Dr. Charles Adler: A Professor of Neurology Explores the Yips

One of the nicest things about living at the Desert Mountain Club here in Scottsdale, Arizona, is that you run into the most amazing people. That happens on the golf courses, of course, but it also happens at one of the club’s other social hubs, the Sonoran Spa and Fitness Center. I’ve spent no time in the spa, but I’m in the fitness center six nights a week.

You mostly know people by sight. See them enough times you move on to first names…and then last names…and then maybe a little about them. I finally found out that Chuck was a neurologist at the Mayo Clinic in Scottsdale…and that he did research on Parkinson’s disease.

I just had no idea that he was one of the leading researchers known internationally for his research on Parkinson’s disease…and that his work there and his interest in golf caused him to add the study of the yips to his portfolio.

So how did you come to all of this?

Well, I’m a movement disorder specialist specializing in the diseases of abnormal movement: Parkinson’s disease, tremor, dystonia, Restless Legs syndrome, and there was a sports psychologist at Mayo Clinic – Rochester who works with Debbie Crews, who is a sports psychologist at ASU. And they were doing work on the yips. They wanted to get a movement disorder doc involved, so that’s how I became involved and that was over ten years ago. 

And the idea is that while many people with the yips probably have a psychological cause, so as people call it, “choking,” and they get nervous under pressure, there’s probably a percentage of people with the yips who have an actual neurologic cause or a dystonia.

And what is a dystonia?

A dystonia is an involuntary movement disorder in which one develops a “posturing” of a body part, in this case it would be the wrist or the fingers or the hand. And that posturing has to take place at least for a brief period of time. It can be sustained or it can be more spasmodic.

It gets stuck in a certain position?

Stuck in a certain position. It can be described, at least in the yips, as a jerking, a twitching, a freezing of movement when they go to make a putt. Mostly putting, but also chipping. Some people describe the yips for many kinds of golf swings and other movements. There are other athletes who have a form of dystonia. I’ve written a paper on dart throwers and tennis players, bowlers, there’s other forms of baseball players who potentially have a dystonia that interferes with the movement that they’re trying to perform. A task-specific dystonia.

And so in the baseball player for example, which we recognize as a very fast motion, how would that dystonia present itself?

Inability to throw the ball or the inability to throw the ball where they want to.

So there’s a motion in there that we can barely see that’s causing them to do that?

Correct. Something that we would be barely able to see or something that we would be able to see if we watched carefully. Same thing with basketball players. I would assume that any athlete, much like people who have writer’s cramp, musician’s cramp, typist’s cramp. Tasks where there are repetitive movements over and over again. Many, or some, individuals will develop an involuntary movement during that movement…they wind up having a cramp in the midst of that and it may interfere with that.

The question is how many people have psychological reasons for it where it’s just a performance anxiety…

Because most golfers think it’s psychological.

Most golfers think it’s psychological and my expectation is that most of them are psychological. I suspect that most people who miss a putt in the setting of having to make the putt in a tournament or for money or whatnot, most of it’s probably performance anxiety. We get jittery, we get nervous and we can’t perform the activity the way we want to.

I think there’s a small percentage, and what that percentage is I’m still working on, actually have a neurologic cause for that.

About what percentage would you guess?

In the first study we did, we thought it was 50%. In the second study, it was about a third of the people we thought had a neurologic cause. If you compare it to what the incidence of neurologic dystonia is, it shouldn’t be more than five or ten percent of all golfers. So it should be a fairly small percentage.

The problem with all of this type of work is there’s no test, there’s no diagnostic test for dystonia or cramping. And so we have to try to tease out or combine different methods to see if we can tease out a neurologic cause.

But the research you did where you had 50 people and you had special gloves on them [Cybergloves] that could measure hand movement and wrist flexion?

Correct. Of the 50 people, we had 25 in a group where they were controls, meaning they did not claim to have the yips, and 25 complained of the yips.

That was a subjective complaint?

Yes. And of those, a similar number of individuals in both groups had contractions of the wrist flexors and extensors at the same time. We call that co-contraction.

Which are in the forearm?

The flexors are on the inside of the forearm [just below the elbow] and the extensors are on the outside of the forearm [just below the elbow]. One of the tests we often do for task-specific dystonias is we have them do the task and we see co-contractions. Normally you would expect that if the hand was going to move forward, the wrist flexors [inside] will move and if the hand is going to move backward, the extensors [outside] are going to move. In dystonia, we see them usually co-contract which causes the posture to be capped or locked in.

