Boston Sports Medicine and Performance Group, LLC Blog

photo and article from StrongFirst Blog

I am often asked for my opinion about the best way to squat, or pull a loaded bar. My answer always is, “It depends on the person.”

We all have a different injury history influencing which tissues may need sparing, different body segment length ratios affecting leverage advantages, different hip socket depths that determine the depth of the squat before the pelvis tucks stressing the lumbar discs, etc. What is best for one person will not be best for their training partner.

Here is a drill I use that will help all lifters set-up their pulls, despite their individual differences. We call it the short-stop squat. If you know American Baseball, you will catch on very quickly.

Begin with the feet apart. Try a few knee bends and adjust the internal/external rotation of the hip, to get perfect knee and ankle hinge tracking. Now look at the turn out of your feet. Remember this angle and start in this position.

Now to start the drill, stand tall and place the hands on the top of the front of the thighs. Make a “V” between the thumbs and the finger. Keeping the arms straight, push the hands down the thighs, only hinging about the hips—do not allow the spine to bend. Stop as the hands reach just above the kneecap and robustly grab around the knee. This is the short stop posture.

Check the position of the knee. If you drew a vertical line down from the knee it will fall between the balls of the feet and the heels. This ensures that the hips are well behind. Play with your balance so you feel the centre of pressure from the ground in the middle of your feet.

Enjoy carrying the weight of your upper body down the arms and onto the thighs. Focus on the curves in your torso – are they the same as when you were standing? If they are you have good form. If they are not, adjust them back to the natural curves.

To lift from this position, many will shrug. You will not. You will perform the “anti-shrug” by compressing the shoulders down into your torso with co-contraction of the pectoral and latissimus dorsi muscles. 

Continue reading by clicking HERE 

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by Art Horne

When treating the common ankle sprain, clinicians should be aware of a not so common treatment approach when faced with recurrent lateral foot and ankle pain.

“Medical professionals must be aware that any lateral foot and ankle pain may be the result of cuboid syndrome. Once properly diagnosed, cuboid syndrome responds exceptionally well to conservative treatment involving specific cuboid manipulation techniques. Other methods of conservative treatment including therapeutic modalities, therapeutic exercises, padding, and low dye taping techniques are used as adjuncts in the treatment of this syndrome. Immediately after the manipulation is performed, the patient may note a decrease or a complete cessation of their symptoms. Occasionally, if the patient has had symptoms for a longer duration, several manipulations may be warranted throughout the course of time. Due to the fact radiographic imaging is of little value, the diagnosis is largely based on the patient’s history and a collection of signs and symptoms associated with the condition. Additionally, an understanding of the etiology behind this syndrome is essential, aiding the clinician in the diagnosis and treatment of this syndrome. After the correct diagnosis is made and a proper treatment regimen is utilized, the prognosis is excellent.

Introduction

            Cuboid syndrome has also been noted as a complication of a plantar flexion and inversion ankle injuries. Inversion ankle sprains are one of the most common athletic injuries, accounting for between 38% and 45% of all injures. Up to 40% of these patients may have residual symptoms, cuboid syndrome being a possible culprit.”

-          Patterson 2006

Clinical Findings

            “The symptoms of cuboid syndrome resemble those of a ligament sprain. Pain is often diffuse along the lateral foot between the CC joint and the fourth and/or fifth cuboid-metatarsal joints and may radiate throughout the foot. A slight sulcus over the dorsum of the cuboid and/or a slight prominence of fullness of the plantar surface may be present with subluxation along with erythema, edema, and/or ecchymosis.

            Cuboid syndrome may be misdiagnosed as a lateral ankle sprain or overlooked when it develops in conjunction with a lateral ankle injury. “

-Durell, 2007

Signs and Symptoms

            Presenting complaints are sharp pain localized at the lateral aspect of the foot at the level of the calcaneal cuboid joint. The pain can occasionally occur at the cuboid-fourth and fifth metatarsal articulations, and infrequently along the cuboid-lateral cuneiform/cuboid-navicular articulations. The patient relates that following the precipitating injury, the pain is either gradual or rapid often becoming a chronic “inability to work through” the injury. There is continued pain primarily during the propulsive phase of gait which impairs walking, and can become disabling. Eventually, the symptoms can be difficult to diagnose because of referred pain and generalized foot pain.

