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How Many Cues Are Too Many?

Simplifying and Shifting to External Cues 

As therapists, we love to teach, explain, coach, remind, cue and correct.  But at what point do our cues stop helping and start getting in the patient’s way?

What the Research Says:

Research suggests that excessive verbal cueing can actually reduce motor learning, especially when patients are trying to acquire a new movement or skill. A 2023 systematic review examining attentional focus strategies in older adults identified 18 studies, with most involving postural control, balance, or gait. More than 60% of the studies found that an external focus of attention produced better motor performance than an internal focus. The authors concluded that practitioners may improve performance by directing attention away from the patient's body and toward the effect or goal of the movement, particularly during balance related tasks.

Clinical Takeaway: The patient doesn't always need more information about their body. They may need a clearer target.

Every cue requires the brain to:

  • Listen
  • Process the information
  • Decide what to change
  • Execute the movement

For many of our patients (particularly those with stroke, dementia, TBI, Parkinson's disease, or cognitive impairment) that processing capacity is limited.

When we provide cue after cue, such as:

"Lean forward."

"Scoot up."

"Feet back."

"Push with your hands."

"Stand taller."

"Straighten your knees."

"Slow down."

...our patients may spend more time trying to remember our instructions than actually learning the intended movement.

Cognitive Load Matters:

  • Think of the brain like a computer, every instruction uses processing power.
  • Too many instructions at once can overload the system, making performance worse instead of better.
  • Sometimes the best cue is only one cue.

Less Can Be More:

  • Instead of giving multiple instructions, try giving one meaningful cue, then pause.
  • Allow the patient time to process and attempt the movement before adding another.
  • Give the patient time to process the information, attempt the movement, and respond before adding another instruction.
  • Research in older adults suggests that additional processing time can improve performance, reinforcing the importance of allowing patients adequate time to respond rather than immediately repeating or adding another cue.
  • Don't mistake silence for lack of skilled intervention.
  • Sometimes the most skilled thing you can do after giving a cue is wait and watch.

But Which Cue Should We Choose?

If the goal is to reduce unnecessary information, the next question becomes: What should our one cue actually be?

Not all cues require the patient to process information in the same way. Some cues direct attention toward the patient's own body and how it should move, while others direct attention toward the environment, a target, or the outcome of the movement.

Consider whether you can replace a detailed, body focused instruction with a simple, goal directed cue.

Instead of telling the patient exactly how to move, try telling them what you want them to accomplish.

External Cues Often Outperform Internal Cues:

  • Internal cues direct the patient’s attention toward their own body or a specific body movement.
    • Internal = “What is my body doing?”
  • External cues direct the patient’s attention toward the environment, an object, a movement outcome, or the result they are trying to produce.
    • External = “What am I trying to accomplish?”

Instead of this:

❌ "Lean your trunk farther forward."

Try this:

✅ "Reach towards the target as you stand."

Instead of this:

❌ "Extend your knees."

Try this:

✅ "Push the floor away."

Instead of this:

❌ Internal: “Lift your foot higher.”

Try this:

✅ External: “Clear the hurdle.”

Instead of this:

❌ Internal: “Rotate your trunk to the left.”

Try this:

✅ External: “Reach for the cone.”

How to Document Cueing:

❌ Don't just write:

  • “Pt required verbal cues for sit-to-stand.”

✅ Show the reason, type of cue, and patient response:

  • “Pt required verbal cues for anterior weight shift due to posterior weight displacement. External cue ‘push the floor away’ improved forward weight shift with decreased cueing required on subsequent trials.”

❌ “Pt required cues for foot clearance.”

✅ “Pt demonstrated intermittent toe drag; external cue to ‘clear the line’ improved foot clearance with decreased cueing required on subsequent trials.” 

❌ “Pt required cues for weight shifting.”

✅ “Pt demonstrated posterior weight displacement; external cue ‘reach for the cone’ improved anterior weight shift with intermittent cues required on following  trials.”

❌ “Pt required constant cues.”

✅ “Pt required frequent one step verbal and visual cues for sequencing due to impaired motor planning and decreased carryover. External cues and increased processing time improved task completion.”

The Bottom Line:

  • Skilled cueing isn't about how much we can tell the patient, it's about knowing what the patient actually needs. Give one meaningful cue, allow time to process and respond, and reassess before adding more. When possible, shift the patient's attention from how their body should move to what they are trying to accomplish. Sometimes the most effective cue isn't another instruction, it’s giving the patient the space to move, adapt, and learn.

Reference:

  • Madan, C. R., & Singhal, A. (2023). Attentional focus strategies to improve motor performance in older adults: A systematic review. International Journal of Environmental Research and Public Health, 20(5), 4047. https://doi.org/10.3390/ijerph20054047