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. 2024 Jun 28;24(8):1143–1151. doi: 10.1002/ejsc.12157

An external focus promotes motor learning of an aiming task in individuals with hearing impairments

Zahra Samadi 1, Rasool Abedanzadeh 1,✉, Ebrahim Norouzi 2, Reza Abdollahipour 3
PMCID: PMC11295103  PMID: 38940066

Abstract

Research has shown that external relative to internal focus (IF) instructions may improve motor performance as well as cognitive function (e.g., attentional stability and task‐focus). The aim of the study was to examine the influence of attentional focus instructions on skill acquisition and learning of an aiming task in individuals with hearing impairments. The participants (N = 39, Mage = 17.87 ± 1.88 years) performed a bowling task with their dominant hand to knock down as many pins as possible. On day 1, they were randomly divided into three attentional focus groups; IF (focus on your throwing hand), external focus (EF) (focus on the pins), and control (no‐focus) instructions. Each participant performed 36 trials, divided into 3 blocks of 12 trials. Attentional focus instructions were given before each block, with a brief reminder provided after each 3 trials. On day 2, retention and transfer (further distance) tests were performed. Results showed that while there were no significant differences between groups in the pre‐test, the EF group outperformed both IF and control groups in retention and transfer tests. No significant difference was found between the control and IF. The findings suggest that the advantages of the external relative to the IF and no‐focus instructions may generalize to individuals with hearing impairments.

Keywords: bowling, EF, hearing impairments, internal focus, motor learning

Highlights

  • External focus (EF) enhances the acquisition of an aiming task in individuals with hearing impairments

  • EF enhances the learning of an aiming task in individuals with hearing impairments

  • Individuals with hearing impairments may use EF instructions in rehabilitation

1. INTRODUCTION

According to the World Health Organization (WHO) over one‐third of the world's population has some degree of hearing impairment, with more than 5% requiring hearing loss rehabilitation interventions (WHO, 2024). Research indicates that individuals with severe, to profound hearing loss and deafness (as described below, Michels et al., 2019), experience delays in motor development compared to those with normal hearing (Carlson, 1972; Fellinger et al., 2015). Importantly, hearing impairment significantly affects motor coordination, performance, and the development of psychomotor tasks, impacting daily activities and social integration (Dobie & Van Hemel, 2004), which warrants specific interventions (Shinn‐Cunningham & Best, 2008). As stated in a recent literature review “Hearing interventions included provision of hearing aids, assistive listening devices, communication strategies, hearing aid trouble shooting, and cochlear implantation” (Dawes et al., 2019). One approach to improving communication strategies is the use of verbal instructions (Wulf, 2007). These instructions have been demonstrated to influence learners' attentional focus, which subsequently impacts skill performance outcomes (Wulf, 2013). Therefore, providing appropriate verbal attentional focus instructions via sign language might be vital not only for enhancing skill acquisition and motor learning in individuals with hearing impairments but also for improving their overall quality of life and involvement in different activities.

Motor development delays in individuals with severe hearing impairments have led to subpar performance in various skills, such as general dynamic coordination, visuomotor coordination, and balance, from childhood into adulthood (Erden et al., 2004; Kowalewski et al., 2018; Wiegersma & Van der Velde, 1983). For instance, Wiegersma and Van der Velde (1983) observed that deaf children aged 6–8 years performed worse in several motor tasks compared to their hearing peers. These tasks included placing perforated discs over three small wooden poles, lacing a shoe‐string through a perforated multiplex board, placing dots in circles to form a human figure, inserting beads and matchsticks with different hands, tracing a maze, vertical jumping, sit‐ups, lateral hopping over the line, changing body position from standing to lying down and returning to standing as fast as possible, moving with platforms, and walking on the beams forward and backward. Similarly, Kowalewski et al. (2018) reported that adults with hearing impairments, both young and older, struggled with maintaining balance on a treadmill, especially when performing dual tasks involving listening and repeating sentences. These findings highlight significant difficulties in visuomotor integration and balance tasks across different age groups among individuals with hearing impairments.

