An introduction to using an external focus of attention in physiotherapy

Authors: Clare Guss-West & Johanna Osmala

If you use a roll, tape or other therapeutic resources in your day to day practice, or you use touch, imagery or focus on the flow of the breath, then it's probable that you are already using an external focus of attention (EFA) in your physiotherapy practice. However, you may not necessarily be aware of the evidenced-benefits of applying an EFA systematically, relative to an internal focus of attention, as your chosen movement control strategy. 

Human movement science defines two principal approaches to movement control that use either an internal (IFA) or external focus of attention (EFA). Both internal and external focus of attention are movement control strategies and both have the objective of improving movement outcomes. However, promoting an EFA has consistently been found to provide physical and mental advantages in both performance and rehabilitation contexts, relative to an IFA. The robust findings in over 200 published studies and 20 years of research spearheaded by Dr Gabriele Wulf are compelling and currently infiltrating high performance sports (Wulf 2013). Promoting an EFA is found to produce immediate and long-term benefits in terms of improved movement effectiveness: balance, strength, consistency, precision, speed (Wulf 2013 p80) and movement efficiency: fluidity, reduced muscular engagement, lower heart rate, minimised energy consumption, increased stamina and improved movement quality (Wulf 2013 p85).   

“A movement pattern is considered more efficient or economical if the same movement outcome is achieved with less energy expended” 

(Wulf 2013 p.84)

Research also demonstrates advantages to learning, speed of mastery, enhanced capacity for retention and learning transfer, promoting permanent long-term changes (Wulf 2013 p 78, Wulf et al. 2003). Using an EFA appears to use less cognitive reserve, freeing up cognitive capacity for other parallel tasks (Wulf et al. 2001), the management of performance pressure, as well as promoting enhanced artistic expression and communication that are so essential for dance (Mornell & Wulf, 2018). These global benefits are evidenced at all skills levels, across all ages, and for those with movement challenges, disability and injury (Guss-West 2021, Wulf 2013). 


What are the key differences between an internal and an external focus of attention?

The interpretation of these two terms, internal and external, can be challenging in practice, as there is more to them than meets the eye.

Internal focus of attentional (IFA), might be referred to as a focus on the PARTS (Dea n.d.). It draws the dancer's or patient's attention to their own body parts promoting a self-conscious adjustment or attempt to control that part. IFA heightens access to something known as the self-system and is known to demand larger amounts of cognitive reserve, making it a less efficient option for optimal movement. An IFA is identified by the naming of the body part/s in the instructions and cues e.g. “lower your shoulder”, “focus on your fingertips”, “rotate your leg” (Guss-West 2021; Wulf 2007).

External focus of attentional (EFA), might be referred to as a focus on the PATTERNS (Dea n.d.). It guides the attention onto the desired  pattern, outcome, trajectory, quality or effect of the movement and away from self. Attention sustained on the desired movement frees cognitive reserve and permits the body's fast, reflexive, automatic movement adjustment to function optimally. An EFA would contain no named body part/s in the instructions and cues (Guss-West 2021) e.g. “focus on the direction”, “elongate the line as far as possible”, “open out the triangle”. 


Choosing to shift to external focus of attention

Choosing to shift towards using more EFA starts by simply becoming aware of your choice of attentional language and noticing in which situations you are already using external focus instructions and when you typically use internal focus cues. 

Traditionally, a physiotherapist may use professional language and specific anatomical terms directly in practice, resulting at times in lengthy verbal instructions to solve movement problems. Knowledge of the anatomy is of course essential in physiotherapy, however, we should consider how much of that professional vocabulary is helpful to share with dancers to promote an effective outcome. True, some dancers do arrive with precise questions such as "what is this muscle?", "which muscle am I supposed to feel?" and expect to hear specific terminology and detailed explanations. Some have the idea that a specific part is not functioning, "I can't activate this muscle" or they want to identify the "right and wrong muscles". Given that none of our muscles work independently, trying to focus on using or not using certain ones may lead to increased self-conscious internal focused control. Although it is perhaps tempting to go deeper into specific details, drawing the dancer’s or patient’s attention to an EF might better support the goal of movement enhancement. This could be achieved by simply shifting the focus to the muscle function, the movement mechanics, or on to the desired shape, trajectory, quality, dynamic or effect of the movement through the use of descriptors, metaphorical imagery or mental rehearsal.      

“The production of maximum forces requires an optimal activation of agonist and antagonist muscles, as well as optimal muscle fiber recruitment.”

