Golf Putting “Yips”: Focal Dystonia Research

Dystonia is a neurological disorder characterized by involuntary twisting movements and postures. There are many different clinical manifestations, and many different causes. The neuroanatomical substrates for dystonia are only partly understood. Although the traditional view localizes dystonia to basal ganglia circuits, there is increasing recognition that this view is inadequate for accommodating a substantial portion of available clinical and experimental evidence. A model in which several brain regions play a role in a network better accommodates the evidence. This network model accommodates neuropathological and neuroimaging evidence that dystonia may be associated with abnormalities in multiple different brain regions. It also accommodates animal studies showing that dystonic movements arise with manipulations of different brain regions. It is consistent with neurophysiological evidence suggesting defects in neural inhibitory processes, sensorimotor integration, and maladaptive plasticity. Finally, it may explain neurosurgical experience showing that targeting the basal ganglia is effective only for certain subpopulations of dystonia. Most importantly, the network model provides many new and testable hypotheses with direct relevance for new treatment strategies that go beyond the basal ganglia. 2.The "yips": a focal dystonia of golfers. Neurology. 1989 Feb;39(2 Pt 1):192-5. The "yips": a focal dystonia of golfers. McDaniel KD, Cummings JL, Shain S. Source Neurobehavior Unit, West Los Angeles VAMC, CA 90073. Abstract The "yips" is an involuntary motor disturbance affecting golfers. A 69-item questionnaire was constructed and distributed to 1,050 professional and amateur golfers in an effort to define and characterize this syndrome. Of the male golfers there was a 42% response rate and 28% reported suffering from the yips. The disorder was described most frequently as jerks, tremors, and spasms affecting the preferred arm distally and primarily during putting. When compared with unaffected golfers, afflicted golfers were significantly older and had more cumulative years of golfing. In 24%, activities other than golfing were affected and 25% reported involvement of body regions beyond the arms. These data support the hypothesis that the yips represents a focal dystonia and shares many features with other occupational dystonias.The "yips" is an involuntary motor disturbance affecting golfers. A 69-item questionnaire was constructed and distributed to 1,050 professional and amateur golfers in an effort to define and characterize this syndrome. Of the male golfers there was a 42% response rate and 28% reported suffering from the yips. The disorder was described most frequently as jerks, tremors, and spasms affecting the preferred arm distally and primarily during putting. When compared with unaffected golfers, afflicted golfers were significantly older and had more cumulative years of golfing. In 24%, activities other than golfing were affected and 25% reported involvement of body regions beyond the arms. These data support the hypothesis that the yips represents a focal dystonia and shares many features with other occupational dystonias. 3.A multidisciplinary study of the 'yips' phenomenon in golf: An exploratory analysis. Sports Med. 2000 Dec;30(6):423-37. A multidisciplinary study of the 'yips' phenomenon in golf: An exploratory analysis. Smith AM, Malo SA, Laskowski ER, Sabick M, Cooney WP 3rd, Finnie SB, Crews DJ, Eischen JJ, Hay ID, Detling NJ, Kaufman K. Source Department of Laboratory Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA. [email protected] Abstract BACKGROUND: The 'yips' is a psychoneuromuscular impediment affecting execution of the putting stroke in golf. Yips symptoms of jerks, tremors and freezing often occur during tournament golf and may cause performance problems. Yips-affected golfers add approximately 4.7 strokes to their scores for 18 holes of golf, and have more forearm electromyogram activity and higher competitive anxiety than nonaffected golfers in both high and low anxiety putting conditions. The aetiology of the yips is not clear. OBJECTIVE: To determine whether the yips is a neurological problem exacerbated by anxiety, or whether the behaviour is initiated by anxiety and results in a permanent neuromuscular impediment. METHODS: In phase I, golf professionals assisted investigators in developing a yips questionnaire that was sent to tournament players (<12 handicap) to establish the prevalence and characteristics of the yips. Phase II measured putting behaviour in scenarios that contribute to the yips response. Four self-reported yips and 3 nonaffected golfers putted 3 scenarios using an uncorrected grip and a standard length putter. Heart rate was superimposed