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Int J Sports Phys Ther
Int J Sports Phys Ther
2159
International Journal of Sports Physical Therapy
2159-2896
NASMI Website: International Journal of Sports Physical Therapy

34909262
29848
10.26603/001c.29848
Clinical Commentary/Current Concept Review
Effective Attentional Focus Strategies after Anterior Cruciate Ligament Reconstruction: A Commentary
Singh Harjiv 1
Gokeler Alli 2
Benjaminse Anne 3
1 Kinesiology and Nutrition Sciences University of Nevada Las Vegas
2 Department Exercise & Health, Exercise Science and Neuroscience, University of Paderborn; Department of Public and Occupational Health, Amsterdam Movement Sciences, VU University Medical Center; OCON Centre of Orthopaedic Surgery and Sports Medicine
3 Human Movement Sciences Center for Human Movement Sciences, University of Groningen; School of Sport Studies, Hanze University Groningen
Corresponding Author: Anne Benjaminse Center for Human Movement Science University Medical Center Groningen University of Groningen Antonius Deusinglaan 1 9713 AV Groningen The Netherlands Email: a.benjaminse@umcg.nl
2 12 2021
2021
16 6 15751585
19 4 2021
24 8 2021
© The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (4.0) which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

Individuals after anterior cruciate ligament reconstruction (ACLR) have a high rate of reinjury upon return to competitive sports. Deficits in motor control may influence reinjury risk and can be addressed during rehabilitation with motor learning strategies. When instructing patients in performing motor tasks after ACLR, an external focus of attention directed to the intended movement effect has been shown to be more effective in reducing reinjury risk than an internal focus of attention on body movements. While this concept is mostly agreed upon, recent literature has made it clear that the interpretation and implementation of an external focus of attention within ACLR rehabilitation needs to be better described. The purpose of this commentary is to provide a clinical framework for the application of attentional focus strategies and guide clinicians towards effectively utilizing an external focus of attention in rehabilitation after ACLR.

Level of Evidence

5

rehabilitation
motor learning
acl
attentional focus
==== Body
pmcINTRODUCTION

A rupture of the anterior cruciate ligament (ACL) is one of the most common sport related injuries. Patients who want to continue to pursue pivoting type of sports often undergo ACL reconstruction (ACLR) followed by extensive periods of rehabilitation. However, patients after ACLR still may have up to a 40 times greater risk of reinjury relative to those without injury.1 Following ACLR, aberrant movement patterns have been linked to an increased risk of a second ACL injury and may also explain why not all patients return to their pre-injury level.2–4 Current rehabilitation approaches may not optimally target deficits in motor control. An emphasis on the dynamics of skill (re)acquisition in current rehabilitation programs have been recommended to target these motor control deficits.5–9 To best improve motor learning and performance after ACLR clinicians may need to consider the way in which verbal instruction and feedback influences attentional focus and thus skill development throughout the rehabilitation process.9–11

A traumatic injury, such as an ACL rupture, may trigger a cognitive disruption and has the potential for maladaptive neuroplasticity with motor and premotor areas of the cortex being more active during simple movement tasks compared to uninjured individuals.12,13 Loss of function, pain, fear of reinjury, and other psychological factors may cause a shift in focus towards the injured area such as the knee. Therefore, the patient recovering from the injury is excessively focusing on the injured area during movement execution.14–17 This focus directed towards body movements, and accompanying brain adaptations, potentially deters motor performance after sports injury. Return to high level performance may benefit from the adoption of an external focus of attention when providing instructions directed towards the intended movement effect.17,18 However, clinicians utilize internal focus instructions over 90% of the time.19,20 This extra focus on the body may stimulate the motor and premotor areas of the cortex to be active to a greater degree. While a rationale may be that an internal focus is necessary to progress from the cognitive stage of learning to the associative and automatic stage, this view is not well supported in the motor learning literature.21,22 Furthermore, misconceptions regarding when to use an external focus of attention (e.g. early vs. late rehabilitation or description vs. execution of movement) alongside a recent body of literature that has attempted to extend this work into hybrid models, warrants a critical evaluation. Therefore, the purpose of this commentary is to provide a clinical framework for the application of attentional focus strategies and guide clinicians towards effectively utilizing an external focus of attention throughout ACLR rehabilitation.

CONSIDERING AN EXTERNAL FOCUS OF ATTENTION TO OPTIMIZE MOVEMENT OUTCOME

A subtle change in the wording of exercise instruction prior to movement execution can promote an external focus of attention so that attention is directed to one’s intended effect of the movement (goal-directed attention), in contrast to paying attention to one’s own body movements (i.e., internal focus of attention or self-directed attention). This external focus of attention centers on the ability to engage both the perceptual-cognitive and physical performance factors in the functional task environment.23 For example, in an effort to improve balance performance, a patient may perform a single leg balance task on a Bosu ball (BOSU, Ashland, OH). A clinician may instruct the patient using an internal focus of attention such as, “minimize movement of the feet”. However, by just changing one word to “minimize movement of the Bosu” the instructions become externally focused. In addition, an external focus of attention can also be elicited by means of a metaphor (e.g., “stand still like you are stuck on Velcro”), analogy (“imagine you are on the peak of a mountain, stay on the mountain!), an object attached to the body (”keep the tape attached to the chest still”), or an imagined object, where a mental image of the movement goal is obtained (e.g., thinking of the leg as a line, “keep the line straight”).24–28