-          Zirm 1995

Treatment

            “The “cuboid whip” was originally introduced by Newell and Woodle in 1981. Marshall modified the procedure in 1988 and named it the “cuboid squeeze.” Both are similar maneuvers that require the surrounding musculature be relaxed, introducing the long extensor as well as the peroneal tendons.

            The cuboid squeeze and the cuboid whip are performed with the patient in the prone position, with a slightly flexed knee. An alternative is standing in the “horse-shoeing” position with the patient braced against a wall or chair. The patient’s entire lower extremity must be fully relaxed. The examiner manipulates the foot and ankle into plantarflexion. The physician is facing the plantar aspect of the foot with thumbs on the medial plantar surface of the cuboid and fingers stabilizing the dorsal aspect of the foot, avoiding the dorsal aspect of the cuboid. When the physician feels the soft tissues relax, a small excursion, high velocity thrust is then directed dorsally at a 60 degree lateral angulation. The cuboid whip uses a more dramatic arc of motion than the more gradual, definitive cuboid squeeze. The squeeze maneuver allows the physician to feel the soft tissues relax, and relocate the cuboid in a controlled fashion. The cuboid squeeze appears to be more effective than the cuboid whip. Forces are better controlled and the intensity is better directed. The whip technique transmits forces to the anterior ankle joint and can result in damage to the soft tissue structures, such as the peroneal nerves where they cross the ankle.

            An alternative technique can be used if the initial manipulation is unsuccessful. Performed with the patient supine, the physician stands at the base of the patient’s feet and grasps the fourth and fifth metatarsals, while allowing gravity and the weight of the leg to distract the cuboid articulations. After muscle relaxation is obtained, the metatarsals are pulled in a longitudinal direction with the forefoot in slight plantarflexion. This maneuver is also useful in relocating the subluxated cuboid metatarsal bases. This is accomplished with the fingers exerting a force in the plantar direction to the dorsal aspect of the metatarsal bases as the thumbs press dorsally at the plantar aspect of the involved metatarsal head(s).”

-Zirm, 1997

When evaluating your traditional lateral ankle sprain it's worth thinking about some sound advice my father used to tell me, “measure twice, cut once”.  Evaluating for bony malposition in the talus, fibula and cuboid upon initial evaluation will save you and your patient a considerable amount of recovery time and potential frustration down the road.

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March 31, 2010
By Dr. Mark Lindsay

Achilles tendinopathy is a major medical injury that afflicts somewhere between 10 and 30 per cent of runners, characterized by localized pain and swelling of the Achilles tendon. It used to be referred to as “tendinitis,” but clinicians have realized that the condition is more complicated than the simple inflammation implied by the -itis suffix.

Three theories:

The conventional view of Achilles tendon injuries is that they’re caused by wear and tear from quick accelerations and decelerations, which place a lot of stress on the tendon. But this overuse theory can’t explain why some diseased tendons improve with exercise, why certain tendons are more susceptible than others, or why even people who don’t exercise can suffer from spontaneous ruptures.

One alternative is the “vascular theory,” which argues that inadequate blood flow to the tendon makes it prone to injury. Alternately, the “neural theory” places the blame on nerves supplying the tendon that trigger destructive inflammatory signals. Most likely, Achilles tendinopathy results from a combination of all these factors.

The first response to an Achilles injury is RICE - rest, ice, compression and elevation - along with ultrasound and eccentric exercises. Traditionally, if it’s not better after three months of this, then surgery is recommended. But there are some newly emerging options that you might want to consider.

Nutritional supplementation:

Several key nutrients can significantly reduce the inflammation and improve the regenerative healing capacity of a traumatized Achilles tendon:

Vitamin A increases the number of white blood cells at the injured area, and promotes collagen cross-links, which enhance tendon strength. (5000 IU daily)

Zinc doesn’t do much during the initial inflammatory stages of repair, but it becomes important as the tissue begins to regenerate. (8-11 mg daily)

EPA (eicosapentaenoic acid), found in omega-3 fish oils, enhances collagen synthesis and healing. (4 g twice daily with food)

Bromelain, found in pineapple, contains a proteolytic enzyme that breaks down the scar tissue that reduces the elasticity of injured tissue.

Curcumin is an extract of the spice turmeric with anti-inflammatory properties, which speeds healing by manipulating the cytokines that regulate cell growth. (0.5-3 g daily in divided doses)

Cutting-edge approaches:

Researchers have been searching for alternatives to Achilles tendon surgery for many years. Here are some of the techniques that show promise:

Extracorporeal Shock Wave Therapy (ESWT) involves sending focused sound waves through tissue to break up scar tissue and stimulate soft tissue regeneration. The high energy produced by ESWT can be uncomfortable, so sedation may be required. A placebo-controlled, double-blind study by Danish researchers in 2008 found that ESWT improved Achilles tendinopathy.