The performance differences between individuals with hearing impairments and their peers often stem from deficits in attentional and cognitive development (Charry‐Sánchez et al., 2022; Dye & Hauser, 2014; Kronenberger et al., 2013; Ward & Grieco‐Calub, 2022). The intricate connection between cognition and attention highlights the critical role of attentional processes in cognitive function (Galotti, 2015). Attention directs focus toward relevant information, influencing both motor performance and learning outcomes (Wulf, 2007, 2013). Moreover, cognition encompasses the thought processes that often shape learning experiences (Lee et al., 1994). Studies on individuals with hearing impairments indicate that early disruption in auditory stimulus exposure can impact attentional resource allocation and motor skill performance (Ward & Grieco‐Calub, 2022). Essentially, children and adolescents with hearing impairments often exhibit lower cognitive function, including working memory, inhibition, and attention, compared to their normal‐hearing counterparts (Charry‐Sánchez et al., 2022; Dye & Hauser, 2014; Kronenberger et al., 2013). Importantly, age‐related hearing loss is associated with cognitive decline or impairment (Croll et al., 2021; Morita et al., 2019; Ray et al., 2018), suggesting that cognitive deficits in individuals with hearing impairments may persist and potentially worsen with age if left untreated. Therefore, focusing attentional resources on specific aspects of the movement may hold promise for enhancing motor skills in individuals with hearing impairments.

In this regard, research has consistently indicated that focusing attention externally, toward movement effects or task goal, leads to better motor performance and learning outcomes compared to an internal focus of attention on body‐related movement techniques (Chua et al., 2021; Wulf, 2013; Wulf et al., 1998). Specifically, adopting an external focus (EF) relative to an IF of attention has been found to enhance motor performance or learning in different motor tasks involving visuomotor integration and balance among healthy individuals of different age groups as well as clinical populations (for a review see Chua et al., 2021, Wulf, 2013). For instance, individuals with clinical conditions such as Parkinson's disease (Kakar et al., 2013; Landers et al., 2005; Wulf et al., 2009), visual impairments (Abdollahipour, Land, et al., 2020), children with ADHD (Saemi et al., 2013), children with intellectual disability (Chiviacowsky et al., 2013) have all demonstrated enhanced performance and/or learning outcomes when employing an EF of attention. Thus, manipulations emphasizing an external attentional focus are beneficial for enhancing motor performance and learning outcomes across a broad spectrum of individuals and contexts (Chua et al., 2021; Wulf, 2013).

While the benefits of employing an EF over an IF are generally robust in enhancing motor performance or learning, a few studies have reported exceptions (Kal et al., 2022; Kim et al., 2017), likely due to methodological differences. For instance, Kal et al. (2022), examined conscious movement processing (CMP) effects on a narrow‐stance balance task using a force plate in older adults. Participants were asked to describe their body status upon hearing a beep while balancing, either in a low‐CMP condition (i.e., distracting attention away from balance using a task‐irrelevant secondary cognitive task such as verbalizing months of the year) or in a high‐CMP (i.e., directing attention to a task‐relevant secondary cognitive task such as reporting body status while balancing). No significant difference was observed between the low‐CMP (EF) and high‐CMP (IF) conditions. This is not surprising as low‐CMP condition promoted a task‐irrelevant EF, possibly hindering participants from focusing on the task goal. In another study, Kim et al. (2017) had stroke patients practice holding a joystick with their affected arm occluded to move a yellow ball on a monitor (i.e., EF) or to focus on their affected arm when the monitor was switched off (i.e., IF). Since these two treatment conditions had distinct task goals, the findings cannot be solely attributed to attentional focus literature. These studies emphasize the importance of methodological consistency when examining the effects of attentional focus on motor performance and learning. Therefore, aligning task goals with EF instructions that promote intended movement effects is crucial for meaningful results.

The explanation for why an EF is more advantageous than an IF is developing, with one prominent theory being the constrained action hypothesis (CAH, Wulf, McNevin, & Shea, 2001; Wulf, Shea, & Park, 2001). According to the CAH, an IF heightens CMP, disturbs automatic control mechanisms, and imposes a heavier cognitive load on motor control, resulting in poorer performance outcomes. Conversely, an EF enhances movement automatization, leads to more efficient movement planning, and the coupling of task goals with actions to achieve optimal motor performance (Wulf & Lewthwaite, 2016). Indeed, this enhanced movement automatization with an EF is evident at the neuromuscular level, where lower muscular recruitment occurs compared to an IF when individuals are instructed to exert the same amount of force (Lohse & Sherwood, 2012; Lohse et al. (2010). Essentially, an EF is suggested to enhance effective structural and functional neural connectivity within and between specific brain regions (Kuhn et al., 2017, 2018, 2021), promoting attentional stability on the task goal (Abdollahipour et al., 2017, 2023), thereby increasing the likelihood of smoothly connecting the movement goals and the resultant action (Abdollahipour et al., 2017, 2023; Wulf & Lewthwaite, 2016). Thus, directing attention externally toward intended movement effects or task goals is proposed to enhance motor performance outcomes by optimizing cognitive processes involved in movement execution.