The benefit of an external focus of attention compared to an internal focus of attention for enhancing motor skill learning and performance has consistently been shown through a large body of evidence across different populations, tasks, and skill levels.10,29,30 These include tasks such as balancing, running, agility performance, change of direction performance, force production, and horizontal and vertical jump performance.6,31–38 Collectively, an external focus of attention has been shown to produce more accurate performance, improved reaction time, and more efficient movement (e.g., reduced muscular activity).39–41 Also in athletes following an ankle sprain, those who received external focus instructions to “keep your balance by stabilizing the platform” demonstrated improved balance after training compared to an internal focus group instructed to “keep your balance by stabilizing your body”.18

In primary ACL injury prevention, there is evidence which illustrates how an external focus of attention can lead to improved movement form, jump performance, and result in safer landing mechanics. A literature review on jump and landing technique showed that an external focus of attention improves movement with greater knee flexion angles, greater center of mass (CoM) displacement, lower peak vertical ground reaction force (vGRF), and improved neuromuscular coordination, while maintaining or improving performance (i.e., jump height or distance).6 These findings suggest a decrease in ACL injury risk.

In another example, the effects of an internal and external focus of attention on landing forces were compared in adolescent rugby players before and after a two-week training program. An external focus directed to “focus on landing softly” resulted in a reduction in landing forces with the addition of a secondary cognitive task compared to an internal focus of attention directed to “focus on bending your knees when you land,” which showed an increase in landing forces with the addition of a secondary cognitive task.42 Therefore, an external focus of attention utilized less conscious control in dual-task conditions which is similar to the conditions that athletes may face when returning to sport. Similarly, using an external focus of attention was also shown to immediately result in reduced landing stiffness in female athletes as well as improved landing technique compared to an internal focus of attention.43,44 In a recent study utilizing the Landing Error Scoring System (LESS), colored tape was attached to each participant’s mid patella alongside the tips of their shoes.45 The external focus of attention instructions were: “when landing from the box, focus on pushing the red tapes (attached to the mid patella) forward, and pointing the green tapes (attached to the tips of the shoes) forward.” The internal focus instructions were, “when landing from the box, focus on pushing your knees forward, and pointing your toes forward.” Better landing quality, expressed by a lower LESS score, was achieved using an external focus of attention compared to internal focus of attention. In another jump landing study, athletes training with an external focus of attention (“push yourself as hard as possible off the ground after landing on the force plate”) demonstrated greater knee flexion range of motion compared to another group training with an internal focus of attention (“extend your knees as rapidly as possible after the landing on the force plate”). These results were not only retained one week later, but also carried over to an unanticipated sidestep cutting task.46

An external focus of attention may be successful by facilitating functional connectivity, modulating surround inhibition, and increasing intracortical inhibition to resemble the sensorimotor integration typically seen in more skilled action.47–49 The constrained action hypothesis suggests that an internal focus disrupts the motor system by promoting conscious control which leads to a breakdown in the in the otherwise natural organized coordination of one’s movement. On the other hand, an external focus allows for a greater degree of self-organization by promoting automatic control processes.32 Therefore, if movements are not planned in terms of the intended movement effect, but in terms of specific body movements, the outcome will be less-than-optimal.50 Additionally, an external focus has been recognized as a critical element to goal-action coupling, strengthening the neuromuscular processes between the patient’s movement goal and desired movement action.51

Thus, it is clear that just a slight change of wording can affect motor learning and performance.52,53 Because instructions and feedback are constantly used in rehabilitation of ACLR patients, the effect of different constructs of language on movement mechanics should not be underestimated. Recent literature shows that several misconceptions of what an external focus is and how it should be implemented within ACL injury rehabilitation exist. In the following sections, a brief review of this literature along with clinical examples is provided to help aide clinicians in effectively utilizing an external focus of attention.

STAGES OF LEARNING

Rehabilitation after ACLR can be categorized into three stages: early, intermediate and late. For the intermediate phase, it has been recommended that an internal focus of attention is necessary to achieve sound movement patterns to restore motor function (i.e., muscle contraction ability) with patients only being able to adopt the ‘right’ way of moving when you tell them explicitly how to do it.22,54 Then, during the progression of the exercises, external factors that increase task complexity such as hurdles or unstable surfaces should be added.22 These assumptions are based on more traditional views of motor learning where a linear progression for learning or re-learning motor skills is paramount.55,56 Traditional teaching of exercise also tends to emphasize specific step-by-step detailed instruction of a movement pattern for repetitive rehearsal (providing an “optimal” way to perform a specific movement), as well as the application of corrective and frequent feedback in repeating a movement technique.57,58 Briefly, through this lens, attentional demands transition from being under high conscious control to being controlled with very little cognitive effort over time as movements become more accurate, consistent, and efficient. However, as described by a more recent non-linear progression for learning, a given range of possible movement solutions should allow clinicians to guide patients as they self-organize and find their optimal movement to reach the goal of the movement (e.g., soft landing).7,57 As compared to internal focus of attention, an external focus provides the opportunity for self-organizing, as shown by efficient recruitment of motor units, fewer co-contraction of muscles, increased functional variability, and a “freeing” of the body’s degrees of freedom.58–60 An external focus seems to speed up the learning process, displaying adoption of movement patterns similar to more skilled performance. This effect can be seen in both the early stages of learning (i.e., novice) and the later stages of learning.10 For example, in an early-phase rehabilitation isometric force production task performed by healthy physically active individuals, an external focus directed to “focus on pushing up into this pad as hard as you can” resulted in an 8% increase in force production of the gluteus medius compared to an internal focus of attention directed to “focus on contracting the muscles of your outer hip as hard as you can.”61 Moreover, using an app-based active muscle training program (GenuSport Knee Trainer, Weber-Spickschen) where the aim is to produce force by pushing the knee down into the measuring unit, patients post ACLR improved strength significantly more compared to a control group who trained with an internal focus of attention. In the former, the patient attends to a game on the tablet, rather than their body part, to control a flight course of an airplane with the aim to destroy balloons.62