Platelet-Rich Plasma involves drawing blood from the patient, spinning it in a centrifuge to obtain concentrated platelets, and then re-injecting it into the injured area. The platelets release growth factors that stimulate the regeneration of tissue. Recent studies of growth factors such as GDF-5, IGF-1 and PDGF-2 on tendons and ligaments suggest they can accelerate healing.

Continue reading this article by clicking HERE. 

See Mark Lindsay present at the 2013 BSMPG Summer Seminar - Where the Leaders in Sports Medicine and Performance meet each year.

BSMPG is proud to announce the addition of Mark Lindsay as a speaker within our Sports Medicine & Rehabilitation Track at the 2013 BSMPG Summer Seminar - May 17th and 18th, 2013!  Mark joins Dr. Stuart McGill and Marco Cardinale for this weekend event along with the leaders in Performance Training and Sports Medicine professionals from around the world! With the greatest speaker line-up assembled to date, the 2013 BSMPG Summer Seminar will be the WORLD'S most sought after Sports Medicine & Performance Seminar to date!!

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See you in Boston this May!!!

DR. MARK LINDSAY, BSc., D.C.

Lindsay Sports Therapy

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Note: Dr. Mark Lindsay and Bill Knowles will be presenting together for 2-1 hour presentation blocks back-to-back

A world-renowned chiropractor and soft tissue specialist, Dr. Mark Lindsay is one of the most sought after therapists amongst professional, world and Olympic athletes.

Dr. Lindsay was named to the Canadian Olympic Committee medical team as a doctor and soft tissue therapist at six Olympic Games, including France (1992), Norway (1994), USA (1996), Japan (1998) and Australia (2000) and Canada (2010), working closely with Short Track Speed Skating Team, Bobsleigh Canada, Alpine Canada and Athletics Canada and Skate Canada. Mark also travelled as team doctor with the Short Track Speed Skating Team to the World Championships in Korea, China, USA, and England; Bobsleigh Canada to the World Championships in Austria and Germany; and Alpine Canada to the World Championship in USA, Italy and Spain. Dr. Lindsay was team doctor for Athletics Canada at the World Championships in Sweden, Spain, Greece and Canada, the Commonwealth Games in Canada, and the Goodwill Games in the United States.

Dr. Lindsay has been recognized for his outstanding work in the area of sports chiropractic when, in 1996, he was named “Outstanding Field Doctor” by the Canadian Chiropractic Sports Fellowship. This prestigious award was presented to Dr. Lindsay following his work with the double gold medalist; Olympic and World champion Donovan Bailey.  Bailey set an Olympic and World record in the 100 meters at the Olympic games in Atlanta, Georgia, putting sports chiropractic on the world stage. During these same Olympic games, Mark worked closely with the Canadian men’s Olympic Relay Team who also won gold in the 4 x 100 meter relay.                                                                     

Dr. Lindsay’s work has brought him around the world, consulting extensively with international and professional teams including NFL teams: the Oakland Raiders, Denver Broncos, Cleveland Browns, Indianapolis Colts; NHL teams: Toronto Maple Leafs, Ottawa Senators, Pittsburgh Penguins, Dallas Stars, Tampa Bay Lighting, the Columbus Blue Jackets; MLB teams: New York Yankees and with the Swedish National Soccer Team at the 2008 Euro Cup. 

Dr. Lindsay is currently consulting with NFL, NHL and MLB players and teams and published his first book entitled: FASCIA – Clinical Applications for Health and Human Performance.

As the President of Lindsay Sports Therapy Inc., Dr. Lindsay runs a private practice and consulting business in Ontario, Canada. He is married to Kate Pace Lindsay, a three-time Olympian, World Champion and World Cup double Gold Medalist in Alpine Skiing and 1994 Canadian Female Athlete of the Year.

Mark received his Doctorate of Chiropractic from Palmer Chiropractic College and his Bachelor of Science in Kinesiology from the University of Guelph.  He is a Certified Active Release Techniques Instructor and Provider and is completing his Masters of Neurological Science in the Clinical Neuroscience Program through the Carrick Institute for Graduate Studies and was appointed as an Assistant Clinical Professor in the Department of Surgery, Faculty of Health Sciences at McMaster University.

