What do we focus on?

The symptom fluctuates for most of us – some people even report periods when they are in full possession of their ability, only to rapidly lose it again. Many of us had the experience of being able to play again for a while, having a false hope that it will be alright, and the dystonia is going to disappear like a bad dream after waking. These periods of success never last for more than a couple of hours, maybe days for some.

I was always wondering how it is possible to magically regain the ability for a short period of time. The only thing I could sense from these narratives is that the good period is somehow associated with ‘letting go’ and the relapse with increased focus and worry.

This seems to strongly resonate with the fact that many retraining strategies use distraction as a coaching technique: doing maths, holding up a conversation, memorising things, or even simply focus on the posture and breathing while doing the therapeutic exercises.

On the other hand, the interview study I conducted last year had a very interesting piece of outcome: many of my participants reported being taught in a strictly technique-focused way, often in an emotionally negative climate – some all their lives, some only prior to the symptoms. Even those, who had no particular problem with their teachers had a tendency to be very self-conscious, especially under pressure, and attempt to control their fine motor movements to make sure they do not make mistakes.

The question of focus appeared in so many ways, that I started to research its connection to movement acquisition and performance. As a result, I have found decades of rich sports psychology research, looking at the role of focus. Apparently, the way we use our attention makes a big difference in the execution of the movement. Researchers were comparing two main categories: internal and external focus. What we mean here by external focus is paying attention to the outcome of the movement, like focusing on the aim of a throw or on the finish line of a run. Internal focus is characterised by paying attention to and consciously control the isolated parts of the body which are executing the movement, like the feet in a football kick, or the knees while skiing.

In general, all of the articles agree on the superiority of external focus opposing internal.

Researchers looked at this from different viewpoints, many different sports, age groups and different levels of expertise. It seems that if we focus on our body while executing an action, we use more force, are less accurate and consistent, and we constrain the motor system as a whole. Furthermore, internal focus inhibits previously learned movements and results in co-contractions of agonist and antagonist muscles (these are muscle pairs which are supposed to work contrastingly – read more about them here.) Opposing this, if we focus on the outcome of the movement, we move more freely, are more precise and efficient, and the joints are moving in all possible directions without constraints.

For full findings have a look at table 1.


Table 1.

One group of researchers tested these ideas on piano-playing as well: here the participants played much more accurately when focusing on the sound they were making opposing the finger movements, the keys or the hammers of the piano.

Even as a musician without dystonia, I remember that I always seemed to play worse on the concerts than in the practice room. Could this be a reason? Is it possible, that the desire to play really well, changed my focus of attention and crippled my motor movements? Quite probably.

And taking one more step forward: can it be that focusing on the small motor movements through years and years of practice contributes to the onset of the symptoms? There is a lot of research which needs to be done before we can give a straightforward answer to that question, but consider the following connections:

  1. There is growing evidence that skill acquisition and performance is impaired with an internal focus – and many musicians in my studies reported being taught in a technique-focused way or were very conscious of the fine motor movements when playing before the onset.
  2. It has been measured that internal focus leads to more muscle activity on a neuromuscular level. Over-activation results in tension, which is one of the typical symptoms of MFD.
  3. With an internal focus, agonist and antagonist muscles start to co-contract. This lack of reciprocal inhibition is repeatedly reported, both in a muscular and neural level in musicians with MFD.
  4. Internal focus interferes or even inhibits previously automatised movements – which the core problem in MFD.


Seeing all this evidence that the role of focus might contribute to the onset is interesting, but there are more practical uses of this theory: we can employ it as a tool to enhance our practice.

It does not matter what kind of retraining you are engaged in, it is possible to pay attention to slightly different things. In the single study which looked at this with piano players, focusing on the produced sound enhanced the movement the most. As you practice your retraining exercises, listening to the sound you are making instead of the movements themselves, might result in an easier playing, possibly with fewer symptoms.

But even if you cannot yet make a sound or find this approach difficult, you can still use external focus. As an example, you can aim your movements at the walls, floor or ceiling, instead of paying attention either to the fingers or the surface they’re touching. If you are working on your embouchure dystonia, you can direct your airstream across the room instead of ‘watching’ the lips. I sometimes make my clients blow through a tube and make a bit of paper move on the other side, just to have a very physical experience of the effect of their breathing across space.

In conclusion: researchers still have a lot of work to do to explore this particular aspect, and I don’t have any solid scientific evidence to make that connection yet.

However, I find the role of focus an extremely useful tool in the retraining which is definitely worth trying – especially because it is employed by the coaches of star athletes frequently. Switching the focus of attention from the body to the outcome or direction of the movement is proven to be helpful in many different ways.

I will soon write a blog post with possible exercises on how to employ these ideas everyday practice, but if you are looking for an approach tailored to your needs, don’t hesitate to contact me for a session:


  • Duke, R.A., Cash, C.D., & Allen, S.E. (2011). Focus of attention affects performance of motor skills in music. Journal of Research in Music Education, 59, 4455.
  • Detari (2018). An investigation of the psychological background of Musician’s Focal Dystonia sufferers and its possible contribution to the onset of the symptoms: A grounded theory study, MSc Thesis, Royal College of Music
  • Edwards, M.J & Rothwell, J.C. (2011). Losing focus: how paying attention can be bad for movement. Movement Disorders, 26, 1969-1970.
  • Enders, L., Spector, J.T., Altenmüller, E., Schmidt, A., Klein, Ch., Jabusch, H.Ch. (2011). Musician’s dystonia and comorbid anxiety: Two sides of the same coin? Movement Disorders, 26(3), 539-542.
  • Ioannou, C.I. & Altenmüller, E. (2014). Psychological characteristics in musician’s dystonia: a new diagnostic classification. Neuropsychologia, 61, 80-88.
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  • Jabusch H. Ch., & Altenmüller, E. (2004). Anxiety as an aggravating factor during onset of focal dystonia in musicians. Medical Problems of Performing Artists, 19 (2), 75-81.
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  • Wulf, G., Hoss, M. & Prinz, W. (1998). Instructions for motor learning: differential effect on internal versus external focus of attention. Journal of Motor Behaviour, 30(2), 169-179.
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