on the videotape and the putter grip was instrumented with strain gauges to measure grip force. Electromyograms and relative putting performance were also measured. RESULTS: The questionnaire was sent to 2,630 tournament players, of whom 1,031 (39%) responded (986 men and 45 women). Of these, 541 (52%) perceived they experienced the yips compared with 490 (48%) who did not. Yips-affected golfers reported that the most troublesome putts were 3, 4 and 2 feet (0.9, 1.2 and 0.6 metres) from the hole. Fast, downhill, left-to-right breaking putts and tournament play also elicited the yips response. Golfers affected by the yips had a faster mean heart rate, increased electromyogram activity patterns and exerted more grip force than nonrffected golfers and had a poorer putting performance. CONCLUSIONS: For <10 handicap male golfers and <12 handicap female golfers, the prevalence of the yips is between 32.5% and 47.7%, a high proportion of serious golfers. This high prevalence suggests that medical practitioners need to understand the aetiology of the yips phenomenon so that interventions can be identified and tested for effectiveness in alleviating symptoms. Although previous investigators concluded that the yips is a neuromuscular impediment aggravated but not caused by anxiety, we believe the yips represents a continuum on which 'choking' (anxiety-related) and dystonia symptoms anchor the extremes. The aetiology may well be an interaction of psychoneuromuscular influences. Future research to test the effect of medications such as beta-blockers should assist in better identifying the contributions these factors make to the yips phenomenon. 4.Geoff Mangum Neurophysiology of Golf Putting: The Mayo Clinic Takes a "Stab" at the Yips (Full Text) ABSTRACT: The Mayo Clinic is undertaking a study of the "yips" in golf--the mysterious affliction in putting manifested by freezing over the putt, shaky hands, and a stabbing stroke. Previous researchers have classified yips as an occupational focal hand dystonia, a type of movement disorder apparently caused by degeneration of neural circuitry following decades of the same hand movement. The Mayo Clinic team departs from earlier researchers by assigning a prominent role in the etiology of the yips to psychological rather than neurological factors. They have also opted for a behavioral definition of yips that does not distinguish between the contributions of anxiety and dystonia. The team may therefore have difficulty identifying effective therapy. (Nov. 2002). The Mayo Clinic is undertaking a study of the "yips" in golf--the mysterious affliction in putting manifested by freezing over the putt, shaky hands, and a stabbing stroke. Previous researchers have classified yips as an occupational focal hand dystonia, a type of movement disorder apparently caused by degeneration of neural circuitry following decades of the same hand movement. The Mayo Clinic team departs from earlier researchers by assigning a prominent role in the etiology of the yips to psychological rather than neurological factors. They have also opted for a behavioral definition of yips that does not distinguish between the contributions of anxiety and dystonia. The team may therefore have difficulty identifying effective therapy. (Nov. 2002). 5.The 'yips' in golf: a continuum between a focal dystonia and choking. Sports Med. 2003;33(1):13-31. The 'yips' in golf: a continuum between a focal dystonia and choking. Smith AM, Adler CH, Crews D, Wharen RE, Laskowski ER, Barnes K, Valone Bell C, Pelz D, Brennan RD, Smith J, Sorenson MC, Kaufman KR. Source Sports Medicine Center, Mayo Clinic, Rochester, Minnesota 55905, USA. [email protected] Abstract The definition of the 'yips' has evolved over time. It is defined as a motor phenomenon of involuntary movements affecting golfers. In this paper, we have extended the definition to encompass a continuum from the neurologic disorder of dystonia to the psychologic disorder of choking. In many golfers, the pathophysiology of the 'yips' is believed to be an acquired deterioration in the function of motor pathways (e.g. those involving the basal ganglia) which are exacerbated when a threshold of high stress and physiologic arousal is exceeded. In other golfers, the 'yips' seems to result from severe performance anxiety. Physically, the 'yips' is manifested by symptoms of jerks, tremors or freezing in the hands and forearms. These symptoms can result in: (i) a poor quality of golf performance (adds 4.9 strokes per 18 holes); (ii) prompt use of alcohol and beta-blockers; and (iii) contribute to attrition in golf. Golfers with the 'yips' average 75 rounds per year, although many 'yips'-affected golfers decrease their playing time or quit to avoid exposure to this embarrassing problem. While more investigation