When working with college athletes it’s often difficult to provide nutritional information that is both "easily digestible" and sticky.  Below you'll find some key points from this 30 minute read that will be sure to stick with even the most nutritionally challenged athlete.

Enjoy.

7. Avoid food products that a third-grader cannot pronounce. Basically the same idea, different mnemonic. Keep it simple!

16. Buy your snacks at the farmers’ market. You’ll find yourself snacking on fresh or dried fruits and nuts – real food – rather than chips and sweets.

18. Don’t ingest foods made in places where everyone is required to wear a surgical cap.

19. If it came from a plant, eat it; if it was made in a plant, don’t.

20. It’s not food if it arrived through the window of your car.

21. It’s not food if it’s called by the same name in every language. (Think Big Mac, Cheetos, or Pringles.)

36. Don’t eat breakfast cereals that change the color of the milk. This should go without saying. Such cereals are highly processed and full of refined carbohydrates as well as chemical additives.

39. Eat all the junk food you want as long as you cook it yourself. There is nothing wrong with eating sweets, fried foods, pastries, even drinking a soda every now and then, but food manufacturers have made eating these formerly expensive and hard-to-make treats so cheap and easy that we’re eating them every day. The French fry did not become America’s most popular vegetable until industry took over the jobs of washing, peeling, cutting, and frying the potatoes – and cleaning up the mess. If you made all the French fries you ate, you would eat them much less often, if only because they’re so much work. The same holds true for fried chicken, chips, cakes, pies, and ice cream. Enjoy these treats as often as you’re willing to prepare them – chances are good it won’t be every day.

57. Don’t get your fuel from the same place your car does. American gas stations now make more money inside selling food (and cigarettes) than they do outside selling gasoline. But consider what kind of food this is: Except perhaps for the milk and water, it’s all highly processed, imperishable snack foods and extravagantly sweetened soft drinks in hefty twenty-ounce bottles. Gas stations have become “processed corn stations” : ethanol outside for your car and high-fructose corn syrup inside for you. Don’t eat here.

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How and where Fascial Manipulation works

"Fascial Manipulation affects principally the ground substance of the fascia. The ground substance unites cells and influences their development, polarity, and behavior. It contains various protein fibers interwoven in a hydrophilic gel composed of GAGs (glycoaminoglycans). The constituent protein of these fibers can be divided into structural protein (collagen and elastin) and adhesive protein (fibronectin and lamina).

The GAGs are divided fundamentally into two groups: hyaluronic acid (not sulphate) and sulphate GAGs. The first is more abundant in the loose connective tissues and facilitates cell migration during morphogenesis and tissue repair processes. For example, it can increase or inhibit the activity of the fibroblast growth factor. The sulphate GAGs are more common in dense packed connective tissues.

GAGs are very gelatinous and are responsible for the viscosity of the extracellular matrix. Apart from hyalonuric acid, GAGs are attached to non-collagenous proteins forming macromolecules called proteoclycans. GAGs can unite many ions and the nature and concentration of the electrolytes influences the macromolecular structure. This can vary from loose to twisted, with consequent changes in viscosity of the solution. Furthermore, proteoglycans can interact via electrostatic attachments with collagen influencing the morphology and the function of the connective tissue fibers. Links between fibronectin and collagen can also be modulated by various GAGs.

In conclusion, densification of the ground substance hinders collagen fiber orientation in response to applied traction, as well as impeding aligned collagen fibers from gliding between one another. Diminished elasticity of the fascia determines incoordination between the muscular fibers of single mf units and between the mf units of a myofascial sequence.

This is where Fascial Manipulation intervenes, creating local heat through friction as well as a local inflammation. The heat immediately modifies the consistency of the ground substance.  The inflammation intervenes in the following hours, as the extracellular proteolytic enzymes secreted locally from cells collaborate in the degeneration of matrix proteins (collagen and fibronectin).

Turnover of collagen and other macromolecules of the extracellular matrix is normally very slow. Hence, unless an external intervention such as Fascial Manipulation is applied, a patient could take years to recover from pain generated by a fascial densification and in the meantime, compensations and counter compensations multiply."