The objective of this study was to investigate the effects of EF, IF, and no‐focus instructions on skill acquisition and motor learning in individuals with hearing impairments, specifically in a motor task requiring a high level of visuomotor coordination (e.g., bowling task). Individuals with hearing impairments often experience deficits in cognitive function including working memory, inhibition, and attention (Charry‐Sánchez et al., 2022; Dye & Hauser, 2014; Kronenberger et al., 2013) which can result in motor learning challenges, poor static and dynamic coordination, slower movement speeds, and reduced motor memory. IF instructions can strain working memory, which may result in less effective improvement in motor learning for those with compromised attention/working memory capacity (Kok et al., 2021). Conversely, EF instructions alleviate attentional and working memory demands (Kal et al., 2013; Poolton et al., 2006), improve attentional stability (Abdollahipour et al., 2023), and task focus or goal‐action coupling for successful performance outcome (Wulf & Lewthwaite, 2016). Therefore, we hypothesized that providing EF instructions may yield greater benefits compared to IF and control (no‐focus) instructions for enhancing motor performance and learning of individuals with hearing impairments.

2. MATERIAL AND METHODS

2.1. Participants

Forty‐five male students aged between 15 and 22 (Mage = 17.87 ± 1.88 years) with bilateral hearing impairment were recruited from the specialized schools for students with special needs in the city of ….. Participants were chosen across different age ranges due to limited access to individuals with hearing impairments who could meet inclusion criteria (described below). Only male participants were included to mitigate any potential gender‐related impacts on hearing impairments, auditory sensitivity, and treatment recommendations (Narne et al., 2016; Nemes, 1999; Villavisanis et al., 2020). A priori power analysis with G*Power 3.1 indicated that 45 participants would be sufficient to identify significant group differences when using an analysis of variance (ANOVA) between‐participants design with a power (1 – β) of 0.80, an effect size ƒ of 0.40 (η2 p = 0.14), and an α level of 0.05 (Faul et al., 2007). Previous research has shown a substantial effect size for the advantages of an EF over an IF on motor learning in specific populations such as adults with visual impairments or children with ADHD (Abdollahipour et al., 2020; Saemi et al., 2013).

The inclusion criteria for individuals with hearing impairments were as follows: a) screening the school medical profile to identify students diagnosed with congenital hearing loss, b) confirmation of a medical doctor, to certify the intensity of hearing loss within the range of 71–90 dB hearing level (dB HL). Hearing loss severity is typically classified as normal (≤25 dB HL), mild (26–40 dB HL), moderate (41–55 dB HL), moderately severe (61–70 dB HL), severe (71–90 dB HL), and profound (≥91 dB HL) (Michels et al., 2019). All participants in this study had congenital hearing loss with severity ranging from 71 to 90 dB HL, diagnosed as severe hearing impairment. The participants' educational backgrounds varied from completed high school (CHS), incomplete high school (HIS), and completed primary education (CPE). “Incomplete” indicates that participants have not yet reached their desired educational level.

Individuals with other physical or mental disabilities (e.g., limb limitations, vision impairments, memory loss, or difficulty in walking or seeing) were excluded from participation. Written informed consent was obtained from the parents or legal guardians, and verbal consent was obtained from students before screening and study participation. The study protocol was approved by the ethical committee of the Shahid Chamran University of Ahvaz adhering to the principles of the Declaration of Helsinki and its subsequent amendments. The participants were informed that the experiment aimed to assess their performance on a bowling task while focusing on specific instructions but were not detailed with specific details regarding the study's aim. Participants had no prior experience with the bowling task.