is needed to determine the cause of the 'yips', this review article summarises and organises the available research. A small study included in this paper describes the 'yips' phenomenon from the subjective experience of 'yips'-affected golfers. The subjective experience (n = 72) provides preliminary support for the hypothesis suggesting that the 'yips' is on a continuum. Based on the subjective definitions of 72 'yips'-affected golfers, the 'yips' was differentiated into type I (dystonia) and type II (choking). A theoretical model provides a guide for future research on golfers with either type I or type II 'yips'.The definition of the 'yips' has evolved over time. It is defined as a motor phenomenon of involuntary movements affecting golfers. In this paper, we have extended the definition to encompass a continuum from the neurologic disorder of dystonia to the psychologic disorder of choking. In many golfers, the pathophysiology of the 'yips' is believed to be an acquired deterioration in the function of motor pathways (e.g. those involving the basal ganglia) which are exacerbated when a threshold of high stress and physiologic arousal is exceeded. In other golfers, the 'yips' seems to result from severe performance anxiety. Physically, the 'yips' is manifested by symptoms of jerks, tremors or freezing in the hands and forearms. These symptoms can result in: (i) a poor quality of golf performance (adds 4.9 strokes per 18 holes); (ii) prompt use of alcohol and beta-blockers; and (iii) contribute to attrition in golf. Golfers with the 'yips' average 75 rounds per year, although many 'yips'-affected golfers decrease their playing time or quit to avoid exposure to this embarrassing problem. While more investigation is needed to determine the cause of the 'yips', this review article summarises and organises the available research. A small study included in this paper describes the 'yips' phenomenon from the subjective experience of 'yips'-affected golfers. The subjective experience (n = 72) provides preliminary support for the hypothesis suggesting that the 'yips' is on a continuum. Based on the subjective definitions of 72 'yips'-affected golfers, the 'yips' was differentiated into type I (dystonia) and type II (choking). A theoretical model provides a guide for future research on golfers with either type I or type II 'yips'. 6.The yips in golf: multimodal evidence f... [Med Sci Sports Exerc. 2006] PubMed NCBI Med Sci Sports Exerc. 2006 Nov;38(11):1980-9. The yips in golf: multimodal evidence for two subtypes. Stinear CM, Coxon JP, Fleming MK, Lim VK, Prapavessis H, Byblow WD. Source Human Motor Control Laboratory, Department of Sport & Exercise Science, University of Auckland, Auckland, New Zealand. [email protected] Abstract PURPOSE: To determine whether a model of two subtypes of yips is supported by evidence from a range of physiological, behavioral, and psychological measures. METHODS: Fifteen golfers who experience yips symptoms while putting (mean age 58.1 yr, SD 13.6 yr), and nine golfers with no yips symptoms (mean age 39.6 yr, SD 19.3 yr) were recruited. Participants completed a golf history questionnaire to determine their playing experience and the nature of any yips symptoms experienced. In experiment 1, participants performed a putting task while electromyographic data were recorded from the forearm flexors and extensors and biceps brachii, bilaterally. The task was performed in two sessions, under low-pressure and high-pressure experimental conditions. The high-pressure condition was intended to increase anxiety through the use of a monetary incentive, video-taping of performance, and the presence of a confederate who provided negative feedback. Participants' state of anxiety was assessed using a questionnaire before each of the experimental sessions. In experiment 2, participants completed a task that required the inhibition of an anticipated response. Their accuracy and ability to inhibit their response was determined. RESULTS: The golfers who experienced yips could be categorized according to whether they reported mainly movement-related symptoms (Type I) or anxiety-related symptoms (Type II). The Type I group exhibited greater muscle activity during putting and greater errors and less inhibition of the anticipated response task. The Type II group exhibited greater changes in cognitive anxiety and normal performance of the anticipated response task. CONCLUSION: This study provides evidence in support of two yips subtypes. Type I is related to impaired movement initiation and execution, whereas Type II is related to performance anxiety. 7.Are the yips a task-specific dystonia or "golfer'... [Mov Disord. 2011] PubMed NCBI Mov Disord. 