So in the control group and the yips group we saw a similar percentage have co-contractions when you define the yips subjectively. As we thought about it more and as we looked at the research more, what we then did was we looked at the video tapes of all the people as they putted. [The videos are anonymous recordings of a series of putts where you can only see the player’s putting motion from just above the elbows to just a foot or so below the bottom of the putting grip.]

What we found was that 17 of the people in this group of 50 had what appeared to be an involuntary movement during putting. And so we did the new analysis of those 17 with the 33 who did not have an involuntary movement while putting. And in that setting, we found more co-contraction with the people with the yips than the people without the yips.

And say again what co-contraction is?

Co-contaction is when the wrist extensors and flexors contract at the same time…

So the hand doesn’t go one way of the other…

Exactly. 

Why that’s important is that if somebody comes into the neurologist’s office and says, “I have a tremor,” and I don’t see a tremor, I’m not going to diagnose them as having a tremor. If somebody comes into the office and says, “I have writer’s cramp,” and I don’t see writer’s cramp, I’m not going to diagnose it.

So much like the yips study, we separate the first group 25 and 25 based on the complaint and in reality, a complaint is not enough to make a diagnosis. So that’s why we then moved into what we saw on video. And when we did that, we did determine that when we used the Cyberglove…

Of the 25 and 25, was that subsequent 17, did that come out of both groups?

15 of the 25 came out of the yips group. 2 of the other 25 had involuntary complaints. We combined them, we separated those who did have the movement versus those who didn’t.

Were the 2 surprised? Or did they know why they had been separated?

No. No. We separated them after the fact looking at the research.

So they had no idea.

No. They have no clue. And that’s one of the interesting things about all this is if we were to examine somebody while they were putting or writing or whatnot and they have an involuntary movement, you would need to decide whether to tell them, yes, you do or you don’t have an involuntary movement.

I’ve seen plenty of golfers who don’t say they have the yips who have an obvious involuntary movement when they’re golfing.

Remind me not to play golf with you. [Laughing]

Exactly.

Thankfully, I don’t have the yips. [Laughing]

Well, they don’t think they have the yips either. The good thing is I won’t say anything. It’s not my role to intervene on the golf course…

You’re not on the clock, right?

I’m not on the clock. And I certainly don’t want to bring attention to something somebody doesn’t want attention brought to.

The interesting thing when you looked at the 17 with the involuntary movement on video versus the 33 without, when you looked at the Cyberglove data, the Cyberglove measures joint movements, so it measures movement of the wrist in three planes: flexion/extension [up and down], lateral movement [sideways with the wrist flat] and rotation.

What we found was that there was much more rotation in the 17 golfers with the golfer’s cramp than there was in the 33 without.

You don’t think it was just people trying to force the release of the putter?

Well, the cause is unclear. So I can’t tell you what caused it. What I can tell you is that the signature, so to speak, of the yip golfers was a rotation. Whether that was due to an anxiety, whether it was due to a neurologic disease, whether it was trying to right the club from the wrong path, or whether it was even voluntary, that’s the way they putt.

But all of them on video had evidence of what we would say was a movement disorder. There was a twitch, a jerk, an involuntary movement. So rotation seems to be a common or certainly a differentiating point between the two groups.

Did it matter whether you were looking at the video in full speed or slow motion? Was it as evident in regular speed as it was in slow motion?

Videos were all looked at in normal speed. We didn’t look at anything in slow motion. And the videos were all “blinded,” meaning that you couldn’t see the person, you didn’t have the name of the person. It was a blinded review of the videos. The goal was to identify — of the putts that the individual did in that study, I think it was 70 putts — how many of them was there evidence of a twitch or involuntary movement.

But you only counted the 6-foot putts? Did I read that correctly?

For looking at the co-contraction and looking at the rotation, we only looked at the straight, 6-foot putts. But we looked at the rotation and all the other measures of the Cyberglove with all the different putting variables and it was all the same. Co-contraction, we just looked at the 6-foot putts.

The conditions were: 6-foot straight, 12-foot straight, 12-foot straight with an experimental putter that had a 3-inch offset so that the ball was actually hit 3 inches before the players would have expected to hit it, right-to-left 6-foot putt, left-to-right 6-foot putt. We did it on the practice putting green at the ASU golf course.