2.2. Apparatus and task

The experiment took place in a standard bowling alley featuring a wooden lane (length 23.73 m × width 1.52 m), 6 bowling balls, 10 pins, and a scoreboard display. The bowling balls ranged from 6 to 12 in number, with a diameter of 21.83 cm, a circumference of 68.58 cm, and an average weight of 4.75 kg. Each pin measured 40 cm in height and weighed 1.6 kg, arranged in a triangle formation spaced 30.84 cm apart at the end of the bowling lane which was 18.29 m away from the beginning of the throwing line. A scoreboard displayed the number of pins knocked down per trial (Abdollahipour, Valtr, & Wulf, 2020). The participants were instructed to use their dominant hand for the bowling task, aiming to knock down as many pins as possible in each attempt. They were allowed to select a ball that suited their finger sizes and comfort level, receiving guidance on proper finger placement in the grip holes. They began each trial by standing 3 m behind the throwing line, taking three steps forward, and then rolling the ball on the throwing lane toward the pins. The participants completed all trials with the same ball.

2.3. Design and procedure

The experiment spanned 2 days and employed a double‐blind design (described below). On day 1, participants completed a 5‐min warm‐up in a hall next to the bowling alley, consisting of 3 min of easy‐paced running on the rubber surface and 2 min of static and dynamic stretching. They then donned bowling shoes suited to their foot size before entering the wooden lane. Then, in cooperation with a sign language specialist, the correct execution of the bowling task was explained and demonstrated to each participant. Each participant performed three familiarization trials, followed by 12 pre‐test trials. Participants were randomly assigned to one of three attentional focus groups: an IF group instructed to “focus on your throwing hand” (N = 14, 13 right‐handed, 1 left‐handed; Education: 1 CHS, 10 IHS, 3 CPE; Mage = 17.57 ± 1.78 years), an EF group, instructed to “focus on the pins” (N = 15, 14 right‐handed, 1 left‐handed; Education: 4 CHS, 9 IHS, 2 CPE; Mage = 18.13 ± 2.13 years), and a control group receiving “no‐focus instructions” (N = 10, 9 right‐handed, 1 left‐handed; Education: 0 CHS, 7 IHS, 3 CPS; Mage = 17.90 ± 1.72 years).

Randomization was conducted by a research assistant unaware of the specific research purpose, who placed the participants in groups 1, 2, and 3 based on the identification numbers, inadvertently. During the acquisition phase, participants in each group completed 36 trials, divided into three blocks of 12 trials. Participants had a rest interval of 30 s after each trial and a three‐minute break after each block of trials. Attentional focus instructions were provided before each block of 12 trials, with a brief reminder of instructions given to IF and EF groups after every three throws. Previous research has suggested that more frequent EF feedback or reminders could positively influence motor learning (An & Wulf, 2024; Wulf et al., 2010).

A double‐blind design was used in which the participants, research assistant, and the sign language specialist (who provided the instructions) were unaware of the group allocation. Participants completed the task individually, with all descriptive explanations, attentional focus instructions, and reminders delivered by a sign language specialist. Given the varied educational backgrounds of participants, measures were implemented to ensure their understanding of the task and focus instructions, including verification of correct task execution. Following the completion of all experimental trials in the acquisition phase, participants were asked the following questions: During performing the task, “How much did you focus on given instructions?” Answers were scored on a five‐point Likert scale ranging from one (very low) to five (very much). A follow‐up posttest consisting of 12 trials without any attentional focus instructions, was carried out after two minutes.

On day 2, within 48 h, participants in each group completed one block of 12 trials for retention. For the transfer test, which was administrated 30 min later, a piece of black tape (100 cm × 5 cm) was affixed to the wooden lane parallel to the start line, positioned one m before the throwing line. Subsequently, participants were asked to perform one block of 12 trials from a greater distance (An & Wulf, 2024; Pascua et al., 2014), specifically four m behind the throwing line, and release the bowling ball behind the black tape.

Due to COVID‐19 symptoms, 5 members of the control group and 1 member of the IF group were unable to attend learning tests on day 2 and therefore, they were excluded from the data analysis.

2.4. Statistical analysis

The average number of pins knocked down on baseline trials, in each 12‐trial block during acquisition, post‐test, retention, and transfer tests served as the dependent variable. Performance outcomes of the groups in the baseline, retention, and transfer were analyzed using a one‐way ANOVA. The performance of the groups in the acquisition phase was analyzed using a 3 (group: internal, external, control) × 3 (blocks) between‐participants ANOVA with repeated measures on the last factor. For the post hoc tests, Bonferroni corrections were used (α altered = 0.05/3 = 0.016). For ANOVAs, effect sizes were reported as partial eta squared values (η2 p), where η2 p = 0.01, 0.06, and 0.14 correspond to small, moderate, or large effects, respectively (Cohen, 1988; Lakens, 2013). Cohen's d values were used for between‐group effect size estimates. For within‐subject effect sizes the repeated‐measures version of Cohen's d was utilized. Cohen's d values correspond to low (d = 0.2), medium (d = 0.5), or large (d = 0.8) effects (Cohen, 1988).

