What are you focused on today? Getting to work on time. Finishing that house project that you’ve been banging away at for months now. Maybe just being a better parent or friend?
Now ask yourself what your clients are focusing on? Are they focused on themselves? Their pain? Their functional loss? Where they hurt? Why they hurt? How it affects them?
Often I find that our subjective reporting and evaluation procedures lead us down a very “internal” perception of body awareness. While this can give us plenty of valuable information to help provide effective treatment, this can also carry over into treatment applications. Is this leading us astray?
I have often found in my clinical practice the dichotomy of asking people where they feel things vs how they are performing. Making sense of the puzzle pieces of rooting through the information that is pertinent to each individual case and whether I should do something about it. Should I strive to have each exercise, manually applied treatment, change of environment, and education piece be internalized, understood and accepted by the client?
Current and prior research findings, by such names as Wulf and Benjaminse, are giving us insight into how to improve our motor learning and body awareness outcomes by replacing internal focus with external focus during treatment applications. How a clinician presents rehabilitation, conditioning and retraining can have a marked effect on the desired outcome and not just the regimen or exercises themselves. How the client responds to the feedback they receive may be just as, or even more important than the activity they are training with.
Instructions or feedback promoting an external feedback (i.e. goal oriented movement or the movement effect) have been shown to enhance learning, compared to those inducing internal feedback (focus on the body movement). Numerous studies over the past decade, learning advantages of an external focus have been found consistently for a variety of skills, age groups, levels of expertise, and non-impaired as well. Adoption of an external focus has ben shown to facilitate automaticity in movement control as well as movement efficiency, whereas internal focus tends to result in conscious control that constrains the motor system disrupt automaticity, and promote unnecessary muscular activity. In short, internal focus may lead to self perceived concerns about performance and “micro-choking” events. Wulf thus argues that when internal focus is given to the client, reduced frequency should be more effective than feedback after every trial. In contrast, when external focused feedback is used, increased frequency may be more effective. Wulf did offer up in her critique of her own work in 2013 that there is still an argument that internal feedback is necessary and beneficial in early learning and there have been positive findings that novices perform effectively when their attention is directed to the skill rather than irrelevant/unnecessary secondary or external tasks. But she is also quick to point out approximately 80 experiments outlining the significant advantages of external relative to internal foci with only a “handful” yielding null effects.
Often the difficulty is attempting to translate this type of information into usable treatments in our clinics. Just because we know what probably will help our clients improve better, faster, stronger; doesn’t always mean we have the resources or capabilities to implement this information. Benjaminse described several options for implementing EF into treatment regimens and even used descriptors in the recently published manuscript in JOPST to help clinicians. Simple effects of changing verbiage to describe the same activity can make a huge difference in altering internal focus to external focus. Some examples are as follows:
These examples are simple, yet effective ways to alter the effect of feedback that we give to our clients during training; trending more toward an external focus of movement. Benjaminse also gives examples of real time feedback in the manuscript in the form of a Visual 3 D software called C-Motion, Inc. This type of technology is wonderful for allowing the client to gain immediate feedback for training purposes of motion. The drawbacks of this type of tool are obvious though in both cost and space necessary to provide. These specific factors are why I prefer the Motion Guidance advanced visual feedback system. The advanced part refers the endless dynamic applications this system allows for. Placing a mounted laser on any body part allows for the client to gain immediate feedback during motion. Adding delayed feedback and review can easily be done with a smartphone or tablet (insert endless aps here to use). This system can provide a bridge between high tech and no tech and give clinicians options for providing an engaging source of external focus to the client. And at less than $300 USD, it is affordable to most.
Regardless of the device, or lack of, that you chose to have in your treatment setting, the research trends are becoming clear. Providing external focus has important implications for improving retention and performance. It has evidence that it speeds up the learning process, thereby enabling performers to achieve a higher level of expertise sooner. A potential solution specific to injury prevention may be grounded in neuromechanics. The training of conscious movement training into unconscious patterns to yield improved motor learning and strengthening to limit undesired movements or improve motor control into all movements. That is our ongoing professional goal in athletic performance.
-Eric M. Dinkins, PT, MS, OCS, Cert. MT, MCT