MIAMI BEACH, April 15-A golfer who acquires the yips, the most dreaded of putting woes, may have a focal dystonia rather than garden-variety performance anxiety, neurologists reported here.
The yips take the greatest toll on short putts. Development of a focal dystonia -- muscle contractions that cause the hands or arms to move involuntary -- have meant the end of the road for many professional golfers, and ruined many a round for the weekend duffer as well. Handicaps shoot up, and one of life’s major pleasures loses its luster.
Action Points
- When patients who golf complain that their dominant hand makes involuntary abrupt movements when they try to putt, a focal dystonia may be the cause.
- An evaluation by a qualified physician is appropriate if a patient is suspected of having a dystonia.
- Hand and wrist dystonias are treated with a variety of approaches, therefore, a correct diagnosis is essential for further care.
- This study was published as an abstract and presented at a conference either as an oral or poster presentation. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication.
In the severe form, the yips cause abrupt, involuntary wrist movements such as stabbing, jabbing, jerking or twisting, along with flexion or tremor. Even when the symptoms are milder, the yips can turn a four-foot putt into an unpleasant adventure.
The yips are generally considered to be psychogenic, but Charles H. Adler, M.D., Ph.D, of the Mayo Clinic Scottsdale (Ariz.), who chairs the movement disorders service throughout the Mayo system, thinks the yips more likely have a neurogenic etiology. He said the symptoms raised suspicion in his mind that the yips are induced by a focal dystonia.
He and his co-investigators studied 10 golfers with the yips and 10 without. All of the 20 participants were men and right-handed. The groups were also matched for age and golf handicap. The group with the yips had posted an average pre-yips handicap of 3.5, which had declined to 6.6 after the onset of yips. The non-yips group had an average handicap of 7.8 and an average previous best handicap of 6.3.
When the investigators examined the participants, none had a detectable movement disorder. The investigation included surface electromyography (EMG) with the subjects sitting at rest, with their arms outstretched, and giving a handwriting specimen. They also underwent median nerve somatosensory evoked potentials (SEPs), which were normal.
The investigators then studied the golfers individually while they were standing at rest, holding a putter at rest, and then using their own putters. The participants performed a total of 75 putts on an artificial 12-foot putting surface; the putts consisted of a combination of three-, six-, and eight-foot putts. The participants then rated the quality of their strokes. The investigators observed all 1,500 putts, and documented the number of putts made and the distance from the hole for missed putts.
The surface EMG criteria in non-golf scenarios, as well as while the golfers were standing and holding the putter, revealed no abnormal arrangements. In the laboratory, only two golfers perceived themselves as having their yips.
However, when the investigators assessed the EMG activity at 200 milliseconds before the putter hit the ball, they found that five of the 10 golfers with the yips had simultaneous contraction, or co-contraction, of the wrist flexor and extensor muscles in the arm with the dominant EMG activity. They found no co-contraction in the golfers without the yips. Co-contracting in this time frame is consistent with task-specific focal dystonia, Dr. Adler said, noting that in subjects with co-contracting, it was present during all putting conditions.
In the yips group, co-contractors were an average of 58.0 years old and those without co-contraction were an average of 42.6 years old. Co-contractors had an average current handicap of 9.2 and an average best previous handicap of 5.4. They had been golfing for 43.8 years and had the yips for 5.5 years. Those with the yips and without co-contractions had a best current handicap averaging 4.0 and an average best premium handicap of 1.6. They had been golfing for 31.4 years and had the yips for 9.2 years.
Co-contractors made 61% of their putts compared with 67% for those with no co-contraction. The co-contractors' missed putts were missed by an average of 4.8 cm compared to an average of 3.2 cm for missed putts among those with yips who had no co-contractions. The SEPs showed that yips-affected golfers had higher amplitude N30 waves in two of the eight electroencephalogram (EEG) leads.
Dr. Adler stressed that physicians need to evaluate patients who complain of these movements, and if appropriate, refer them to neurologists who have an expertise in movement disorders, because focal dystonia often responds to oral medications such as benzodiazepines and anticonvulsants. He also stressed that treatment needs to be individualized to determine whether the benefits of treating a given patient with a given medication offsets its side effects.
"This is an important study because there isn't much known about golfers' yips," commented Christine Klein, M.D., of the University of Lubeck in Lubeck, Germany, in an interview. "A common perception of the yips is that it's psychogenic, and Dr. Adler's work shows that it may be neurogenic instead."
"Furthering our understanding of the pathogenesis of the yips is a big contribution," she added. "Focal dystonias affects many people, and if this study is replicated and dystonia is identified as the cause, physicians should take seriously patients who complain of these symptoms, so that they can be appropriately evaluated and treated."
Primary Source
American Academy of Neurology, 57th annual meeting, abstract P06.146
Source Reference: American Academy of Neurology, 57th annual meeting, abstract P06.l46: Electrophysiologic Evaluation of Yips-Affected and Unaffected Golfers: Evidence for a Task-Specific Dystonia. Adler CH, Crews D, Hentz JG, et al.