A Levene's test for equality of variances was used to assess performance variability in the pre‐test (p > 0.05). Additionally, Spearman's rank correlation coefficient analysis was conducted to explore any potential associations between performance variability in the pre‐test (measured as the standard deviation of scores for each participant within each group) and performance gains during practice (quantified as performance improvement scores derived by subtracting each participant's pre‐test score from their post‐test and retention test scores, independently).

Also, a non‐parametric Mann‐Whitney U test was used to compare the adherence of participants to the external and IF instructions.

3. RESULTS

3.1. Performance accuracy

The averages and standard errors of the accuracy scores for the pretest, practice phase, retention, and transfer tests are shown in Figure 1. On day 1, there were no significant group differences in the pre‐test, F(2, 36) = 0.06, p = 0.93, η2 p = 0.004. For the acquisition phase, the main effect of the group was significant, F(2, 36) = 5.52, p = 0.008, η2 p = 0.235. Follow‐up Bonferroni‐corrected post hoc tests indicated a significant difference between the EF (M = 2.43 ± 0.76) and the IF (M = 1.86 ± 0.56, p = 0.010, d = 0.849) groups. No significant difference was found between EF and control (M = 1.97 ± 0.63, p = 0.080, d = 0.649), nor IF and control (p > 0.99, d = 0.186) groups. Also, no significant differences were found for the blocks F(2, 72) = 2.682, p = 0.075, η2 p = 0.069, as well as the interaction of group and blocks F(4, 72) = 1.224, p = 0.308, η2 p = 0.064. Significant group differences were observed in the post‐test, F(2, 36) = 15.40, p < 0.001, η2p = 0.46. Participants in the EF group (M = 2.88 ± 0.62) outperformed those in the IF (M = 2.04 ± 0.68, p = 0.001, d = 1.290) and control (M = 1.63 ± 0.23, p < 0.001, d = 2.673) groups, as revealed by Bonferroni post‐hoc tests. No significant difference was found between the IF and control (p = 0.289, d = 0.807) groups.

FIGURE 1.

FIGURE 1

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Accuracy scores for external focus, internal focus, and control groups during the pre‐test, practice phase, post‐test (day 1), retention, and transfer tests (day 2). Error bars represent standard errors.

On day 2, there was a significant difference between the groups in the retention test, F(2, 36) = 10.63, p < 0.001, η2 p = 0.37. Bonferroni post‐hoc tests showed that the participants in the EF group (M = 2.41 ± 0.54) outperformed those in the IF (M = 1.69 ± 0.63, p = 0.002, d = 1.231) and control (M = 1.53 ± 0.20, p = 0.001, d = 2.036) groups. No significant difference was observed between the IF and control (p > 0.99, d = 0.325) groups. Also, there were significant differences between the groups in the transfer test, F(2, 36) = 8.06, p = 0.001, η2 p = 0.30. Bonferroni post‐hoc tests showed that the participants in the external group (M = 2.28 ± 0.72) outperformed those in the IF (M = 1.69 ± 0.60, p = 0.040, d = 0.887) and control group (M = 1.31 ± 0.37, p = 0.001, d = 1.618). No significant difference was observed between the IF and control (p = 0.428, d = 0.741) groups.

3.2. Performance variability

No significant correlation was observed between pre‐test performance variability and practice gains compared to the post‐test within each of the IF (p = 0.684), EF (p = 0.995), and control groups (p = 0.730). Similarly, no significant correlation was found between pre‐test performance variability and practice gains compared to retention within each of the IF (p = 0.606), EF (p = 0.606), and control (p = 0.730) groups. These results indicated that any potential variability in pre‐test performance did not affect practice‐related gains.

3.3. Attentional focus compliance

The ratings on the reported adherence to internal or external foci “how much did you focus on given instructions?” were relatively high, ranging from three (“intermediate”) to five (“very much”) with an overall mean value of 4.00 ± 0.80. Specifically, average ratings of 4.00 ± 0.78 and 4.00 ± 0.84, were reported for an IF or an EF group, respectively. There was no significant difference between external (MRank = 15.00, Median = 4.00) and internal (MRank = 15.00, Median = 4.00) focus groups on the intensity of foci, U = 105.00, z = 0.000, p > 0.99.

