Rethinking Rehabilitation: External Focus of Attention and the Need for a Paradigm Shift in Clinical Practice and Knowledge Translation

For decades, rehabilitation has been guided by models emphasizing precise biomechanical control and conscious muscle activation. While these approaches have contributed significantly to clinical progress, they may not always represent the most efficient pathway for motor recovery or functional restoration. Increasingly, research in motor learning and neuroscience challenges these assumptions, suggesting that alternative strategies may better align with how the human nervous system acquires and refines movement.

This shift is particularly evident in emerging approaches that prioritize external focus of attention, where individuals direct their attention toward movement outcomes rather than internal bodily processes. Such perspectives invite a broader reflection: not only on how we treat patients, but also on how we produce and translate scientific knowledge into practice.

Traditional rehabilitation strategies used by most health and performance professionals often rely on internal focus cues, such as consciously activating specific muscles. In contrast, motor learning research, for the last 25 years, has consistently shown that an external focus of attention enhances motor performance, efficiency, and automaticity [1,2].

From a neurophysiological standpoint, this started to be explained through the constrained action hypothesis, which proposes that internal focus disrupts automatic motor control processes, whereas external focus facilitates more natural and efficient movement patterns [3]. These findings have been replicated across a wide range of populations and tasks since then.

Importantly, recent clinical evidence supports the application of these principles in rehabilitation settings. For instance, a study examining postpartum women with diastasis recti demonstrated that exercises performed with external focus instructions were associated with increased transversus abdominis thickness during task execution, suggesting effective muscle recruitment without explicit voluntary contraction cues even for such a deep and specific muscle [4]. This challenges long-standing practices, in the corepelvic floor- after birth rehabilitation field, that uses to prioritize conscious muscle activation, internal focus and explicit cues as the primary therapeutic mechanism.

Such findings reinforce the idea that implicit, task-oriented approaches may not only reduce cognitive load wile performing and learning a movement or exercise but also enhance the ecological validity and transferability of motor learning [5].

While advances in research continue to reshape our understanding of rehabilitation, a persistent challenge remains: the gap between scientific knowledge and clinical application.

Clinicians often encounter significant barriers, including limited access to full-text articles, time constraints, and the complexity of translating research findings into practical interventions [6]. As a result, much of the available evidence fails to reach the point of care, limiting its real-world impact.

To address this issue, it is not enough to produce high-quality research. We must also ensure that knowledge is accessible, interpretable, and actionable. This requires a shift specially in scientific communication toward greater clarity, clinical relevance, and practical guidance. In this context, the concept of knowledge translation becomes central. Effective knowledge translation involves not only disseminating information, but also adapting it to the needs, contexts, and constraints of clinicians [7].

Adopting new therapeutic paradigms requires more than technical adjustments—it demands a cultural shift within both research and clinical communities. For scientific journals this means demanding more real-world applicability to the researchers. For researchers, this means prioritizing clinically meaningful questions and presenting findings in ways that facilitate implementation. For clinicians, it involves maintaining a critical yet open mindset, recognizing that established practices may need to evolve in light of new evidence. Importantly, doing things differently does not imply abandoning evidence-based practice. Rather, it reflects a deeper commitment to it—one that integrates the best available evidence with clinical expertise and patient needs.

Rehabilitation is at a crossroads. Emerging evidence in the use of external focus and task-oriented approaches challenge traditional assumptions and offers new opportunities to improve efficiency, effectiveness, and patient experience. At the same time, persistent barriers limit the translation of this knowledge into practice. Moving forward requires embracing innovation while maintaining scientific rigor. It requires making knowledge not only valid, but usable. Ultimately, progress in rehabilitation depends on our willingness to question established norms and explore alternative approaches. Because in many cases, things can indeed be done differently.

1. Wulf G 2013 Attentional focus and motor learning: A review of 15 years. International Review of Sport and Exercise Psychology 6(1): 77-104.
2. Wulf G, Höß M, Prinz W 1998 Instructions for motor learning: differential effects of internal versus external focus of attention. J Mot Behav 30(2): 169-179.
3. Wulf G, McNevin N, Shea CH 2001 The automaticity of complex motor skill learning as a function of attentional focus. Q J Exp Psychol A 54(4): 1143-1154.
4. Cañamero de León S, Covas T.B, Gonzalez M.S, Da Cuña Carrera I, Pascoal A.G 2026 Effect of Exercises Performed with External Focus Instructions on Transversus Abdominis Thickness in Postpartum Women with Diastasis Recti. Healthcare 14(7): 907.
5. Kal E, Prosée R, Winters M, van der Kamp J 2018 Does implicit motor learning lead to greater automatization of motor skills compared to explicit motor learning? A systematic review. PLoS One 13(9): e0203591.
6. Glasziou P, Haynes B 2005 The paths from research to improved health outcomes. Evid Based Nurs 8(2): 36-38.
7. Straus S. E, Tetroe J & Graham ID (2013) Knowledge Translation in Health Care: Moving from Evidence to Practice. Wiley-Blackwell.