(Stecco, The Myofascial Sequence, p.154-155)

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by Jason Belzer, Contributer to Forbes.com

Over the better part of the last decade, no team has captivated the attention of sports fans across the country like the Butler University Bulldogs. A living embodiment of the mythical Hoosiers, the small school in Indianapolis has risen to the echelons of college basketballs elite over the last several years using modest resources and a budget substantially less than those teams it defeats on a regular basis. Time and again the Bulldogs manage to win games they shouldn’t with a roster of players who received little recruiting interest from blue-blooded programs like Duke and Kentucky. All the while, behind the curtain stands their mysterious young coach, Brad Stevens, concocting his next delightful magic trick.

While many have offered their own fleeting opinions as to why Butler has been so successful, the true answer has remained an enigma. To begin to unravel the mystery, one must dive deep into they culture of the school, athletics program, coaches and its players.

Almost 100 years ago, the legendary Paul “Tony” Hinkle began what would become a legendary half century reign over the Butler athletics program and community. A true renaissance man, Hinkle accumulated an incredible 1060-800-16 record over the course of his career coaching the Butler football, basketball and baseball teams. While the future “Wizard of Westwood”, John Wooden, was still perfecting his jump shot as a player up the road at Purdue, Hinkle was performing his own wizardry, leading the Bulldogs to two national titles and a reputation as “Big Ten Killers”. Even then, the small school from a small Midwest city was slaying giants.

The impact Hinkle had on the Butler program goes beyond just wins and losses. Under his leadership, Butler developed not only the first true culture of success in sports, but among modern day organizations as we know. Hinkle passed down his teachings to his coaching proteges and players throughout the years, the programs culture propagating into all aspects of the Butler community. Barry Collier, former head coach and now athletic director of the Bulldog program, eventually formalized the program philosophies by creating five pillars collectively called, “The Butler Way”:

1. Humility – Those who humble themselves will be exalted;
2. Passion – Do not be lukewarm, commit to excellence;
3. Unity – Do not divide our house, team first;
4. Servanthood – Make teammates better, lead by giving; and
5. Thankfulness – Learn from every circumstance

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The Overactive Posterior Hip Complex

"Overactivation of the deep hip rotators, otherwise referred to as ‘butt gripping’ by Diane Lee and Linda-Joy Lee, is a common cause of hip dysfunction. As the name suggests, this pattern is caused by a contraction of the deep hip rotators and superficial gluteus maximus and looks as if the individual is standing or walking in a perpetual contraction. In actuality, they are. This stabilization pattern is a result of several causes, including trying to make the rear end look smaller (generally females are guilty of this); weakness in the pelvic floor, causing reflexive overactivation of the deep hip rotators and adductors; instability anywhere in the lower extremity, causing overactivation of the posterior hip musculature; and learned cuing techniques from trainers and therapists who stress to ‘squeeze the glutes as hard as possible.’

Palpation over the lateral hip region just behind the greater trochanter will reveal an indentation or hollowing, created by overactivation of the deep external rotators of the hip. In supine position, the head of the femur can be palpated by placing the hands just medial to the anterior superior iliac spine (ASIS) and pushing lightly posteriorly. It is common to palpate increased tone or ‘fullness’ in the tensor fasciae latae (just lateral to the ASIS). With this ‘gripping’ pattern, the head of the femur will generally be pushed forward and superior in the acetabulum. Not so ironically, the superoanterior aspect of the femoral head is the most common region of cartilaginous degenerative changes of the hip.

By cuing the individual to relax the hips and spread the sit bones, there is a change in the tone in the posterior hip region. Palpation over the anterior hip region will reveal the head of the femur has been centered in the socket secondary to the relaxation of the posterior hip muscles.

While the previous technique is extremely effective for releasing butt-gripping patterns, some individuals require more specific techniques for decreasing activation of the deep hip rotators and/or the posterior hip capsule. The next section demonstrates a release technique effective for releasing the posterior hip capsule as well as reducing myofascial restrictions." (p.111) 

Corrective Exercise Solutions to common Hip and Shoulder Dysfunction 

by Evan Osar

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BSMPG is proud to announce the return of Joel Jamieson as a speaker within the popular Sports Fusion (formally Hockey & Basketball Specific Training) Track at the 2013 BSMPG Summer Seminar - May 17th and 18th, 2013!  Joel joins Dr. Stuart McGill and Marco Cardinale for this weekend event along with the leaders in Performance Training and Sports Medicine professionals from aournd the world!  With the greatest speaker line-up assembled to date, the 2013 BSMPG Summer Seminar will be the WORLD'S most sought after Sports Medicine & Performance Seminar to date!!