4. DISCUSSION

The aim of the current study was to examine the effects of attentional focus instructions on the learning of an aiming (e.g., bowling) task in individuals with hearing impairments. The results revealed that the skill acquisition of bowling in individuals with hearing impairments improved with EF relative to IF instructions within a practice session (e.g., on day 1). Importantly, during both retention and transfer tests on day 2, the EF group demonstrated superior bowling performance compared to both IF and no‐focus instructions (control) groups. These findings suggest that EF instructions not only provide immediate (practice) benefits to performance but also facilitate longer‐term learning in individuals with hearing impairments when performing aiming tasks such as bowling. These findings contribute to the literature by highlighting the positive influence of EF instructions on motor skill acquisition and learning, in individuals with hearing impairments, especially given their potential sensory deficits (as discussed below).

Our findings align with previous research demonstrating the benefits of an external over an IF of attention for motor performance and/or learning across various populations. This includes healthy individuals as extensively reviewed by Wulf (2013) and Chua et al. (2021). Similar benefits have been observed in various clinical populations, such as individuals with visual impairments (Abdollahipour, Land, et al., 2020), Parkinson's disease (Beck et al., 2018; Landers et al., 2005; Wulf et al., 2009), stroke patients with relatively intact proprioception and good balance skill (Kal et al., 2019), children with attention deficit hyperactivity disorder (Saemi et al., 2013), individuals with and without cerebrovascular accident (Fasoli et al., 2002), children with intellectual disability (Chiviacowsky et al., 2013) or children with developmental coordination disorder (Psotta et al., 2020). Together, it could be suggested that the benefits of an external relative to an IF of attention in a variety of clinical populations (Chua et al., 2021). The consistent benefits observed across such diverse populations suggest that an EF of attention holds promise as an effective learning strategy in various clinical contexts. These findings highlight the potential utility of incorporating EF instructions into motor skill training programs for individuals with different clinical conditions, including those with severe to profound hearing impairments, to optimize motor performance and learning outcomes.

The advantages of utilizing an EF over an IF for motor learning in individuals with severe hearing impairments, who may lack sensory inputs, crucial insights into the mechanism of attentional focus instructions within the CAH framework (Wulf, McNevin, & Shea, 2001; Wulf, Shea, & Park, 2001). Previous research suggests that an IF of attention on body movements induces excessive self‐focus, intensifying self‐awareness and cognitive load, which in turn disrupts the automaticity of movement control, hindering effective movement execution Wulf, McNevin, & Shea, 2001). Conversely, an EF of attention on the movement goal (e.g., focusing on pins in bowling) facilitates a transition towards a more automatic form of motor control by engaging proceduralized processes instead of controlled ones (Kal et al., 2013; McKay et al., 2015; Wulf, McNevin, & Shea, 2001; Wulf, Shea, & Park, 2001). This shift reduces conscious attentional demands and enhances automaticity in movement execution (Kal et al., 2013; Poolton et al., 2006). Importantly, this effect appears to persist regardless of the presence of sensory inputs, such as vision or hearing (Abdollahipour, Land, et al., 2020, Land et al., 2013; the current study). The engagement of EF is facilitated through improved structural and functional neural connectivity within and between specific brain regions responsible for translating goals into actions (Kuhn et al., 2017, 2018, 2021). This process involves filtering out task‐irrelevant information and maintaining attentional stability on goal‐relevant parameters (Abdollahipour et al., 2017, 2023; Singh et al., 2022), which increases the likelihood of smooth goal‐action coupling, resulting in successful performance outcomes (Abdollahipour et al., 2017, 2023; Wulf & Lewthwaite, 2016).