So the offset on the putter was in front of the shaft.

In front of the shaft with the idea that if you had a yip, you would have hit the ball by the time your hand would rotate or twitch. We didn’t find any difference between those two conditions, so that did not show any benefit.

So what’s the next step in terms of your next research project on this?

The goal now is twofold. Number one is instead of looking at controls or people without the yips and people with the yips we’re going to concentrate mainly on people with the yips, and the yips now being defined for sure as somebody who we see with the involuntary movement.

So how would you create that sample? Advertising?

Advertising at the Southwest Section of the PGA, a newsletter, we’ve spoken with multiple golf pros around the Valley [of the Sun, i.e. greater Phoenix]. People would probably need to live here. It would be rare that they would fly in.

What sample size would you be looking for?

The sample size is going to be 25 people with the yips. We’re also looking at 20 golf pros with the idea that that becomes the comparison sample of individuals and we’ll watch them for the yips. It’s not that they won’t have it, but they’ll be very, very low handicap individuals who hopefully will show us what normal putting motions should be, if there is such a thing as normal putting. This will help calibrate the system in terms of what we’ll be able to measure.

So 25 people with exam evidence of a twitch at the time of putting. We exclude people who have twitches or tremors when they’re doing other things because it would be expected that they would twitch when they putt.

And then we’re going to have them hooked up to the muscle monitor to try to determine if they have co-contraction. Instead of using the Cyberglove, we now have accelerometers which are going to sit on the wrists and the forearms. 

How big are those?

The accelerometers are about the size of a half dollar. They’re squares, they get taped on and the idea is the accelerometer will be able to measure the movement of the wrists in three planes.

Are they hooked up, or is it some kind of wireless?

The wires to the surface EMG, pasted electrodes that go over the wrist flexors, extensors and then the muscles that pronate and supinnate the wrists; so rotate the wrists. It’ll be four pairs of electrodes on both forearms and those are wired to a computer. The accelerometers which measure wrist flexion, wrist extension, rotation and lateral movement of the wrists, those will be wireless. So that’s pretty easy to look at.

And then the last measure we’re using is the Science&Motion putting lab at the Jim Flick Golf Performance Center here at Desert Mountain. So this will be the first time that we’ll have outcome data. What the SAM PuttLab does is measure 28 different parameters to determine the movement of the putter as it goes from address all the way through the stroke.

All of that is going to be time-stamped: the EMG, the accelerometry and the SAM PuttLab. Every case will be videotaped and we will be able to look back on a millisecond by millisecond basis at all of those parameters and know when the actual movement occurred. And be able to look at what the muscles did, what the wrists did and what the putter did. So that will be the first time that’s ever been done.

Dale Abraham, our Director of Instruction here at Desert Mountain, is actually one of the investigators in the study. The other investigators are John Caviness from Mayo Clinic is a neurologist, Debbie Crews is a PhD Sports Psychologist at ASU, and Troy McDaniel is a PhD specialist in terms of movement and analysis at ASU. The last person is Christian Marquardt, he’s a  PhD in Germany who works with the SAM PuttLab and has collected a lot of data on people with and without the yips with the putting aspect, but he’s never looked at the muscle movement of the accelerometry.

So that’s Part I. Twenty-five golfers are going to do 9-foot putts in the PuttLab. They’re going to do eyes looking down at the ball, eyes looking at the hole, right hand only…

Left hand only?

No, Dr. Marquardt had found that people with the yips have more of the yips when they use one hand alone. Right hand-only brings out the yips. Left hand-only usually does not have as much in the way of the yips. By bringing out the yips with right hand-only, we hope to see more of the twitch or involuntary movement.

Because a lot of really good putters putt left-hand dominant.

Correct.

I’m one of them. [Laughs] Steve Stricker putts left handed…

So you’re talking about left hand low instead of right hand low?

No, I’m talking about a conventional grip and the left hand is the dominant…

Correct.

So you think those people have less…

I don’t know. I don’t want say the answer to that.

That’s because you’re a scientist right?

Correct.

And then the second aspect for those people with the golfer’s cramp is that we’re going to treat them with a medication called, Propranolol. It’s a beta blocker.

Say a little bit about what a beta blocker is.

