The Path to Translating Focus of Attention Research into Canadian Physiotherapy

For over two decades, research has shown that providing instructions and feedback to promote an external focus (i.e., mentally focusing on movement effects or outcome) leads to enhanced motor performance and learning, compared to an internal focus (i.e., mentally focusing on the muscles and joints, or movement kinematics). Notably, while a majority of the research has been on healthy young adults, the external focus benefit has also been found to extend to individuals recovering from musculoskeletal dysfunction. Despite the potential benefit of an external focus for rehabilitation, observational studies have revealed that physiotherapists provide their clients with more internal, than external, focus statements and have little awareness of the focus of attention literature. Consequently, the end goal of this doctoral research was to translate the focus of attention research findings into Canadian physiotherapy practice through the design, delivery and assessment of an educational workshop for practicing physiotherapists. With this in mind, the first step became to determine whether such a workshop was warranted by assessing the self-reported focus of attention provision by Canadian physiotherapists. Thus, in Study 1 a study-specific questionnaire, titled the "Therapists' Perceptions of Motor Learning Principles Questionnaire" (TPMLPQ), was designed and completed by 121 Canadian physiotherapists. Results showed an overall low relative frequency of self-reported external focus promotion (M = 31.3%, SD = 14.9), across six hypothetical rehabilitation scenarios. Markedly, descriptions of a functional reaching (M = 55.5 %, SD = 37.0) and pelvic floor task (M = 65.6%, SD = 32.9) resulted in a greater self-reported promotion of external, than internal, focus of attention. These results suggested that Canadian physiotherapists could benefit from an educational workshop on focus of attention, and that there was a potential task dependency for their focus of attention promotion. Study 2 employed virtual one-on-one interviews with eight Southern Ontario-based physiotherapists, all whom completed the TPMLPQ just prior to the interview. The first few questions gathered participants' perceptions on factors that influence physiotherapists' focus of attention use, as well as barriers to promoting an external focus and potential solutions to them. Coding of the interview data generated four themes related to factors that influenced focus of attention use: (1) physiotherapist experiences and characteristics, (2) client experiences and characteristics, (3) task characteristics and (4) focus of attention statement provision strategies. Moreover, the barriers to external focus promotion were organized into three themes: (1) educational experiences, (2) reinforcement of internal focus encouragement once in practice and (3) research aspects. All interviewed physiotherapists proposed continuing education on focus of attention as a solution to these barriers. Questions in the second half of the interview garnered input on how to get physiotherapists to attend a focus of attention workshop, and what activities to include before, during or after the workshop to promote physiotherapists to use more externally focusing statements in their practice. This information was used to inform the workshop design and delivery. In addition to the physiotherapists' input, I also considered previous research that has emphasized the importance of evidence-based training programs to be based on theoretical frameworks. In this regard, Bandura's social cognitive theory was selected as a theoretical foundation. Further, knowing that the target population for the workshop consisted of adults with higher education, Knowles' adult learning theory was also selected as a complimentary theoretical foundation. Additionally, the Kirkpatrick model for training evaluation was selected to guide the assessment of the workshop, due to its strong overlap with constructs from both theoretical frameworks adopted. A final contribution to the workshop design process was holding a virtual group session with four focus of attention researchers in order to gain input on workshop content. The final workshop product consisted of two parts: seven self-directed asynchronous website modules and a synchronous virtual group session. Ultimately, in Study 3, the workshop was delivered to fifteen Canadian physiotherapists. In addition to completing the two workshop components (asynchronous and synchronous), participants completed assessment packages at three time points: (1) one-week pre-synchronous workshop, (2) immediately post-synchronous workshop, and (3) one-week post-synchronous workshop. Analysis of the data revealed a chain of evidence supporting the merits of the workshop. Explicitly, physiotherapists reported high satisfaction (Mdn = 4.60), perceived relevance (Mdn = 4.83), and engagement in the workshop (Mdn = 4.83). Comparing one-week pre- to immediately post-workshop, analyses revealed significant improvements to physiotherapists' (1) scores on the knowledge assessment (pre M = 51.30%, SD = 22.30; post M = 84.30%, SD = 11.50; p < .001, d = 2.06) with an accompanying decrease in the uncertainty in their responses (pre M = 23.19%, SD = 18.05; post M = 1.16%, SD = 1.99; p < .001, d = 1.28), (2) relative frequency of externally focusing to total focus of attention statements created on the skill assessment (pre M = 18.23%, SD = 13.17; post M = 67.95%, SD = 25.13; p < .001, d = 2.11), (3) self-reported attitudes towards learning and practice of external focus promotion (pre M = 88.25, SD = 11.00; post M = 92.83, SD = 6.59; p = .024, d = 0.56) and self-efficacy (pre M = 59.50, SD = 22.36; post M = 85.72, SD = 7.95, p < .001, r = 0.86). Using descriptive statistics, physiotherapists reported that participating in the workshop allowed them to increase their encouragement of external focus adoption (M = 79.00, SD = 15.14). Thirteen of the physiotherapists reported that they believed that their use of externally focusing statements led to improvements in their clients' rehabilitation outcomes (n = 13; M = 68.08, SD = 22.13), while the other two physiotherapists noticed no difference. Finally, those 13 physiotherapists also reported a high intention to continue to provide external focus statements in their practice (M = 87.31, SD = 15.09). In the context of social cognitive theory, these findings suggest that the workshop was successful in strengthening the physiotherapists' behavioral capabilities, self-efficacy, and outcome expectations, suggesting that the behavior change self-reported by the physiotherapists (i.e., more external focus promotion) could extend beyond the short-term assessment period used here. The whole of this doctoral research acts as a powerful step on the pathway to translate focus of attention research into Canadian physiotherapy, and also provides a useful framework for future studies aiming to translate motor learning research into the field - in Canada or globally.

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