Attentional Focus: can how we cue patients change…everything?

Motor learning is something every clinician should pay attention to! This is an way of working with our patients that can make the therapy we give them more effective, more meaningful, and overall translate to better outcome. Part of this process is noting HOW we instruct our patients during therapy sessions and WHAT we tell them to pay attention to!

In this article, we discuss the concept of specificity of training, motor learning, and techniques for how to make your therapy sessions really count!

Physical and Occupational therapists are very well-rounded healthcare providers.  We not only have an in-depth background in anatomy, physiology, biomechanics, exercise, orthopedics, and neurologic function (that’s the short list!), but we are also very much like- teachers!  Day in and day out, we are teaching people how to relearn complex motor skills after sickness or injury. 

Let’s take the rehab environment for example.  If you ask any patient in any rehab hospital what their number one goal is, you will get a resounding, “I want to walk!”  Now… we are going to ignore for the moment how crazy this drives all the OTs.  We all know there is more to daily life than that!  But when you think about walking… to us (uninjured people), it seems to be very automatic and easy.  It’s what we’ve been doing since early childhood.  We don’t even think about it!  To a person who is recovering from some type of physical insult, however, it doesn’t come as easily as it once did.  And through a therapist’s eyes, walking isn’t “easy” at all.  It is a complex series of steps in a motor loop that requires a specific amount of strength and flexibility at the ankle, knee, hip and trunk; motor planning and coordination of all body parts; and certain cognitive functions to be relatively intact in order for walking to occur in the most functional and efficient way possible.  If any of these factors are compromised, there will be a break down in the gait cycle that causes functional impairment.  And we, as therapists, have been trained to identify where the breakdown is occurring in order to get our patients up and moving again.  We often have to provide strength training, help them regain flexibility, etc.… but we also have to provide opportunities for the person to practice the specific task of walking.  And during these practice sessions we have to train them (teach them) to relearn how.

Extrinsic motivation versus intrinsic motivation in terms of attention

The concept of specificity of training is only one aspect of a very well researched area – Motor Learning.   Another motor learning concept, that we often don’t pay attention to (ironically!) is attentional focus.  When we are training our patients to relearn a motor task… what kinds of instructions are we using? What are we telling them to pay attention to during the activity? You’re probably thinking… what does it matter? How does my wording affect how my patients learn?  Well, research suggests that it matters a great deal! 

Attentional Focus can be defined as either external or internal.  In simplistic terms, internal attentional focus means something within the body or within the learner.  Whereas, external attentional focus means something outside of the body.  Something in the environment or external to the learner.  To see the difference, we can use the example of someone trying to balance on a wobble board.  A cue using an internal attentional focus would sound like… “I want you to balance on the wobble board by trying to keep your feet level. Shift your weight to the front or back of your feet if you need to.” Their attention is focused on their feet – something internal.  An external attentional focus cue would be… “I want you to balance on the wobble board by keeping it level.  Don’t let the edges of the wobble board touch the floor.”  Their attention is focused on the wobble board – something external.  Makes sense, right?  But is one superior than the other when it comes to how effectively we learn a motor tasks?

Studies suggests that adopting an external focus when practicing a motor task facilitates better learning and retention in multiple age groups and diagnoses.  One example is a study by Wulf, HoB, and Prinz (1998) where they ran 2 experiments looking at differences in types of instruction given when participants were on a stabilometer or a ski-simulator.  Each experiment ran for 3 days – 2 days of practice with either external focus instruction, internal focus instruction, or no instruction.  On day 3, retention of the skill was tested with no instruction given before performance of the task.  Both experiments showed that external focus instruction enhanced learning as measured by retention on Day 3.  Interestingly, the results of this study also showed that the internal focus instructions were not more effective than no instructions!  Think about that… if we are cueing our patients the “wrong” way… we might as well not cue them at all. This is supported in further research by Landers et. al (2005), Chiviacowski et. al (2010)- and more!

I can tell you… I’ve done it wrong a million times!  But after reviewing the research, I have become more thoughtful about how I teach my patients, in terms of the instructions I’m giving them.  So, I hope the next time you’re teaching your patients the complex task of walking, or dressing, or bathing, or any other motor skill, you will have them focusing on what will best facilitate learning of the task!  Here are some useful examples of how you can change some of our most common cues from an internal focus to an external one.

Don’t say… Instead say…
Raise your hand higherTry to touch the ceiling!
Lift your foot higher (with decreased clearance during swing)When you step, don’t scuff the floor!
Bend at the waistLean closer to me
Take a bigger step with your left footWhen you step, step closer to the wheel of the walker; Step all the way past your other foot
Shift your weight onto your right footLean closer to the bed (which happens to be on the right)
Lift your head upLook at me; Look out the windows
  Straighten your backTry to stand taller than me! (depending on patient’s height!)

As we can see, Making small changes here and there to the wording of our instructions can have an unmeasurable effect on how our patients will learn from us.  They will not only learn better with an external focus, but will be able to retain the learned skill long after we are done seeing them- and really, isn’t that the best we can do for them?

This is an excerpt from our popular seminar, Home Based Balance Rehab: A Review of the Literature. Learn more about our class by following this link. To attend this 2.5 hour online seminar, sign up right here! We look forward to learning with you!

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