The second assumption is that once one starts to transition into the late rehabilitation phase, adding aspects to the environment (e.g., hurdle, ball, or an unstable surface) leads to a shift to an external focus of attention.22 However, adding environmental factors do not shift the patient’s attention to an external focus but simply refer to objects in the environment and not one’s intended movement effect. Likewise, in the later stages of rehabilitation, it is suggested to progress from closed skills (e.g., usually self-paced, predictable skills that are decontextualized from the environment) with an internal focus of attention to more open, sport-specific skills with an external focus.22 Here, it is assumed that an internal focus of attention is better or equivalent for closed skills and external focus for open skills (e.g., patients have to make decisions and adapt their skills to an unpredictable environment).22 In contrast, it is also assumed that practicing closed skills cannot benefit from external focus instructions because the individual lacks correct movement patterns. However, the benefit of an external focus has been shown in both closed and open skills.10,34,63,64 This effect also extends across early and late stages of learning. Therefore, clinicians should evaluate the task goal, establish an optimal challenge level, consider patient preferences regarding the appropriate instructions, and create an external focus in relation to the patient’s action capability within the functional task environment.32,65–68 Regardless of utilizing a closed or open skill, it is recommended to keep exercises as representative as possible of conditions that patients will return to through all stages of rehabilitation.23

DESCRIPTION VS. EXECUTION

Another misconception is that with an external focus of attention, patients are not allowed to know the goal of the exercises (e.g., increase knee flexion, deeper landing) or focus on their body to perform the requested movement.69 However, an external focus does not mean that the patient is not aware of her or his body movements50 but rather means the patient is focusing on the intended movement effect – while preparing for the execution of a ballistic skill (e.g., throwing or hitting a ball) or during the execution of a continuous skill (e.g., balancing, swimming, cross-country skiing). Adopting an external focus is thus related to the planning of the movement, not with the processing of intrinsic feedback or bodily awareness.50 This does not mean that a clinician must never use body related words that elicit an internal focus of attention but verbiage should be limited to the description portion prior to the execution of the motor skill.

It is important to differentiate between telling the patient the goal of the exercise and the instructions and feedback being provided during practice. In case of rehabilitation after ACLR, this would mean that you can explicitly tell the patient the general goal of an exercise. For example, “the goal of this exercise is to improve your knee bending while landing, as this promotes a softer landing, which is better for your knee.” Then, as your patient is preparing to execute the exercise, it is critical to shift their attentional focus that corresponds closest to the task goal. This means, the physiotherapist can choose either an internal focus of attention (e.g. “flex your knee when landing”, as most frequently done) or an external focus of attention (e.g. “focus on landing with as little noise as possible” or “pretend you are going to sit on a chair when landing”) (Figure 1).6 With the external focus of attention, you do not have to explicitly tell the patient how, rather give the patient the freedom to come up with a solution to complete the goal of the task in the functional environment (less noise during landing from a jump). Here the patient is allowed to seek out relevant features of the task environment to shape self-organization. One must recognize there will not be one perfect movement solution.7 Based upon the intrinsic dynamics of the patient and the channeling of exploratory movement solutions, clinicians should highlight the existence of a multitude of stable movement patterns and solutions for a task.70 In the example above, the end effect is the same (i.e., increased bending in the knee when landing), however the focus of the patient when executing the motor task is different. As a result, shifting to an external focus may lead to better movement form both in practice, during retention, and upon transfer to more competition and game-like interactions.

75328 Figure 1. Illustrating the difference between explaining the goal of an exercise and the subsequent attentional foci a clinician can choose for his/her instruction/feedback just prior to practice.

THE RIGHT FOCUS

While the purpose of this commentary is to illustrate that word choices are crucial to implement an external focus of attention, this is not a new phenomenon or discussion. Over the last several years there has been an increase in research related to attentional focus, ACLR rehabilitation, and biomechanical risk factors related to ACL injury. However, the terminology encompassing an external focus of attention has lately been extended to descriptions such as: ’external factors’, ‘external cueing’, ‘external focus of control’, ‘external goal’, ‘externally focused motivation’, ‘external feedback’, ‘external feedback motivation’, ‘visual external focus’ and ‘external visuospatial environment’.54,71–74 As a result, the research relating to attentional focus can be hard to interpret. Attentional focus is defined as the conscious effort of a patient to focus their attention on explicit thoughts or feelings in an effort to execute a task with superior performance.69Attentional focus relates closely to what you tell your patient(s) prior to the execution of the exercise whereby you direct them where to focus their attention: internally (i.e. on body part(s) and movement(s)s) or externally (i.e. on intended movement effect). Hybrid instructions, such as “step toward the cone by pushing the floor away with your back foot” for the execution of a lunge or “balance a board flat across your shoulders” for the correction of excessive lateral trunk flexion on squat jump landing are not recommended.54,74 These hybrid instructions are not purely an external focus of attention as they include a reference to a body part: the back foot. This “self-invoking trigger” may result in inefficient activation of the neuromuscular system.75,76 A minor change such as “step toward the cone by pushing the floor away with your back shoe” or “balance a board flat across your shirt” would make this instruction solely an external focus instruction. While the inclusion of motor learning principles in physical therapy have been around for over a decade, the above-mentioned misinterpretations regarding the definition and application of an external focus offer an opportunity to re-evaluate how motor learning principles are being applied as a means to treat complex injuries such as the ACL injury.6–9,11 Creating and implementing an external focus takes time and requires practice but may help to optimize patient care. Clinical examples that will offer clinicians examples of how to incorporate external focus in their practice are provided for the early (Table 1), intermediate (Table 2), and late (Table 3) phases of rehabilitation.

