The 'yips' in golf: a continuum between a focal dystonia and choking

Treatment of task-specific dystonia in sports: A systematic review

Introduction

Task specific dystonia is a movement disorder only affecting a highly practiced skill and is found in a broad set of expert movements including in sports. Despite affecting many sports, there is no comprehensive review of treatment options, which is in contrast to better studied forms of task specific dystonia in musicians and writers. For this reason, studies involving an intervention to treat task specific dystonia in sports were systematically reviewed, with special attention for the quality of outcome measures.

Methods

The PICO systematic search strategy was employed on task-specific dystonia, and all synonyms. Inclusion criteria were peer reviewed published studies pertaining to sports, studies with a measurement and/or intervention in TSD, all in English. We excluded abstracts, expert opinions, narrative review articles, unpublished studies, dissertations and studies exclusively relating to choking. We included case reports, case studies and case-control studies.

Results

In April 2022 Pubmed, Embase, Web of Science, and Psychinfo were searched. Of the 7000 articles identified, 31 were included that described psychological and invasive and/or pharmacological interventions. There was a lack of formal standardized outcome measures in studies resulting in low quality evidence for the effectiveness of treatment options. A descriptive synthesis showed emotional regulation was effective, but was exclusively tried in golfers. Interventions like botulinum toxin or pharmacology had a similar effectiveness compared to studies in musicians dystonia, however there was almost no formal evidence for these treatments.

Conclusion

The quality of studies was low with a lack of standardized outcome measures. Future studies with larger cohorts and quantitative outcome measures are needed to improve understanding of treatments for task specific dystonia in athletes.

A theory of the skill-performance relationship

The skill-performance relationship is a cornerstone of a meritocratic society. People are selected for schools, colleges and jobs based on the premise that more skillful individuals perform better. Scientific understanding of the skill-performance relationship demands that the effect of skill on performance is objectively assessed without subjective, social, and political considerations. One of the best areas for this analysis is sports. In many sports settings, the skill-performance relationship can objectively be examined at the technical, behavioral, psychological, and neurological levels. This examination reveals that skill and performance are inextricably intertwined. While skill affects performance, performance in turn defines and affects skill. To disentangle the previously confusing and interchangeable use of these key constructs, the paper presents a theoretical model specifying that ability and effort have their own direct effects on performance, as well as indirect effects on performance through skill possession and skill execution in cognitive and physical domains of human performance. Thus, ability and skill are not the same. Although skill is a key determinant of performance, recent theory and research suggests that successful performers are successful not just because of their skills per se, but because they take advantage of their skills by creating more occurrences of momentum, making them last longer, and using them to bounce back faster from streaks of unsuccessful performance. Thus, momentum is an important mediator of the effects of skill on performance.

Spatiotemporal patterns of throwing muscle synergies in yips-affected baseball players

"Yips" are involuntary movements that interfere with the automatic execution of sports movements. However, how the coordination among the various muscles necessary for sports movements is impaired in athletes with yips remains to be fully understood. This study aimed to assess whether muscle synergy analysis through non-negative matrix factorization (NMF) could identify impaired spatiotemporal muscle coordination in baseball players with throwing yips. Twenty-two college baseball players, including 12 with and 10 without yips symptoms participated in the study. Electromyographic activity was recorded from 13 ipsilateral upper extremity muscles during full-effort throwing. Muscle synergies were extracted through NMF. Cluster analysis was conducted to identify any common spatiotemporal patterns of muscle synergies in players with yips. Whether individual players with yips showed deviations in spatiotemporal patterns of muscle synergies compared with control players was also investigated. Four muscle synergies were extracted for each player, but none were specific to the yips group. However, a more detailed analysis of individual players revealed that two of the three players who presented dystonic symptoms during the experiment exhibited specific patterns that differed from those in control players. By contrast, each player whose symptoms were not reproduced during the experiment presented spatiotemporal patterns of muscle synergies similar to those of the control group. The results of this study indicate no common spatiotemporal pattern of muscle synergies specific to the yips group. Furthermore, these results suggest that the spatiotemporal pattern of muscle synergies in baseball throwing motion is not impaired in situations where symptoms are not reproduced even if the players have yips symptoms. However, muscle synergy analysis can identify the characteristics of muscle coordination of players who exhibit dystonic movements. These findings can be useful in developing personalized therapeutic strategies based on individual characteristics of yips symptoms.

