Golfers' "Yips" May Be Caused by a Focal Dystonia

Paula Moyer, MA

April 15, 2005

April 15, 2005 (Miami Beach) — Golfers who get "the yips" may have a focal dystonia rather than the performance anxiety that is often considered the driving cause of the condition, according to investigators whose findings were presented here at the 57th annual meeting of the American Academy of Neurology.

"The yips" is a golfing slang term for the abrupt, involuntary wrist movements, typically in the dominant hand. The movements are described by affected people as stabbing, jabbing, jerking, or twisting, along with flexion or tremor, when the golfer is putting. The condition typically ends the career of professional golfers and can take the joy out of the game for recreational golfers as well, said principal investigator Charles H. Adler, MD, PhD. He is a professor of neurology at Mayo Clinic of Scottsdale, Arizona, and the chair of movement disorders throughout the Mayo Clinic system.

"The possibility that this is caused by an underlying focal dystonia...has implications beyond golf," Dr. Adler said. In other occupations where controlled hand motion is essential and people experience involuntary jerks, the findings raise suspicion that focal dystonia could be the underlying cause. Therefore, patients who complain of the yips should be referred to neurologists and evaluated, he said.

Dr. Adler and colleagues studied 10 golfers with the yips and 10 without. All 20 participants were men and right-handed. The groups were also matched for age and golf handicap. The group with the yips had an average current handicap of 6.6 and an average previous best handicap of 3.5. The nonyips 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 a handwriting specimen. They also underwent median nerve somatosensory evoked potentials (SEPs), which were normal.

The investigators then studied the subjects 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' putting surface; the putts consisted of a combination of 3', 6', and 8' 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 nongolf 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 the 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 cocontraction, of the wrist flexor and extensor muscles in the arm with the dominant EMG activity. They found no cocontraction in the golfers without the yips. Cocontracting in this time frame is consistent with task-specific focal dystonia, Dr. Adler said, noting that in subjects with cocontraction, it was present during all putting conditions.

In the yips group, cocontractors were an average of 58.0 years old and those without cocontraction were an average of 42.6 years old. Cocontractors 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 had the yips for 5.5 years. Those with the yips and without cocontractions 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 had the yips for 9.2 years.

Cocontractors made 61% of their putts compared with 67% for those with no cocontraction. The cocontractors' missed putts were missed by an average of 4.8 cm compared with an average of 3.2 cm for missed putts among those with yips who had no cocontractions. The SEPs also showed that yips-affected golfers had higher amplitude N30 waves in two of the eight electroencephalogram leads.

Dr. Adler stressed that physicians need to evaluate patients who complain of these movements, and, if appropriate, refer them to neurologists who have expertise in movement disorders, because focal dystonia often responds to oral medications such as benzodiazepines and anticonvulsants. He added that treatment needs to be individualized to determine whether the benefits of treating a given patient with a given medication offsets its adverse effects.

"There isn't much known about golfers' yips, so this is an important initial study," said Christine Klein, MD, in an interview seeking outside comment. "A common perception of the yips is that it's psychogenic, and Dr. Adler's work shows that it may be neurogenic instead." Dr. Klein is the Lichtenberg professor of clinical and molecular genetics at the University of Lubeck in Germany.

"Furthering our understanding of the pathogenesis of the yips is a big contribution," Dr. Klein added. "Focal dystonias affect 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."

AAN 57th Annual Meeting: Abstract P06.146. Presented April 14, 2005.

Reviewed by Gary D. Vogin, MD

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