A beta blocker is a medication that slows heart rate, it reduces tremor, it can reduce some other involuntary movements.

Are there some other brand names that people would recognize?

Inderal would be a trade name that most people would know. The generic name is Propranolol. Use a low dose and see if we can improve performance. We’ll test them once before taking the medication and test them a second time forty-five minutes to an hour later.

I know a retired MD who used to prescribe beta blocks to players.

So I prescribe beta blockers for many patients with tremor and involuntary movements. The thing is it’s also prescribed for performance anxiety, so it’s not a diagnostic test, meaning if you get better with a beta blocker, it doesn’t mean you have a movement disorder, you could just have performance anxiety.

One of the key issues is that beta blockers are banned by the PGA Tour. Any players that are using them have to have a TUE [Therapeutic Use Exemption], an exemption. It is possible that they would have a medical condition that would require them to take a beta blocker. But beta blockers are banned in the Olympics, banned in a lot of different sporting activities.

The reason we’re using the beta blockers is it’s one of the few drugs you can take on an as-needed basis to try to help with a movement disorder. Many of the drugs have to be taken on a daily basis and the dose has to be built up high enough.

So an hour before you play, you dose up and that’s the end of it until you play again?

Potentially. It depends on what the problem is whether a beta blocker will help. It’s important to realize that 10 milligrams is the lowest dose. So it’s possible that various individuals may need 40 or 60 milligrams. So we had to start somewhere, so that’s why we’re starting with 10 milligrams.

Would it take a whole new study if went to 20?

It would take a whole new study if you changed dosing, it would take a whole new study if we chose to use different medications, different treatments. Everything would require a new study.

Is it appropriate, or do you want to say how much these studies cost?

Uhhh…

Tens of thousands of dollars?

Tens of thousands of dollars. This study is being funded by Mayo Clinic. 

So anything else you’re looking at other than beta blockers? So for my readers, what hope is there out there?

Beta blockers is just the medication aspect of it. Looking at the hole, some people say that when you look at the hole it improves people who have the yips. So this will give us a chance where people are going to be looking at the ball, and people are going to be looking at the hole. We’ll have a chance to compare those two methods of golf to see if that changes. We’re going to have the one hand, we’ll be able to see if that changes things.

I think the hope for the readers is that if we can identify neurologic cause that’s probably going to be a different set of treatments than somebody who has performance anxiety. So you can’t will away, you can’t teach away, you can’t practice away a neurologic disorder.

So where does that emanate from the brain?

We think it emanates from the brain. So all the people with other forms of dystonia, writer’s cramp, musician’s cramp, the thought is that it emanates from the brain. But also there may be a component of a sensory feedback loop. So there is some sort of abnormal sensation being detected by the body, by the brain, by the spinal cord…

When you grasp a violin?

When you grasp a violin, when you grasp a pen, a pencil or typing and that results in a different motor program that leads to the twisting, turning, or posturing. So that work is being done around the world trying to determine if there’s a sensory feedback loop that is causing all of this.

Geez. That would have to be a pretty elaborate study, I would think?

It’s very elaborate. A lot of it uses the surface EMG that we talked about, pasting electrodes on the arm. Some of it is using magnetic treatment; using magnetic stimulation to see if you can reset the circuits. A lot of work on magnetic stimulation is being done. There’s some work being done using functional MRI, means that the MRI is being done while somebody is doing a task. So that could be imagining putting and seeing if the brain lights up in a certain region compared to somebody who does or doesn’t have the yips. Those are tremendously expensive.

[Laughing] I know what my MRI’s cost!

Yeah, anytime you put imaging in, the costs of the studies go way up.

So the answer is that we don’t know yet in terms of what might be a treatment for someone who has psychological yips.

Right. Well, I think psychological yips, people approach it mainly through training, through various, different sports psychology methods. I think that’s a good way to go if somebody has psychological or performance anxiety issues. The problem is not everybody has that. I’ll go back to the fact that many people with dystonia, years ago were thought to have psychological problems. And that if you had head tilting or turning to the left, which we now call cervical dystonia, they were thought to have a psychological disorder.

