Yips

A  motor  phenomenon  affecting  golfers,  the  yips consist of involuntary movements during the performance  of  shots  requiring  fine  motor  control, such  as  chipping  and  putting.  Although  the  yips are mainly reported by golfers, the psychological characteristics  of  a  small  group  of  cricket  bowlers who experience yips-like symptoms have also been reported, suggesting the condition is generalizable beyond golf. Generally, the yips are characterized  by  excessive,  involuntary  muscle  activity, resulting  in  unwanted  movement,  or  an  inability  to  initiate  movement.  In  the  past  decade,  the definition of the yips has expanded to encompass an  etiological  continuum,  anchored  by  two  subtypes, with a neurological basis (focal dystonia) at one  end  and  a  psychological  basis  (performance anxiety) at the other. Subtypes can be defined by identifying themes in golfers’ descriptions of their experiences.  Those  with  descriptions  of  dystonia can be classified as Type I yips, while those whose descriptions   include   performance   anxiety   or choking theme can be classified as having Type II yips.  Type  I  yips  have  many  characteristics  in common with other forms of focal dystonia. The aim  of  this  entry  is  to  encourage  the  use  of  the term yips only for those with a task-specific focal dystonia. The intention is that a more consistent terminology will clarify appropriate management strategies of those with a true dystonia (the yips) versus those who suffer symptoms of performance anxiety.

The  symptoms  of  upper-limb  focal  dystonias are  dominated  by  involuntary  contractions  of the  hand  and  forearm  musculature  that  result  in awkward, uncoordinated movements of the wrist, fingers,  or  both.  These  symptoms  are  due  to  the inappropriate  cocontraction  of  antagonists  and agonists,  which  is  often  associated  with  excessive  levels  of  muscle  activity.  Symptoms  are  triggered  by  the  repetitive  performance  of  a  skilled motor  task  over  months  or  years,  such  as  writing,  playing  a  musical  instrument,  or  putting  a golf  ball.  Multiple  lines  of  investigation  support the hypothesis that focal dystonias are associated with impaired inhibitory function at multiple levels of the central nervous system, which may stem from  basal  ganglia  dysfunction.  Cathy  Stinear  et al. showed that low-handicap golfers with experiences of Type I versus Type II yips could be dissociated by their electromyography activity in muscles of the putting arm under low-stress conditions, as well as by their performance on a computer-based response inhibition task. In both cases, Type I yips golfers showed excessive electromyographic activity compared to Type II, and to matched controls. Similarly,  through  the  use  of  an  instrumented kinematic glove, Charles Adler et al. observed that yips-affected  golfers  had  excessive  involuntary pronation–supination of the forearm.

Like other forms of focal dystonia, golfers with the  yips  may  opt  to  retrain  themselves  to  perform  the  task  differently,  given  that  no  effective rehabilitation  strategy  has  yet  been  developed. The  symptoms  of  focal  hand  dystonia  and  Type I yips can sometimes be temporarily alleviated by the use of sensory tricks, such as wearing a glove on the affected hand, using a different grip, or by changing to a different (usually longer) putter. The management  of  yips  could  draw  from  the  treatments  used  for  occupational  dystonias,  such  as writer’s  cramp  and  musician’s  cramp.  A  range  of therapeutic  strategies  have  been  trialled  for  these types of dystonia, including immobilization of the affected hand or upper limb, often combined with ergonomic  changes,  motor  training,  and  sensory training.  Unfortunately,  these  types  of  interventions  have  produced  mixed  results  for  writer’s cramp  and  musician’s  cramp  and  would  require a  considerable  time  commitment  from  the  golfer, under the guidance of a trained physical therapist.

If the overactive forearm muscles can be clearly identified in an individual, injection of botulinum toxin can markedly reduce the level of involuntary activity. However, this treatment carries the risk of the  toxin  spreading  to  adjacent  musculature  not intended  for  treatment,  and  the  effects  of  treatment  are  temporary,  lasting  approximately  3  to 4   months.   Interestingly,   an   isolated   case   of improvement  in  yips  symptoms  during  golf  was reported  by  a  patient  undergoing  memantine administration  for  treatment  of  Alzheimer’s  disease, but a systematic trial has yet to be conducted.

Many  studies  of  the  yips  have  used  questionnaires  to  explore  the  symptoms,  clinical  history, and  sport  experience  of  the  participants.  For  the sport psychologist, it is interesting to note that golfers  who  experience  performance  anxiety  exhibit yips-like  symptoms  when  they  experience  choking, where severe performance anxiety impairs the preparation  and  execution  of  movement,  degrading  performance.  A  model  proposed  by  Aynsley Smith  et  al.  was  developed  on  the  basis  of  questionnaires  completed  by  70  golfers  who  experience yips symptoms. One of the limitations of this study is a potential response bias, as only 39% of invited  participants  (both  with  and  without  yips symptoms)  completed  and  returned  the  questionnaires. A further limitation is that the respondents’ descriptions of their symptoms are subjective, and therefore may not accurately describe the range of physical manifestations of the yips. Still, this model is  effective  for  differentiating  patients  with  focal dystonia  from  those  with  performance  anxiety, thus  reflecting  an  important  advance.  Generally, the  combination  of  distraction  by  the  specific competitive context and an increase in arousal and self-awareness, increases performance anxiety and decreases  confidence,  which  in  turn  increases  the likelihood  of  suboptimal  performance.  The  most anxiety-provoking  situations  for  affected  golfers include (1) leading the competition, (2) tricky putts (those putts with more than one change in inclination), (3) playing against specific competitors, and (4)  the  need  to  make  easy  putts.  Most  researchers  and  clinicians  are  in  agreement  that  yips-like symptoms are exacerbated by heightened anxiety. However, it should be reinforced there is considerable debate concerning whether excessive anxiety is sufficient to trigger actual yips symptoms.

References:

  1. Adler, C. H., Crews, D., Kahol, K., Santello, M., Noble, B., Hentz, J. G., et al. (2011). Are the yips a task-specific dystonia or “golfer’s cramp”? Movement Disorders, 26, 1993–1996.
  2. McDaniel, K. D., Cummings, J. L., & Shain, S. (1989). The “yips”: A focal dystonia of golfers. Neurology, 39, 192–195.
  3. Smith, A. M., Adler, C. H., Crews, D., Wharen, R. E., Laskowski, E. R., Barnes, K., et al. (2003). The “yips” in golf: A continuum between a focal dystonia and choking. Sports Medicine, 33, 13–31.
  4. Stinear, C. M., Coxon, J. P., Fleming, M. K., Lim, V. K., Prapavessis, H., & Byblow, W. D. (2006). The yips in golf: Multimodal evidence for two subtypes. Medicine & Science in Sports & Exercise, 38, 1980–1989.

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