It's in the game: A review of neurological lesions associated with sports

INTRODUCTION

The practice of sports may lead to neurological injuries. While relatively uncommon (overall incidence of approximately 2.5%), and mostly benign and transient, some conditions may be life-threatening and permanent. Thus, both clinical neurologists and sports physicians should be aware of their existence and relevance. We aimed to review all sports-related neurological injuries and illnesses reported in the literature.

METHODS

Following SANRA guidelines, we performed a narrative review and searched PubMed and Scopus databases. Relevant sports were selected based on their recognition as an Olympic sport by the International Olympic Committee. Chronic traumatic encephalopathy (CTE) and other neurodegenerative disorders were not included.

RESULTS

A total of 292 studies were included concerning 33 different sports. The most reported neurological injury was damage to the peripheral nervous system. Traumatic injuries have also been extensively reported, including cerebral haemorrhage and arterial dissections. Non-traumatic life-threatening events are infrequent but may also occur, e.g. posterior reversible encephalopathy syndrome, cerebral venous thrombosis, and arterial dissections. Some conditions were predominantly reported in specific sports, e.g. yips in baseball and golf, raising the possibility of a common pathophysiology. Spinal cord infarction due to fibrocartilaginous embolism was reported in several sports associated with minor trauma.

CONCLUSION

Sports-related neurological injuries are increasingly receiving more social and medical attention and are an important cause of morbidity and mortality. This review may serve as a guide to physicians managing these challenging situations.

Sports-Related Dystonia

Background

Task-specific dystonia (TSD) is a form of focal dystonia that occurs in the context of the performance of selective, highly skilled, often repetitive, motor activity. TSD may be apparent during certain tasks such as writing, playing musical instruments, or other activities requiring fine motor control, but may also occur during certain sports, and maybe detrimental to professional athletes' careers. Therefore, sports physicians and movement disorder neurologists need to be aware of the presentation and phenomenology of sports-related dystonia (SRD), the topic of this review.

Methods

A broad PubMed search using a wide range of keywords and combinations was done in October 2021 to identify suitable articles for this review.

Results

Most of the publications are on yips in golfers and on runners' dystonia. Other sports in which SRD has been reported are ice skating, tennis, table tennis, pistol shooting, petanque, baseball, and billiards.

Discussion

Yips, which may affect up to half of the golfers and rarely athletes in other sports (e.g., baseball, cricket, basketball, speed skating, gymnastics) seems to be a multi-factorial form of TSD that is particularly troublesome in highly skilled professional golfers. Runners' dystonia, affecting the foot, leg, and hip (in decreasing order), may evolve into more generalized and less specific dystonia. The pathophysiologic mechanisms of SRD are not well understood. Botulinum toxin has been reported to alleviate dystonia in golfers', runners', and other forms of SRD. Future studies should utilize neurophysiologic, imaging, and other techniques to elucidate mechanisms of this underrecognized group of movement disorders.

Perception of yips among professional Japanese golfers: perspectives from a network modelled approach

'Yips' in golf is a complex spectrum of anxiety and movement-disorder that affects competitive sporting performance. With unclear etiology and high prevalence documented in western literature, the perception and management of this psycho-neuromuscular problem among Japanese elite golfers is unknown. The objective of this study was to explore factors associated with yips, investigate the performance deficits and the strategies implemented to prevent yips. We surveyed approx. 1300 professional golfers on their golfing habits, anxiety and musculoskeletal problems, kinematic deficits, changes in training and their outcomes. Statistical procedures included multiple logistic regression and network analysis. 35% of the respondents had experienced yips in their career, their odds increasing proportionally to their golfing experience. Regardless of musculoskeletal symptoms, about 57% of all yips-golfers attributed their symptoms to psychological causes. Network analysis highlighted characteristic movement patterns, i.e. slowing, forceful or freezing of movement for putting, approach and teeing shots respectively. Golfers' self-administered strategies to relieve yips were mostly inconsequential. Within the limits of our self-reported survey, most golfers perceived yips as a psychological phenomenon despite evidence pointing to a movement-disorder. While self-administered interventions were satisfactory at best, it may be imperative to sensitize golfers from a movement-disorder standpoint for early management of the problem.