They wouldn’t look people in the eye…

Right. They wouldn’t look people in the eye, their head was always turned, or they had a yes-yes or a no-no head tremor as part of it. Now we know those people have a neurologic disorder. The problem with all of the dystonias is there’s no diagnostic. So it’s still looking at pattern recognition. For me, it’s trying to find a pattern that would say this is more neurologic rather than psychological and then trying to approach that in a different treatment form, either some sort of oral medications, potentially the use of botulinum toxin to inject in the muscles that involuntarily contract…

Botox?

Botox is one brand of botulinum toxin. So much like the word Xerox, there are multiple kinds of copy machines. There are multiple kinds of toxins and all of the toxins work by whatever muscle group you inject them in, they weaken that muscle group.

For how long?

For up to three to four months. So the benefit is that the involuntary movement doesn’t occur.

Now is that banned by the PGA Tour?

No. As of now, it’s not. Valium and various different drugs like Valium, are not banned by the PGA Tour. Those are legal treatments.

And are they effective for psychological yips?

They would be somewhat effective potentially, but potentially addictive as well. So I think you have to be really careful when using drugs like Valium. They are all potentially addictive drugs. The reason we didn’t study them in our studies is that they have the potential to make people tired and have trouble with concentration. You don’t want our subjects coming to the Performance Center taking a medication that makes them tired and sleepy and then driving home. So we chose to use the beta blockers instead.

So are those as-needed drugs as well?

Yeah. You can take them as needed. And there are players using those kind of drugs.

But it’s really not a good idea, given that the thing that golfers really need is a high level of consciousness.

I think there’s potential for side effects that effect their ability to concentrate and make them very tired. Again, I’m very worried about these addictive qualities of these medications.

People shouldn’t fool around with those.

Well, I think under doctor’s care, it may or may not be appropriate. I have people I know who use that. Players I know who drink alcohol to try to reduce the involuntary movements. But again, you have an addicting medication, so to speak, with potential harmful effects. 

Does alcohol work?

Some people describe alcohol as beneficial, yes. We know that alcohol helps people with tremor disorders, the problem is that if you have a younger person who uses alcohol to treat a tremor disorder, very often over the years, the tremor disorder actually gets worse. Alcohol has pretty bad effects on the brain. It can cause a lot of nerve degeneration over time, so you have to be really careful.

So where we are is kind of in limbo until the rest of these things sort themselves out. I think most people are interested in the psychological yips rather than the stuff that’s neurological.

I think most people still consider yips psychological and again, I think the important fact is that if it’s psychological we go down one route to try to treat it. The key is to identify people who have neurological cause because that route, the psychological route, is not going to help them. And now I need to find a different way to benefit those subjects. To me that’s the whole key is to identity what the cause of the problem is, so you can appropriately consider what the best treatment options are. And the treatment options are different for a neurologic cause than for a psychological cause.

And most people have subjectively, a psychological cause.

I would say that my expectation remains that most people with the yips, it’s psychological and not neurologic.

70/30?

If you were to go based on the presence of dystonia and tremor in our general population, it’s not nearly as common — you wouldn’t expect a third of the people with the yips would have a neurologic disease. So I have to believe that it’s a smaller percentage than that. And trying to tease that out is the key to my research.

Anything else about the psychological side of it?

No, I think — again, from the psychological standpoint, I think there are plenty of things that can be done. One of the key issues has been, if somebody switches their grip, or somebody has a trick that they can use, that doesn’t mean that it’s psychological.

People who have writer’s cramp and change the way they grip the pen, or people with other forms of dystonia can manipulate things and actually have sensory tricks to improve their function, and so, the treatment doesn’t necessarily give us the cause. So I think that’s really critical with that.

Debbie Crews is down at ASU and a sports psychologist. What’s her experience been in treating the yips from the psychological side?

She does a lot of work with people with the yips in trying to change grips and trying to have them think. She uses a lot in terms of mental preparation. And so she is one of the best. She really does a great job with her subjects. She talks to all the people who come through the program in terms of what they may or may not be able to do to try to help themselves.

Has she written about that?

She has written a number of papers about it. She has — I don’t know how much she has in the lay literature — she’s written a lot about it. She’s worked on brain waves as well, trying to look at — she’s been interested in left to right brain dominance and how that might play a role. In the first study we did with the 10 subjects, we looked at that, as well. But it’s impractical; it requires way too many wires and too much of a setup. We’ve gone the route of taking away the brain wave aspect of the study.

Well, okay.

I think that’s all I can think of. I think you hit on — you did a good job.

Well, thank you very much. You did too!