the coach in our previous example has their elbow in an inefficient position above their hand when showing how to throw the ball, forcing the player to attend to their own elbow during imitation. While this research is ongoing, the results are encouraging. The data suggest that individuals with apraxia have difficulty reproducing inefficient arm joint positions compared to controls, consistent with the notion that this joint-centered route to imitation is particularly difficult. Though it is unlikely that patients will encounter this precise task in their daily lives, the results have implications for rehabilitation strategies—for example, it might be best to avoid joint-focused instructions during therapeutic interventions (e.g., “keep the elbow in line with the shoulder”). Moreover, these findings add yet another small piece to the expansive puzzle that is movement planning.