The Impact of Attentional Focus on the Treatment of Musculoskeletal and Movement Disorders

Abstract

Treatment plans employed by physical therapists involved in musculoskeletal rehabilitation may follow a conventional medical-model approach, isolating care at the tissue level but neglecting consideration for neurocognitive contributions to recovery. Understanding and integration of motor learning concepts into physical therapy practice is integral for influencing the human movement system in the most effective manner. One such motor learning concept is the use of verbal instruction to influence the attentional focus of the learner. Evidence suggests that encouraging an external focus of attention through verbal instruction promotes superior motor performance, and more lasting effects of a learning experience than an internal focus of attention. Utilizing an external focus of attention when instructing a patient on a motor task may facilitate improved motor performance and improved functional outcomes in treatment plans devised to address musculoskeletal injury and movement disorders. The purpose of this review is to summarize the basic principles of motor learning and available evidence on the influence an external focus of attention has on motor learning and performance, including the benefits of an external focus of attention over an internal focus of attention and how therapists may inadvertently encourage the latter. Furthermore, the benefits of possessing greater awareness of neurocognitive mechanisms are discussed to exhibit how implementing such concepts into musculoskeletal rehabilitation can maximize treatment outcomes. Level of Evidence: 5

Long-term unsupervised mobility assessment in movement disorders

“…With an internal focus, attention is directed to controlling the body parts when performing a certain movement. 40 An external focus of attention results, at least sometimes, in more fluent movements. 41 Second, performance can be influenced by several psychological and physiological phenomena that may differ across settings.…”

Visual Perturbation to Enhance Return to Sport Rehabilitation after Anterior Cruciate Ligament Injury: A Clinical Commentary

“…[52][53][54] Further, physical therapy following ACL injury may also increase visual attention to the knee, as clinicians primarily utilize visually-dominated exercises and provide feedback with an internal focus of attention (i.e., emphasizing movement kinematics or muscle activation, rather than movement actions) to the injured joint. 37,[55][56][57][58][59] However, weighting vision to guide lower limb movement may be maladaptive for athletes returning to a competitive sport environment, where the high demand to integrate dynamic visual information may limit the CNS's capacity to allocate neural resources to guide movement. Therefore, patients with ACL injuries may benefit from therapeutic interventions that encourage sensory reweighting from vision towards proprioception for motor control.…”

“…71,83,84 Visual information processing is further recruited for motor control following ACL injury, potentially due to sensory reweighting from the deafferentation of joint mechanoreceptors and/or the use of visually-dominated exercises and internal feedback to the injured joint during physical therapy. 36,37,[55][56][57][58][59] While patients may be able to compensate with increased visual processing for simple exercises, an inundation of dynamic visual information on the sporting field may overwhelm neural processing resources and the visually biased movement compensation strategy may become a re-injury risk liability. ACL rehabilitation efforts may consider incorporating complex sensory challenges, like visual perturbation, in order to simulate the dynamic sport environment that athletes will face once they leave the clinic.…”

Effects of a neuromuscular training program using external focus attention cues in male athletes with anterior cruciate ligament reconstruction: a randomized clinical trial

“…The specific instructions for each exercise were based on those proposed by Benjaminse et al (2015) [ 30 ]. and were intended to promote an external focus of attention, which has been shown to result in better performance and retention of learned movement patterns for a wide-range of movement tasks (vs. an internal focus) [ 31 ]. The specific instructions we provided are included in Table 2 .…”