75329 Table 1. Example exercises and attentional focus strategies for early phase rehabilitation.

EARLY	
Using a criteria-based, evidence-based constructed approach to rehabilitation after ACL surgery is essential to progress a patient systematically and successfully through the rehabilitation process. It is imperative to control post-operative pain, inflammation and swelling during the first weeks of rehabilitation. Calming the knee down initially, starting slowly, will allow the rehabilitation to accelerate faster in the long run. Post-operative rehabilitation begins with a range of movement exercises, emphasizing full passive knee extension and weight-bearing activities immediately post-operatively.	
EXERCISE EXAMPLES	
Knee Extension on a Bolster	Straight Leg Raise	Glute Bridge	Balance (Single-leg on balance board)	Gait	
INTERNAL FOCUS	
“Press your knee toward the table”	“Lift your leg 6 inches off the ground”	“First, tighten your abdominals, keep them activated, then lift your hips off the floor”	“Focus on keeping your pelvis as still as possible"	“Extend your knee while walking”	
EXTERNAL FOCUS	
“Press the bolster toward the ground”	“Lift your shoe 6 inches off the ground”	“Push into the ground and bring this marker off the floor” (marker on waist)	“Minimize the movement of the balance board”	“Focus on the markers drawn on the floor” (markers based on symmetrical gait cycle)	

75330 Table 2. Example exercises and attentional focus strategies for intermediate phase rehabilitation.

INTERMEDIATE	
As the patient becomes stronger and elicits more stable motor patterns, exercises are varied more often and become sport specific. Both pain and amount of exertion should continue to be monitored.	
EXERCISE EXAMPLES	
Running	Bilateral squat on unstable surface	Split squat jump	Bilateral rotational jump 90° turn	Single leg hopping multiple directions	
INTERNAL FOCUS	
“Land on your forefoot”	“Lower your hips until your thighs are parallel to the floor, then return to standing”	“Flex your knees to 90° when landing”	“Start in a squat position, jump and turn so that your hips are facing the wall while flexing the knees when landing”	“Flex your knees to 90° when landing”	
		“Extend your knees away from the ground”		“Keep your knee above your toes when landing”	
		“Keep your knee over your toes when landing”			
EXTERNAL FOCUS	
“Touch floor with coloured part of your shoes” (tape on forefoot)	“Imagine you are going to sit on a chair and then return to standing”	“Push the floor away when jumping”	“Start in a squat position, jump and turn so that the marker is facing the wall” (tape marker (or shirt logo) on chest)	“Point the tape towards the cones when landing” (tape on tibial tuberosity)	
“Lower noise from both feet from 8 to 4” (using VAS scale 0 is no noise, 10 is loud noise)	“Lower down until you slightly tap the bench” (bench behind person)	“Get away from the grass/floor when jumping”	“Start in a squat position, jump and keep tension on the cord and land” (elastic cord around waist)	“Keep the pieces of tape in line of each other when landing” (tape on tibial tuberosity and on dorsal side of foot)	
	“Keep the water as still as possible” (cup of water on the unstable surface)	“Drive the tape to the sky”(tape on chest)	“Lower noise when landing from 8 to 4”(using VAS scale 0 is no noise, 10 is loud noise)		
		“Lower in line with your laces”	“Drive the tape down and back” (tape on hips)		

75331 Table 3. Example exercises and attentional focus strategies for late phase rehabilitation.

LATE	
As the patient engages in more sport-specific activities, multi-planar movements are incorporated in preparation to return to sport.	
EXERCISE EXAMPLES	
Agility “L” Run	Lateral Shuffle	Unanticipated Change of Direction Cone Drill	
INTERNAL FOCUS	
“For the turn, focus on planting your foot as quickly as possible”	“Bend your knees to 90° when shuffling”	“When making the cut, bend your knee”	
		“When making the cut, keep your knees over your toes”	
EXTERNAL FOCUS	
“For the turn, focus on getting to the next cone fast”	“While shuffling, keep the bottom of your shorts parallel to the floor”	“When making the cut, push yourself off of the ground as hard as possible”	
“When making the turn, move the logo on your shirt towards your running direction”		“When making the cut, move towards the new cone quickly”	
“When making the turn, point the tip of your shoe towards new running direction”		“When making the cut, point the tape on the tip of your shoe towards new running direction”	

CONCLUSION

Targeting deficits in motor control is a critical component for ACLR rehabilitation. One way to potentially improve neuromuscular control is by altering how attentional focus is directed when performing motor skills across early, middle, and late phases of rehabilitation. An external focus of attention offers an alternative strategy that facilitates automatic movement control and results in more effective performance and learning than an internal focus of attention. Clinicians are encouraged to adopt an external focus of attention in their practice over an internal focus of attention to promote optimal movement strategies throughout rehabilitation interventions. Further, researchers should strive to use similar terminology when it comes to describing attentional focus interventions into experimental designs.