2011 Sep;26(11):1993-6. doi: 10.1002/mds.23824. Epub 2011 Jun 14. Are the yips a task-specific dystonia or "golfer's cramp"? Adler CH, Crews D, Kahol K, Santello M, Noble B, Hentz JG, Caviness JN. Source Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA. [email protected] Abstract This study compared golfers with and without the yips using joint movement and surface electromyographic detectors. Fifty golfers (25 with and 25 without complaints of the yips) were studied while putting. All putts were videotaped. Surface electromyography assessed arm cocontraction. A CyberGlove II (Immersion Technologies, Palo Alto, CA) assessed right-arm angular movements. Primary analysis was done by subjective complaint of the yips, whereas secondary analysis was done by video evidence of an involuntary movement. When grouped by subjective complaints, there were no differences in any movement parameter. When grouped by video evidence of an involuntary movement, yips cases had more (P < 0.001) angular movement in wrist pronation/supination and a trend (P = 0.08) for wrist flexor/extensor cocontraction (yips: 7 of 17, 41.2%; no yips: 6 of 33, 18.2%). Golfers with video evidence of an involuntary movement while putting have excessive rotation of the right wrist in a pronation/supination motion and, as previously reported, a trend for wrist flexor/extensor cocontraction. 8.Mayo Clinic study on yips presented at World Scientific Congress of Golf | Mayo Clinic News Mayo Clinic study on yips presented at World Scientific Congress of Golf Posted on March 13, 2012 by susanashephard A recent Mayo Clinic study on yips, a condition that has baffled golfers and scientists for decades, will be a featured presentation on March 16, 9:45 a.m., at the upcoming World Scientific Congress of Golf. The Congress tees off March 12-16 at the Embassy Suites and Stonecreek Golf Club, 4415 East Paradise Village Parkway, Phoenix. The yips, affecting a significant number of already anxious golfers during putting or chipping, may be a physical movement disorder and not only the result of undue pressure to perform at the crucial moment of a stroke. In fact, in some cases the affliction can be likened to writers’ or musicians’ cramps, according to Charles H. Adler, M.D., Ph.D., neurologist and researcher at Mayo Clinic. His latest research on the yips was recently published in the journal Movement Disorders. Dr. Adler and his colleagues at Mayo Clinic and Arizona State University suggest that in a subset of golfers, involuntary muscle contractions are to blame, resulting in “golfer’s cramp.” The annoying condition (sometimes described as “twitches” or “jerks”) that can ruin an otherwise successful round of golf was often thought to be psychological. Dr. Adler said that the overall effect of this study is to try to identify golfers who have a neurologic rather than a psychological cause to their yips. Held every four years, the World Scientific Congress of Golf began in 1990 at St. Andrews, Scotland. For more information on the Congress visit golfscience.org. Below is a link to a YouTube video with Dr. Adler where he describes the study findings. http://yt.cl.nr/ooln7e-DM2A 9.Are the yips a task-specific dystonia or "golfer's cramp"? Arizona State University SciVal Experts 4.2 Are the yips a task-specific dystonia or "golfer's cramp"? Charles H. Adler; Debra Crews; Kanav Kahol; Marco Santello; Brie Noble; Joseph G. Hentz; John N. Caviness (Profiled Authors: Marco Santello; Kanav Kahol) Movement Disorders 2011;26(11):1993-1996 This study compared golfers with and without the yips using joint movement and surface electromyographic detectors. Fifty golfers (25 with and 25 without complaints of the yips) were studied while putting. All putts were videotaped. Surface electromyography assessed arm cocontraction. A CyberGlove II (Immersion Technologies, Palo Alto, CA) assessed right-arm angular movements. Primary analysis was done by subjective complaint of the yips, whereas secondary analysis was done by video evidence of an involuntary movement. When grouped by subjective complaints, there were no differences in any movement parameter. When grouped by video evidence of an involuntary movement, yips cases had more (P < 0.001) angular movement in wrist pronation/supination and a trend (P = 0.08) for wrist flexor/extensor cocontraction (yips: 7 of 17, 41.2%; no yips: 6 of 33, 18.2%). Golfers with video evidence of an involuntary movement while putting have excessive rotation of the right wrist in a pronation/supination motion and, as previously reported, a trend for wrist flexor/extensor cocontraction. © 2011 Movement Disorder Society.Convergent mechanisms in etiologica... [Expert Opin Ther Targets. 2011] PubMed NCBI 10.Acupuncture for treatment of the yips?--a case ... [Acupunct Med. 2005] PubMed NCBI Acupunct Med. 2005 Dec;23(4):188-9. Acupuncture for treatment of the yips?--a case report.