It is important to acknowledge that methodological differences may account for the discrepancies observed in some studies regarding the benefits of an EF of attention relative to an IF on motor performance or learning, particularly in certain populations such as healthy children (Saemi et al., 2023; van Abswoude et al., 2018), children with special education needs (e.g., Kok et al., 2021), or children with developmental coordination disorder (Jarus et al., 2015; van Cappellen – van Maldegem et al., 2018). For instance, unclear or irrelevant focus instructions (e.g., focus on throwing water down in crawl swimming, Saemi et al., 2023) or a set of instructions (e.g., Kok et al., 2021), may potentially lead children not to focus on given instructions (e.g., van Abswoude et al., 2018), and consequently prevent them to focus on the task goal. Indeed, research has shown that task‐relevant EF instructions, as compared to task‐irrelevant EF or IF instructions, led to improved performance of an aiming task (e.g., basketball free throw), regardless of the availability of sensory inputs (e.g., vision) (Saemi et al., 2018). Moreover, other methodological issues such as insufficient sample size in between‐subject‐design experiments (Jarus et al., 2015), or performance differences between experimental groups in the pre‐test (van Cappellen–van Maldegem et al., 2018) can also impact the clarity of the findings regarding the effectiveness of external versus IF instructions. Therefore, careful consideration of methodological factors is crucial when interpreting research outcomes related to attentional focus effects on motor performance and learning to ensure a clear understanding of the efficiency of different focus instructions.

4.1. Clinical implications

Applying the findings of the current research to practice, clinicians can incorporate EF instructions into motor learning interventions to assist individuals with hearing impairments in addressing challenges associated with disrupted auditory processing and enhancing their motor coordination and performance (Erden et al., 2004; Kowalewski et al., 2018; Wiegersma & Van der Velde, 1983). This approach may assist individuals with hearing impairments in developing their perceptual processing capabilities, ultimately contributing to improvements in their independence and overall quality of life.

4.2. Limitations and implications for future research

While the findings of the current study effectively show the impact of attentional focus on motor learning in individuals with severe hearing impairments, future research in this area could benefit from several enhancements. For instance, increasing the number of practice trials/days and including a transfer test (such as a dual‐tasking paradigm) to verify that participants achieve movement automaticity, and equalizing the number of participants in each group could enhance the reliability of the results, particularly in longer‐term studies such as retention tests conducted after 1 week or 3 weeks, which can provide insights into the sustainability of observed improvements. In addition, incorporating different motor task domains, particularly those related to balance, is crucial given the prevalence of balance issues in individuals with hearing impairments (Kowalewski et al., 2018). Moreover, incorporating motor tasks with greater ecological validity, such as performing the task in the presence of an audience, could offer a more realistic assessment of motor learning outcomes in real‐world scenarios. This approach provides insights into the effectiveness of attentional focus strategies across various motor domains and contexts, enhancing the generalizability of research findings.

Even though in the current study we did not incorporate an open‐ended questionnaire/interview, we employed a rating scale to estimate participants' adherence to the attentional focus instructions. The results revealed a high level of adherence (about 80% in each attentional focus group), indicating that participants followed the provided instructions closely. Nonetheless, future studies could benefit from integrating open‐ended post‐performance questionnaires or interviews to understand how individuals with hearing impairments interpret and apply attentional focus instructions based on their educational background and individual characteristics.

The decision to include only male participants in the current study was based on several factors related to gender differences in hearing acuity and the potential impact of gender on the occurrence of hearing impairment, auditory sensitivity, and treatment recommendations (Narne et al., 2016; Nemes, 1999; Villavisanis et al., 2020). While this approach enhanced internal validity by ensuring a homogeneous sample and minimizing gender‐related influences on motor learning, mixed‐gender studies can provide a more holistic understanding of how attentional focus instructions influence skill acquisition and learning in individuals with hearing impairments.

4.3. Conclusions

In sum, the findings of the present study demonstrate that an EF of attention on the movement effect or movement goal (e.g., target) led to greater benefits compared to an IF of attention on body movement (e.g., hand) or receiving no‐focus instructions during acquisition and learning of an aiming task (e.g., bowling) among individuals with hearing impairments. Consequently, individuals with hearing impairments, who commonly encounter challenges in perceiving auditory stimuli, could significantly enhance their motor skills learning in rehabilitation settings by adopting EF instructions.

AUTHOR CONTRIBUTIONS

Zahra Samadi: Conceptualization, methodology, investigation, formal analysis, writing ‐ original draft. Rasool Abedanzadeh: Conceptualization, Methodology, supervision, formal analysis, review, and editing ‐ original draft. Ebrahim Norouzi: Conceptualization, methodology, review, and editing ‐ original draft. Reza Abdollahipour: Conceptualization, methodology, formal analysis, review, and editing ‐ original draft.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ACKNOWLEDGMENTS

The authors would like to thank Dr. Elmar Kal for his insightful comments, suggestions, and careful reading of the manuscript. The authors would acknowledge and thank the subjects who participated in this study.

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