Disclosure statement

No financial interest or benefit has arisen from the direct applications of this research. The authors report no conflicts of interest.
==== Refs
Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: A systematic review and meta-analysis: A systematic review and meta-analysis The American Journal of Sports Medicine Wiggins Amelia J. Grandhi Ravi K. Schneider Daniel K. Stanfield Denver Webster Kate E. Myer Gregory D. SAGE Publications 15 1 2016
44 7 1861 1876 0363-5465 10.1177/0363546515621554 10.1177/0363546515621554 26772611
Limb asymmetries in landing and jumping 2 years following anterior cruciate ligament reconstruction Clin J Sport Med Paterno Mark V Ford Kevin R Myer Gregory D Heyl Rachel Hewett Timothy E 7 2007
17 4 258 262 1050-642X 10.1097/jsm.0b013e31804c77ea 10.1097/jsm.0b013e31804c77ea 17620778
Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport The American Journal of Sports Medicine Paterno Mark V. Rauh Mitchell J. Schmitt Laura C. Ford Kevin R. Hewett Timothy E. SAGE Publications 21 4 2014
42 7 1567 1573 0363-5465 10.1177/0363546514530088 10.1177/0363546514530088 24753238
Movement patterns of the knee during gait following ACL reconstruction: A systematic review and meta-analysis Sports Medicine Kaur Mandeep Ribeiro Daniel Cury Theis Jean-Claude Webster Kate E. Sole Gisela Springer Science and Business Media LLC 2 3 2016
46 12 1869 1895 0112-1642 10.1007/s40279-016-0510-4 10.1007/s40279-016-0510-4
Correction to: Principles of motor learning to support neuroplasticity after ACL injury: Implications for optimizing performance and reducing risk of second ACL injury Sports Medicine Gokeler Alli Neuhaus Dorothee Benjaminse Anne Grooms Dustin R. Baumeister Jochen Springer Science and Business Media LLC 21 2 2019
49 6 979 979 0112-1642 10.1007/s40279-019-01078-w 10.1007/s40279-019-01078-w 30788801
Novel methods of instruction in ACL injury prevention programs, a systematic review Phys Ther Sport Benjaminse Anne Welling Wouter Otten Bert Gokeler Alli 5 2015
16 2 176 186 1466-853X 10.1016/j.ptsp.2014.06.003 10.1016/j.ptsp.2014.06.003 25042094
ACL injury prevention, more effective with a different way of motor learning? Knee Surgery, Sports Traumatology, Arthroscopy Benjaminse Anne Otten Egbert Springer Science and Business Media LLC 2011
19 4 622 627 0942-2056 10.1007/s00167-010-1313-z 10.1007/s00167-010-1313-z 21079917
Using principles of motor learning to enhance ACL injury prevention programs Sports Orthopaedics and Traumatology Gokeler Alli Benjaminse Anne Seil Romain Kerkhoffs Gino Verhagen Evert 2 2018
34 1 23 30 0949-328X 10.1016/j.orthtr.2017.12.006 10.1016/j.orthtr.2017.12.006
Feedback techniques to target functional deficits following anterior cruciate ligament reconstruction: Implications for motor control and reduction of second injury risk Sports Medicine Gokeler Alli Benjaminse Anne Hewett Timothy E. Paterno Mark V. Ford Kevin R. Otten Egbert Myer Gregory D. Springer Science and Business Media LLC 24 9 2013
43 11 1065 1074 0112-1642 10.1007/s40279-013-0095-0 10.1007/s40279-013-0095-0 24062274
Attentional focus and motor learning: A review of 15 years International Review of Sport and Exercise Psychology Wulf Gabriele 9 2013
6 1 77 104 1750-984X 10.1080/1750984x.2012.723728 10.1080/1750984x.2012.723728
Optimization of the anterior cruciate ligament injury prevention paradigm: Novel feedback techniques to enhance motor learning and reduce injury risk Journal of Orthopaedic & Sports Physical Therapy Benjaminse Anne Gokeler Alli Dowling Ariel V. Faigenbaum Avery Ford Kevin R. Hewett Timothy E. Onate James A. Otten Bert Myer Gregory D. Journal of Orthopaedic & Sports Physical Therapy (JOSPT) 3 2015
45 3 170 182 0190-6011 10.2519/jospt.2015.4986 10.2519/jospt.2015.4986 25627151
Central Nervous System Adaptation After Ligamentous Injury: A Summary of Theories, Evidence, and Clinical Interpretation Sports Medicine Needle Alan R. Lepley Adam S. Grooms Dustin R. Springer Science and Business Media LLC 22 12 2016
47 7 1271 1288 0112-1642 10.1007/s40279-016-0666-y 10.1007/s40279-016-0666-y
Neuroplasticity following anterior cruciate ligament injury: A framework for visual-motor training approaches in rehabilitation Journal of Orthopaedic & Sports Physical Therapy Grooms Dustin Appelbaum Gregory Onate James Journal of Orthopaedic & Sports Physical Therapy (JOSPT) 5 2015
45 5 381 393 0190-6011 10.2519/jospt.2015.5549 10.2519/jospt.2015.5549 25579692
Fear of reinjury in athletes: Implications for rehabilitation Sports Health: A Multidisciplinary Approach Hsu Chao-Jung Meierbachtol Adam George Steven Z. Chmielewski Terese L. SAGE Publications 2017
9 2 162 167 1941-7381 10.1177/1941738116666813 10.1177/1941738116666813 27590793
Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery The American Journal of Sports Medicine Ardern Clare L. Taylor Nicholas F. Feller Julian A. Whitehead Timothy S. Webster Kate E. SAGE Publications 3 6 2013
41 7 1549 1558 0363-5465 10.1177/0363546513489284 10.1177/0363546513489284 23733635
A review of return to sport concerns following injury rehabilitation: Practitioner strategies for enhancing recovery outcomes Physical Therapy in Sport Podlog Leslie Dimmock James Miller John 2 2011
12 1 36 42 1466-853X 10.1016/j.ptsp.2010.07.005 10.1016/j.ptsp.2010.07.005
Differences in attentional focus associated with recovery from sports injury: Does injury induce an internal focus? J Sport Exerc Psychol Gray Rob 12 2015
37 6 607 616 0895-2779 10.1123/jsep.2015-0156 10.1123/jsep.2015-0156
Effect of attention focus on acquisition and retention of postural control following ankle sprain Arch Phys Med Rehabil Laufer Yocheved Rotem-Lehrer Nirit Ronen Zohar Khayutin Giora Rozenberg Ilanit 1 2007
88 1 105 108 0003-9993 10.1016/j.apmr.2006.10.028 10.1016/j.apmr.2006.10.028
Use of information feedback and attentional focus of feedback in treating the person with a hemiplegic arm: Use of attentional focus of feedback following stroke Physiotherapy Research International Durham Katherine Van Vliet Paulette M. Badger Frances Sackley Catherine Wiley 2009
14 2 77 90 1358-2267 10.1002/pri.431 10.1002/pri.431 19107706
Internal and external focus of attention during gait re-education: An observational study of physical therapist practice in stroke rehabilitation Phys Ther Johnson Louise Burridge Jane H. Demain Sara H. 1 7 2013
93 7 957 966 0031-9023 10.2522/ptj.20120300 10.2522/ptj.20120300
Human Performance Fitts P.M. Posner M.I. Praeger Westport, CT 1979

Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture Best Practice & Research Clinical Rheumatology Filbay Stephanie R. Grindem Hege 2 2019
33 1 33 47 1521-6942 10.1016/j.berh.2019.01.018 10.1016/j.berh.2019.01.018 31431274
Shaping the Functional Task Environment in Sports Injury Rehabilitation: A Framework to Integrate Perceptual-Cognitive Training in Rehabilitation Athletic Training & Sports Health Care Gokeler Alli McKeon Patrick O. Hoch Matthew C. SLACK, Inc. 11 2020
12 6 283 292 1942-5864 10.3928/19425864-20201016-01 10.3928/19425864-20201016-01
Performance of gymnastics skill benefits from an external focus of attention Journal of Sports Sciences Abdollahipour Reza Wulf Gabriele Psotta Rudolf Palomo Nieto Miriam 16 3 2015
33 17 1807 1813 0264-0414 10.1080/02640414.2015.1012102 10.1080/02640414.2015.1012102
The effects of using imagery to elicit an external focus of attention Res Q Exerc Sport. Published online Yamada M. Raisbeck L.D. Porter J.M. 2020 1 7
The learning advantages of an external focus of attention in golf Research Quarterly for Exercise and Sport Wulf Gabriele Lauterbach Barbara Toole Tonya 6 1999
70 2 120 126 0270-1367 10.1080/02701367.1999.10608029 10.1080/02701367.1999.10608029 10380243
Manipulations to the timing and type of instructions to examine motor skill performance under pressure Frontiers in Psychology Ong Nicole T. Bowcock Alison Hodges Nicola J. 2010
1 196 1664-1078 10.3389/fpsyg.2010.00196 10.3389/fpsyg.2010.00196 21833255
Mind over body: Creating an external focus for sport skills European Journal of Sport Science Singh Harjiv Wulf Gabriele 28 2 2021
2021 1 7 1746-1391 10.1080/17461391.2021.1887367 10.1080/17461391.2021.1887367
Attentional focus affects movement efficiency Skill Acquisition in Sport: Research, Theory, & Practice Lohse K.R. Wulf G. Lewthwaite R. Hodges N.J. Williams M.A. Routledge 2012
40 58
Directing attention to movement effects enhances learning: A review Psychonomic Bulletin & Review Wulf Gabriele Prinz Wolfgang 12 2001
8 4 648 660 1069-9384 10.3758/bf03196201 10.3758/bf03196201
Instructions for motor learning: Differential effects of internal versus external focus of attention Journal of Motor Behavior Wulf Gabriele Höß Markus Prinz Wolfgang 6 1998
30 2 169 179 0022-2895 10.1080/00222899809601334 10.1080/00222899809601334 20037032
Increasing the distance of an external focus of attention enhances learning Psychological Research McNevin Nancy H. Shea Charles H. Wulf Gabriele 2 2003
67 1 22 29 0340-0727 10.1007/s00426-002-0093-6 10.1007/s00426-002-0093-6
The effect of attentional focus on running economy Journal of Sports Sciences Schücker Linda Hagemann Norbert Strauss Bernd Völker Klaus 10 2009
27 12 1241 1248 0264-0414 10.1080/02640410903150467 10.1080/02640410903150467
The attentional focus impact on tennis skills’ technique in 10 and under years old players: Implications for real game situations Journal of Human Sport and Exercise Tsetseli Marina Zetou Eleni Vernadakis Nikolas Mountaki Fereniki 2018
13 2 1988-5202 10.14198/jhse.2018.132.15 10.14198/jhse.2018.132.15
Attentional focusing instructions and force production Front Psychol Marchant D.C. 2010
1 210
Standing long-jump performance is enhanced when using an external focus of attention J Strength Cond Res Porter Jared M Ostrowski Erik J Nolan Russell P Wu Will F W 7 2010
24 7 1746 1750 1064-8011 10.1519/jsc.0b013e3181df7fbf 10.1519/jsc.0b013e3181df7fbf 20543731
Standing long jump performance with an external focus of attention is improved as a result of a more effective projection angle J Strength Cond Res Ducharme Scott W. Wu Will F.W. Lim Kenny Porter Jared M. Geraldo Fransini 1 2016
30 1 276 281 1064-8011 10.1519/jsc.0000000000001050 10.1519/jsc.0000000000001050
Increases in jump-and-reach height through an external focus of attention: A response to the commentary by Keith Davids International Journal of Sports Science & Coaching Wulf Gabriele 9 2007
2 3 289 292 1747-9541 10.1260/174795407782233173 10.1260/174795407782233173
The influence of attention on learning and performance: Pre-movement time and accuracy in an isometric force production task Human Movement Science Lohse Keith R. 2 2012
31 1 12 25 0167-9457 10.1016/j.humov.2011.06.001 10.1016/j.humov.2011.06.001
An external focus of attention enhances golf shot accuracy in beginners and experts REs Q Wulf Gabriele Su Jiang 9 2007
78 4 384 389 0270-1367 10.1080/02701367.2007.10599436 10.1080/02701367.2007.10599436
Increased jump height and reduced EMG activity with an external focus Human Movement Science Wulf Gabriele Dufek Janet S. Lozano Leonardo Pettigrew Christina 6 2010
29 3 440 448 0167-9457 10.1016/j.humov.2009.11.008 10.1016/j.humov.2009.11.008 20409600
Training rugby athletes with an external attentional focus promotes more automatic adaptions in landing forces Sports Biomechanics Widenhoefer Tricia Lee Miller Taylor Matthew Weigand Mark Steven Watkins Emily Ann Almonroeder Thomas Gus 4 3 2019
18 2 163 173 1476-3141 10.1080/14763141.2019.1584237 10.1080/14763141.2019.1584237 31042140
The influence of attentional focus on landing stiffness in female athletes: A cross-sectional study International Journal of Sports Physical Therapy Almonroeder Thomas Gus Jayawickrema Jithmie Richardson Carlee Tonia Mercker Kristin Leigh 8 2020
15 4 510 518 2159-2896 10.26603/ijspt20200510 10.26603/ijspt20200510 33354384
Enhanced retention of drop vertical jump landing technique: A randomized controlled trial Human Movement Science Welling Wouter Benjaminse Anne Gokeler Alli Otten Bert 2 2016
45 84 95 0167-9457 10.1016/j.humov.2015.11.008 10.1016/j.humov.2015.11.008
The effects of attentional focus instructions specific to body movements on movement quality and performance J Sport Rehabil Yamada Masahiro Raisbeck Louisa D. 1 3 2021
30 3 422 429 1056-6716 10.1123/jsr.2019-0344 10.1123/jsr.2019-0344
Transfer of improved movement technique after receiving verbal external focus and video instruction Knee Surgery, Sports Traumatology, Arthroscopy Benjaminse Anne Welling Wouter Otten Bert Gokeler Alli Springer Science and Business Media LLC 2018
26 3 955 962 0942-2056 10.1007/s00167-017-4671-y 10.1007/s00167-017-4671-y 28799030
Adopting an external focus of attention alters intracortical inhibition within the primary motor cortex Acta Physiologica Kuhn Y.-A. Keller M. Ruffieux J. Taube W. 2017
220 2 289 299 1748-1708 10.1111/apha.12807 10.1111/apha.12807 27653020
Surround inhibition can instantly be modulated by changing the attentional focus Scientific Reports Kuhn Yves-Alain Keller Martin Lauber Benedikt Taube Wolfgang Springer Science and Business Media LLC 18 1 2018
8 1 2045-2322 10.1038/s41598-017-19077-0 10.1038/s41598-017-19077-0 29348536
Attention focus modulates afferent input to motor cortex during skilled action Hum Mov Sci Suzuki L.Y. Meehan S.K. 2020
74 102716 102716 33202315
An external focus of attention is aconditio sine qua nonfor athletes: A response to Carson, Collins, and Toner (2015) Journal of Sports Sciences Wulf Gabriele 29 1 2016
34 13 1293 1295 0264-0414 10.1080/02640414.2015.1136746 10.1080/02640414.2015.1136746
Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning Psychonomic Bulletin & Review Wulf Gabriele Lewthwaite Rebecca Springer Science and Business Media LLC 29 1 2016
23 5 1382 1414 1069-9384 10.3758/s13423-015-0999-9 10.3758/s13423-015-0999-9
Words matter: Instructions dictate “self-selected” walking speed in young adults Gait & Posture Brinkerhoff Sarah A. Murrah William M. Hutchison Zach Miller Matthew Roper Jaimie A. Elsevier BV 7 2019
0966-6362 10.1016/j.gaitpost.2019.07.379 10.1016/j.gaitpost.2019.07.379
Effect of verbal instructions on muscle activity and risk of injury to the anterior cruciate ligament during landing Br J Sports Med Cowling E J Steele J.R. McNair P.J 1 4 2003
37 2 126 130 0306-3674 10.1136/bjsm.37.2.126 10.1136/bjsm.37.2.126 12663353
Shifting focus: A clinician’s guide to understanding neuroplasticity for anterior cruciate ligament rehabilitation Current Sports Medicine Reports Faltus John Criss Cody Ryan Grooms Dustin Robert 2 2020
19 2 76 83 1537-8918 10.1249/jsr.0000000000000688 10.1249/jsr.0000000000000688
Mechanisms of skill acquisition and the law of practice Cognitive skills and their acquisition Newell A. Rosenbloom P.S. 1981
1 1981 1 55
A theoretical model to describe progressions and regressions for exercise rehabilitation Physical Therapy in Sport Blanchard Sam Glasgow Phil 8 2014
15 3 131 135 1466-853X 10.1016/j.ptsp.2014.05.001 10.1016/j.ptsp.2014.05.001 24913914
Dynamics of Skill Acquisition: A Constraints-Led Approach Human Kinetics Davids K.W. Button C. Bennett S.J. 2008

