Considerable literature on the role of attentional focus in motor performance and learning has accumulated for over two decades. We report the results of comprehensive meta-analyses that address the impact of an external focus (EF, on intended movement effects) versus internal focus (IF, on movements of body parts) of attention on the performance and learning of motor skills. Values of effect sizes (ES) from 73 studies with 1,824 participants and 40 studies with 1,274 participants were used for examining the effects of EF versus IF on behavioral outcomes of motor performance and learning (separately for retention and transfer phases) respectively. The EF condition was more effective than the IF condition for performance, Hedges’ g value = 0.264 (95% CI [0.217, 0.310]), retention learning, Hedges’ g value = 0.583 (95% CI [0.425, 0.741]), and transfer learning, Hedges’ g value = 0.584 (95% CI [0.325, 0.842]). Multivariable metaregression analyses on behavioral measures further indicated that neither age group, health status, or skill level, nor their two-way interactions, moderated the ES differences between EF and IF in performance, retention, and transfer models (all p > .100). A secondary analysis on 12 studies with 216 participants that examined the effects of EF versus IF on electromyographic outcomes of motor performance also indicated that EF was associated with more efficient neuromuscular processing, Hedges’ g value = 0.833 (95% CI [0.453, 1.213]). From nine studies with 272 participants, performance measured by behavioral outcomes was found to be more effective when a more distal, rather than proximal, EF was used, Hedges’ g value = 0.224 (95% CI [0.019, 0.429]). Overall, the meta-analytic results are consistent with prior narrative reviews and indicate that an external focus is superior to an internal focus whether considering tests of motor performance or learning, and regardless of age, health condition, and level of skill expertise.

In the OPTIMAL theory of motor learning (Wulf & Lewthwaite, 2016), three factors are postulated to facilitate motor performance and learning: Enhanced expectancies (EE) for performance, autonomy support (AS), and an external focus (EF) of attention. We examined whether EE, AS, and EF would have immediate performance benefits and whether implementing these factors consecutively would lead to incremental performance increases. Participants were assigned to the optimized or control groups and performed a maximal jump. After the first trial block (baseline), optimized group participants were provided different conditions on each of the following 3 blocks: (a) Positive social-comparative feedback (EE); (b) choice of figure on the ground from which to jump (AS); and (c) instructions to focus on a marker on their waist (EF). The order of conditions was counterbalanced. Control group participants performed all 4 blocks under the same (control) condition. The optimized group outperformed the control group on Blocks 2-4. Moreover, their jump height increased with each addition of another variable, whereas it did not change across blocks in the control group. Thus, EE, AS, and EF had additive or incremental benefits for performance. The findings corroborate the importance of key variables in the OPTIMAL theory for motor performance.

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Objectives: The feasibility and safety of the use of neurorehabilitation technology (SMARTfit® Trainer system) by physical therapists in implementing a gamified physical-cognitive dual-task training (DTT) paradigm for individuals with Parkinson disease (IWPD) was examined. Additionally, the efficacy of this gamified DTT was compared to physical single-task training (STT), both of which were optimized using physio-motivational factors, on changes in motor and cognitive outcomes, and self-assessed disability in activities of daily living. Methods: Using a cross-over study design, eight participants with mild-to-moderate idiopathic PD (including one with mild cognitive impairment) completed both training conditions (i.e., gamified DTT and STT). For each training condition, the participants attended 2–3 sessions per week over 8.8 weeks on average, with the total amount of training being equivalent to 24 1 h sessions. A washout period averaging 11.5 weeks was inserted between training conditions. STT consisted of task-oriented training involving the practice of functional tasks, whereas for gamified DTT, the same task-oriented training was implemented simultaneously with varied cognitive games using an interactive training system (SMARTfit®). Both training conditions were optimized through continual adaptation to ensure the use of challenging tasks and to provide autonomy support. Training hours, heart rate, and adverse events were measured to assess the feasibility and safety of the gamified DTT protocol. Motor and cognitive function as well as perceived disability were assessed before and after each training condition. Results: Gamified DTT was feasible and safe for this cohort. Across participants, significant improvements were achieved in more outcome measures after gamified DTT than they were after STT. Individually, participants with specific demographic and clinical characteristics responded differently to the two training conditions. Conclusion: Physical therapists’ utilization of technology with versatile hardware configurations and customizable software application selections was feasible and safe for implementing a tailor-made intervention and for adapting it in real-time to meet the individualized, evolving training needs of IWPD. Specifically in comparison to optimized STT, there was a preliminary signal of efficacy for gamified DTT in improving motor and cognitive function as well as perceived disability in IWPD.