(Wulf 2013, p.86)

Research has demonstrated that this shift of focus has the potential to increase force production in simple and complex tasks. In a study by Lohse et al., an internal focus of attention was shown to degrade accuracy, due to both reduced movement efficiency (demonstrated by increased co-contractions between the agonists and antagonists) and reduced efficiency at the intra-muscular level (demonstrated by increased motor unit recruitment (i.e., larger motor units with faster conduction times)) (Lohse et al. 2011, as cited in Wulf 2014).      

When choosing to shift the attentional focus of cueing, a quick-win might be to simply leave out the body-part from the instruction. For example, the instruction "push with your hand while externally rotating your shoulder" might simply become "push and rotate" accompanied by a visual demonstration (EF). You can build on this later. For example, the action of the external rotators of the hip, might be explained by describing the movement pattern as ‘spiralling’ (EFA), or by asking the dancer to press (their knee) against an object (EFA), or by asking them to focus on the direction of our hands guiding from the thigh (EFA). The hands are one of the best EFA tools available. Using the hands and asking the dancer or patient to focus on sensory feedback from the touch, the pressure, the direction of our hands provides a perfect EF – even the recall of that touch provides a lasting EF to refer to. Alternatively, we might ask dancers to focus on other sensory, kinesthetic and proprioceptive feedback (EF), which are the result of listening to and sensing the body, rather than a conscious attempt to control or adjust the body-part movement (IF). These EFA can be effectively used to support the specific and micro movement adjustment so essential in physiotherapy.

In summary, the different types of potential external focus available to choose from are: 

    • real, tangible foci in the environment, objects, therapy resources, clothing;
    • descriptors of the movement mechanics, shape, trajectory, quality, dynamics or effect; 
    • sensory, kinesthetic and proprioceptive feedback: focusing on the touch, warmth, pressure, direction or a focus on the flow of the breath; 
    • using metaphorical imagery or mental rehearsal 
    • even referencing the dancer’s artistic interpretation or rhythmical/musical dynamics of the movement

Choosing to shift the attentional focus of our cueing and feedback to harness the evidenced-benefits of an EFA might be as simple as consciously doing more of something that we are already doing quite naturally (Guss-West 2021). Like learning any new language, it takes a conscious decision to implement at first, however soon becomes more fluent with practice, operating in a virtuous circle - the more we experience the benefits, the more we are encouraged to use an EFA in practice!



Clare Guss-West MA is Chair of IADMS Dance for Health committee, author and international teaching artist/teacher trainer specializing in attention and focus training in professional and adaptive dance practice: Finnish National Ballet, Bern University, Université Côte d’Azur, The Royal Academy of Dance.

Johanna Osmala is a senior physiotherapist at the Finnish National Ballet responsible for injury prevention, rehabilitation and coaching of professional dancers, she is a master student in Sport Science (biomechanics), a member of the IADMS program committee and former president of DHF (Dance Health Finland).



Resources and References:

Bourdon, E., Ramos, W., Mavor, M. P., Beaudette, S. M. & Graham, R. B. 2018. The effect of attentional focus on local dynamic stability during a repetitive spine flexion task. Journal of Biomechanics, 80, 196-199.

Dea, G. n.d. “Feedback and cueing part 2 – Reliable Strategies.” On Target Publications. Accessed April 14, 2020.

Guss-West, C. 2021. Attention and Focus in Dance. Champaign, IL: Human Kinetics Books.

Lohse, K.R., Sherwood, D.E., & Healy, A.F. 2011. Neuromuscular effects of shifting the focus of attention in a simple force production task. Journal of Motor Behavior. 43, 173-184. 

Mornell, A, & Wulf, G . 2018. “External Focus of Attention Enhances Musical Performance.” Journal of Research in Music Education. 66: 375-391.

Wulf, G. 2013. Attentional focus and motor learning: a review of 15 years. Int Rev Sport Exerc Psychol. 6(1):77- 104.

Wulf, G. 2014. Changing patients focus of attention to enhance motor performance and learning. Las Vegas, NV: Combined Sections Meeting American Physical Therapy Association

Wulf, G. 2007. Attention and Motor Skill Learning. Champaign, IL: Human Kinetics Books.

Wulf, G., Weigelt, M., Poulter, D.R., & McNevin, N.H. 2003. Attentional focus on suprapostural tasks affects balance learning. Quarterly Journal of Experimental Psychology, 56, 1191_1211.

Wulf, G., McNevin, N.H., & Shea, C.H. 2001. The automaticity of complex motor skill learning as a function of attentional focus. Quarterly Journal of Experimental Psychology, 54A, 1143_1154.