Knowledge of results and motor learning: A review and critical reappraisal. Psychological Bulletin Salmoni Alan W. Schmidt Richard A. Walter Charles B. 1984
95 3 355 386 1939-1455 10.1037/0033-2909.95.3.355 10.1037/0033-2909.95.3.355 6399752
The role of attention in motor control. Journal of Experimental Psychology: General Lohse Keith R. Jones Matt Healy Alice F. Sherwood David E. 2014
143 2 930 948 1939-2222 10.1037/a0032817 10.1037/a0032817 23647310
The automaticity of complex motor skill learning as a function of attentional focus The Quarterly Journal of Experimental Psychology Section A Wulf Gabriele McNevin Nancy Shea Charles H. 11 2001
54 4 1143 1154 0272-4987 10.1080/713756012 10.1080/713756012
The effect of attentional focus on gluteus medius recruitment and force production Athletic Training & Sports Health Care Taylor Molly Golden Grace 11 2020
12 6 272 282 1942-5864 10.3928/19425864-20200922-01 10.3928/19425864-20200922-01
Improving maximal strength in the initial postoperative phase after anterior cruciate ligament reconstruction surgery: Randomized controlled trial of an app-based serious gaming approach JMIR Serious Games Clausen Jan-Dierk Nahen Niclas Horstmann Hauke Lasch Florian Krutsch Werner Krettek Christian Weber-Spickschen Thomas Sanjay 24 1 2020
8 1 e14282 2291-9279 10.2196/14282 10.2196/14282 32012046
Directing attention externally enhances agility performance: A qualitative and quantitative analysis of the efficacy of using verbal instructions to focus attention Frontiers in Psychology Porter Jared M. Nolan Russell P. Ostrowski Erik J. Wulf Gabriele 2010
1 216 1664-1078 10.3389/fpsyg.2010.00216 10.3389/fpsyg.2010.00216 21833271
The effect of internal and external focus of attention on game performance in tennis Acta Gymnica Tsetseli Marina Zetou Eleni Vernadakis Nikos Michalopoulou Maria Palacky University Olomouc 31 12 2016
46 4 162 173 2336-4912 10.5507/ag.2016.021 10.5507/ag.2016.021
Forward thinking: When a distal external focus makes you faster Human Movement Science Banks Stephen Sproule John Higgins Peter Wulf Gabriele 12 2020
74 102708 102708 0167-9457 10.1016/j.humov.2020.102708 10.1016/j.humov.2020.102708
Lets go surfing now, everybody’s learning how; attentional strategies on expert and novice surfing performance under both practice and competition conditions European Journal of Sport Science Lawrence Gavin P. Virian Jana Oliver Samuel J. Gottwald Victoria M. 2020
20 2 229 239 1746-1391 10.1080/17461391.2019.1626489 10.1080/17461391.2019.1626489 31148515
The distance effect and level of expertise: Is the optimal external focus different for low-skilled and high-skilled performers? Human Movement Science Singh Harjiv Wulf Gabriele 10 2020
73 102663 102663 0167-9457 10.1016/j.humov.2020.102663 10.1016/j.humov.2020.102663
Optimizing external focus of attention instructions: The role of attainability J Mot Learn Dev Coker Cheryl 6 2016
4 1 116 125 2325-3193 10.1123/jmld.2015-0024 10.1123/jmld.2015-0024
The Language of Coaching: The Art and Science of Teaching Movement Winkelman N.C. Human Kinetics Publishers 2020

