Attentional focus of feedback and instructions in the treatment of musculoskeletal dysfunction: A systematic review

doi:10.1016/j.math.2013.07.002

Manual Therapy

Volume 18, Issue 6, December 2013, Pages 458-467

https://doi.org/10.1016/j.math.2013.07.002 Get rights and content

Abstract

Background

An external focus of attention (EFA) during the learning of a motor task improves performance and retention in healthy individuals. People with musculoskeletal dysfunction also learn motor tasks and could potentially benefit from adopting an EFA during practice.

Objectives

To determine whether instructions and feedback provided to individuals with musculoskeletal dysfunction is more effective in improving function and decreasing pain when inducing an external rather than an internal focus of attention (IFA).

Design

Systematic review

Search methods

MEDLINE, Embase, CINAHL, AMED, the Cochrane Library and five additional databases were searched.

Selection criteria

Randomised, quasi-randomised and non-randomised controlled trials, cross over trials and observational studies involving participants with any form of musculoskeletal dysfunction, comparing IFA or EFA with a different attentional focus (AF), control, placebo or no focus condition.

Data collection and analysis

Two review authors independently screened titles, abstracts and full texts, then extracted data and appraised the quality of trials using the GRADE system of rating methodological quality.

Results

Seven studies were included with a total of 202 participants. Two studies compared an IFA with an EFA, two compared IFA with biofeedback with a different focus condition, and three compared IFA with biofeedback with a no focus condition. Statistically significant improvements in motor performance directly attributable to the focus of attention were only found in the EFA groups. There were no significant improvements in function or pain.

Conclusion

There is insufficient evidence to draw conclusions regarding the effects of attentional focus of instructions and feedback on outcomes in musculoskeletal dysfunction.

Introduction

Musculoskeletal dysfunction is a major cause of morbidity and disability worldwide (Mock and Cherian, 2008). As well as the personal cost to individuals and their families, musculoskeletal dysfunction is a significant drain on the health and social care system (Handoll et al., 2007) and the leading cost driver in workers compensation (Cusimano-Reaston and Carney, 2011). Healthcare costs attributable to musculoskeletal spinal pain alone are estimated at $86 billion annually and predicted to rise (Martin et al., 2008). The treatment of musculoskeletal dysfunction may be improved through effective rehabilitation. Indeed, early rehabilitation of musculoskeletal dysfunction has demonstrated large financial benefits, with one onsite industrial physical therapy program reporting a benefit-to-cost ratio of greater than nine to one (Hochanandel and Conrad, 1993).

Rehabilitation in musculoskeletal dysfunction frequently involves relearning motor skills with the use of instructions and feedback. Feedback, by increasing an individual's knowledge and understanding of how they are performing a skill or of their success in achieving a desired result, helps a person learn motor skills more quickly and easily, motivating a learner to continue to strive towards achieving a skill goal (Magill, 2007). A large body of research in healthy people has investigated the effects of an individual's focus of attention during their movement performance (Wulf et al., 2001, Wulf and Prinz, 2001). Instructions that direct an individual's attention to the effects of their movements on the environment (e.g. the tool they are using) are said to induce an external focus of attention (EFA). Alternatively, when an individual is focussing on movement of the body or body parts, they have an internal focus of attention (IFA).

A convincing body of evidence in healthy subjects shows an EFA during the learning of a motor task improves performance and retention of that motor task (for a review, see Wulf et al., 2001b). To explain this phenomenon, McNevin et al. (2003, p.22) propose a ‘constrained action hypothesis.’ They argue that consciously trying to control one's movements constrains the motor system by interfering with automatic motor control processes that would “normally” regulate the movement. Supporting this notion, an EFA during a balance task has been found to result in better task performance, increased frequency of responding to permutations and decreased attention demands compared to an internal focus (Wulf et al., 2001). This increased efficiency is indicative of more automatic motor control processing (Wulf et al., 2001). Moreover, the further the attentional focus (AF) is shifted from the body, the better the individual's response frequency and overall performance (Wulf et al., 2001, McNevin et al., 2003). It is thought that focussing on a movement effect near to the body invites more conscious intervention in the movement process than when the focus is further away and hence easier to distinguish from the body (McNevin et al., 2003). However, the movement effect must be near enough to the body to be easily related to the movement performed (Wulf et al., 2001b). Thus the proposed optimal focus is directed to an effect that is as remote as possible from the body, whilst being as closely related as possible to the action that caused it (Wulf et al., 2001b).

