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

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