Instructions as constraints in motor skill acquisition Published online Newell K.M. Ranganathan R. 2010

Visual perturbation to enhance return to sport rehabilitation after anterior cruciate ligament injury: A clinical commentary Int J Sports Phys Ther Wohl T.R. Criss C.R. Grooms D.R. 2021
16 2 552 564 33842051
Cueing the youth athlete during strength and conditioning: A review and practical application Strength Cond J Barillas Saldiam R. Oliver Jon L. Lloyd Rhodri S. Pedley Jason S. 25 5 2020
43 3 29 42 1524-1602 10.1519/ssc.0000000000000567 10.1519/ssc.0000000000000567
Vertical jump biomechanics altered with virtual overhead goal J Appl Biomech Ford Kevin R. Nguyen Anh-Dung Hegedus Eric J. Taylor Jeffrey B. 4 2017
33 2 153 159 1065-8483 10.1123/jab.2016-0179 10.1123/jab.2016-0179 27918689
The immediate effects of expert and dyad external focus feedback on drop landing biomechanics in female athletes: An instrumented field study Int J Sports Phys Ther Leonard K.A. Simon J.E. Yom J.. 2021
16 1 96 105 33604139
The self: Your own worst enemy? A test of the self-invoking trigger hypothesis Quarterly Journal of Experimental Psychology McKay Brad Wulf Gabriele Lewthwaite Rebecca Nordin Andrew 9 2015
68 9 1910 1919 1747-0218 10.1080/17470218.2014.997765 10.1080/17470218.2014.997765
Effortless motor learning?: An external focus of attention enhances movement effectiveness and efficiency Effortless Attention Wulf Gabriele Lewthwaite Rebecca The MIT Press 9 4 2010
75 102 10.7551/mitpress/9780262013840.003.0004