Be sure to save the date now - hotels will fill fast with this event along with normal Boston traffic so start making plans now!

See you in Boston this May!!!

JOEL JAMIESON

SPONSORED BY:

8Weeksout.com

Topic: Advanced Recovery Strategies to Maximize Performance

Joel Jamieson is widely regarded as one of the world’s foremost authorities on strength and conditioning for combat sports. He has more than 7 years experience working with many of the top athletes in the sport and has trained over 30 of the biggest names in MMA, including 7 world champions.

He formerly served as the Director of Strength & Conditioning for Pride FC and currently works in a similar capacity for Dream. Prior to his work in MMA and combat sports, he spent time training D-1 football players and worked in the NFL with the Seattle Seahawks. He has trained countless teams and athletes from the NFL, MLS, NHL and NBA and Olympic competitors from 5 different sports.

Joel is also the founder of www.8weeksout.com and author of the highly acclaimed book, “Ultimate MMA Conditioning.” Since its release in 2009, it has been sold in more than 103 countries and widely regarded as the definitive book on the subject. He is a regular featured contributor to Fight! Magazine, Fighting Fit (UK) Sherdog.com, Men’s Health, Muscle & Fitness and his training programs and articles have been featured in a variety of online and print media throughout the globe.

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from Attention and Motor Skill Learning – Gabriele Wulf

“Zachry had participants perform a jump-and-reach task using a Vertec measurement device (see photo).  Participants were instructed to jump straight up and touch the highest rung on the Vertec they could reach with the tips of their fingers.  Each participant performed five trials under one of three conditions: control, internal focus, and external focus.  For the control condition, no additional focus instruments were given.  Under the internal focus condition, participants were instructed to concentrate on the tips of their fingers.  Under the external focus condition they were instructed to concentrate on the object to be touched, that is, the rungs of the Vertec.

Participants indeed reached higher rungs when they adopted the external focus (on average 4.79 rungs) compared to the internal focus (4.12 rungs) or when they received no attentional focus instructions (4.10 rungs).  Also the time they spent in the air was longer under the external (0.491 s) than under the internal focus (0.477 s) or the control condition (0.478 s)  Thus a change in the focus of attention significantly affected reach height: Focusing on the object to be touched resulted in more effective performance than did focusing on the finger with which the object was to be touched.  Perhaps most interestingly, instructing the participants to adopt an external focus increased jump height above and beyond what participants achieved under “normal” conditions (i.e., control conditions without instructions).  These results were recently replicated by Carolina Granados in my lab (Wulf, Zachry, Granados, & Dufek, 2006, Experiment 2).  In addition to looking at reach height, Granados calculated the displacement of participants’ center of mass during the jumps.  Interestingly, she found not only the greatest reach heights under the external focus condition, but also greater vertical displacements of the center of mass (0.51 cm) compared to those in the internal focus (0.47 cm) and control conditions (0.47 cm).

These findings might seem surprising given that one might expect the jump height to be determined mainly (although not exclusively) by the participant’s strength.  Yet we also know, for example, that the coordination between and within muscles influences maximum force production as well (Hollmann & Hettinger, 2000).  It is possible tha an external focus optimizes those coordination patterns.  While we have to await further research to find out how exactly the attentional focus instructions affected jump height, the findings of this study could have implications for sports in which maximum forces must be generated in a short periods of time (e.g., high jump, long jump, pole vault, basketball layup).  In those cases, focusing on the target (e.g., the bar in the high jump) might also result in more effective performance than focusing on movement coordination or not focusing on anything in particular.” Pg 58-59

“The studies we have reviewed in this chapter confirm the anecdotal observation (in windsurfing) that the performance of motor skills seems to be more effective if one focuses on the effects one’s movements have on the environment rather than on the movements themselves.  The results from studies using various laboratory tasks as well as sport skills provide converging evidence for the advantage of instructions that induce an external relative to an internal focus.  The benefits of an external focus appear to be even more pronounced if the movement effect occurs at a distance from the body, thus making it more easily distinguishable from the body movements that produced it.  Furthermore, this effect seems to be rather general and not dependent on individual preferences.  In fact, performers often notice immediate changes in their performance as a function of their focus of attention.  Importantly, the effects of adopting an external focus when practicing a skill is not just temporary, that is, present only when the individual adopts that focus; rather, these benefits are seen in the retention of the skill and in transfer to novel variations of the skill.” Pg 77

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