Though an EFA is reported as more effective for skill mastery in asymptomatic persons (Wulf et al., 2001b) and in patients with stroke (van Vliet and Wulf, 2006), it is not known if this also occurs in patients with musculoskeletal dysfunction, nor whether this improved learning effect results in improved patient outcomes. This review aims to examine and synthesise the available evidence regarding the impact of AF during motor learning among people with musculoskeletal dysfunction. The objective of this systematic review was to determine whether instructions and feedback inducing an external focus of attention are more effective than instructions and feedback inducing an internal focus of attention, in improving function and decreasing pain in patients with musculoskeletal dysfunction.

Section snippets

Method

The method followed a review protocol established before the review was conducted that included details of the research question, eligibility criteria, search methods, selection of studies, grading of methodological quality, data extraction and data synthesis.

Flow of studies through the review

Searches of the electronic bibliographic databases identified 2676 records (317 from Medline, 757 from Embase Classic + Embase, 614 from CINAHL, 16 from AMED, 270 from The Cochrane Library (9 from CENTRAL, 4 from DARE, 251 from Trials, 6 from Methods Studies, 0 from Technology Assessment, Economic Evaluations and Cochrane Groups), 53 from Web of Science, 126 from Scopus, 0 from OTseeker, 523 from PEDro, and 0 from REHABDATA). Duplicates were removed by the first author. Fig. 1 shows the study

Discussion

The results of this review suggest that there is insufficient evidence to determine if an EFA or an IFA is more effective in improving function and decreasing pain in patients with musculoskeletal dysfunction. Only two of the included studies, both investigating ankle sprain (Laufer et al., 2007, Rotem-Lehrer and Laufer, 2007), were designed specifically to examine the effect of differing attentional foci. The remaining studies' results are confounded by the provision of biofeedback to the

Conclusions

There are no studies that directly compare an EFA to an IFA and report its effect on pain or functional outcomes in patients with musculoskeletal pain. There is limited evidence from two studies that an EFA may be superior to an IFA for improving motor performance in patients with lateral ankle sprain, but there is insufficient evidence at this stage to make firm recommendations for clinical practice.

Conflict of interest statement

I certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on me or on any organization with which I am associated.

Acknowledgements

The authors would like to thank Debbie Booth, Faculty Librarian at The University of Newcastle who assisted with search strategies for this review. The authors report no conflict of interest.

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^☆: Institution to which the work should be attributed: Discipline of Physiotherapy, School of Health Sciences, and Hunter Medical Research Institute, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.

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Review articleAttentional focus of feedback and instructions in the treatment of musculoskeletal dysfunction: A systematic review☆

Abstract

Background

Objectives

Design

Search methods

Selection criteria

Data collection and analysis

Results

Conclusion

Introduction

Section snippets

Method

Flow of studies through the review

Discussion

Conclusions

Conflict of interest statement

Acknowledgements

Arch Phys Med Rehabil

Physiotherapy

Arch Phys Med Rehabil

Behav Ther

Videotape immediate playback: A tool in rehabilitation of persons with amputations

Arch Phys Med Rehabil

Biofeedback in back muscle strengthening

Spine

EMG biofeedback and tension headache: a controlled outcome study

Psychometric Med

Legal changes necessitates proactive management of musculoskeletal disorders: the role of electrodiagnostic functional assessment soft tissue management program

IEEE Eng Med Biol Soc

GRADE – an emerging consensus on rating quality of evidence and strength of recommendations

Br Med J

Moving towards evidence-based healthcare for musculoskeletal injuries: featuring the work of the Cochrane Bone, Joint and Muscle Trauma Group

J R Soc Promot Health

Cochrane handbook for systematic reviews of interventions

Evolution of an on-site industrial physical therapy program

J Occup Med

Motor learning and control: concepts and applications

Review article
Attentional focus of feedback and instructions in the treatment of musculoskeletal dysfunction: A systematic review☆