Difference in Personality Traits and Symptom Intensity According to the Trigger-Based Classification of Throwing Yips in Baseball Players

The triggers of initial onset of yips symptoms can be broadly divided into psychological and non-psychological factors; however, a trigger-based classification of yips has not been established. This study aims to obtain insight into the prevention of yips by clarifying whether there are differences in symptoms and personality traits according to a trigger-based classification of yips in baseball players. A total of 107 college baseball players responded to a questionnaire assessing the presence or absence of yips and its symptoms. They were classified into the psychologically triggered yips group, the non-psychologically triggered yips group, and the non-yips group based on the presence or absence of yips and the triggers of its initial onset. Additionally, we compared whether personality traits examined by the NEO Five-Factor Inventory differed across these three groups. The psychologically triggered yips group had significantly higher agreeableness scores compared with the non-yips group, whereas the non-psychologically triggered yips group had significantly higher neuroticism scores compared with the psychologically triggered yips group. In the non-psychologically triggered yips group, there was a significantly higher frequency of throwing errors than in the psychologically triggered yips group, with a tendency to develop yips symptoms gradually. Since the trigger-based classification of yips is closely related to the strength of the yips symptoms and the players' personality traits, the results of this study contribute to a better understanding of the symptoms of yips and establishment of the prevention of yips. Large prospective studies are necessary to determine the causal relationship between a trigger-based classification of yips and the personality traits and symptoms of athletes with yips.

Modulation of sensorimotor cortical oscillations in athletes with yips

The yips, an involuntary movement impediment that affects performance in skilled athletes, is commonly described as a form of task-specific focal dystonia or as a disorder lying on a continuum with focal dystonia at one end (neurological) and chocking under pressure at the other (psychological). However, its etiology has been remained to be elucidated. In order to understand sensorimotor cortical activity associated with this movement disorder, we examined electroencephalographic oscillations over the bilateral sensorimotor areas during a precision force task in athletes with yips, and compared them with age-, sex-, and years of experience-matched controls. Alpha-band event-related desynchronization (ERD), that occurs during movement execution, was greater in athlete with yips as compared to controls when increasing force output to match a target but not when adjusting the force at around the target. Event-related synchronization that occurs after movement termination was also greater in athletes with yips. There was no significant difference in task performance between groups. The enhanced ERD is suggested to be attributed to dysfunction of inhibitory system or increased allocation of attention to the body part used during the task. Our findings indicate that sensorimotor cortical oscillatory response is increased during movement initiation in athletes with yips.

Seeing Is Believing: Blind Putting Drills Confer No Advantage to the Novice Golfer

Purpose: Golf coaches may recommend "blind" putting drills in which golfers close their eyes to improve their feel. Research on specificity of learning suggests, however, that adding or removing a source of sensory information after practicing under differing circumstances can cause performance decrements. Specificity of learning is also dependent upon specific task requirements. The purpose of this study was to examine whether golf putting, requiring body positioning and aiming an implement, would benefit from blind training. Method: Novice golfers (n = 24) in Vision Training (VT) & No-Vision Training (NVT) groups completed 108 trials of a 10-ft putt. After a 24-hr delay, both groups completed sighted- and blind-putting tests. Results: Acquisition results revealed Group × Block interactions in RE (p = .025) and y-VE (p = .032). Post hoc procedures revealed significant differences between the groups on Block 2 (p = .017), with the NVT group producing longer mean RE. During testing, RE and x-VE results revealed Group × Test interactions (p = .027 & .041), such that performance of the VT group suffered when transferred to blind putting, while performance of the NVT group did not differ when transferred. Conclusion: NVT did not confer any advantage for subsequent performance with vision. Moreover, results were not consistent with the specificity of learning hypothesis and suggest that putting does not rely on complete sensory integration to support subsequent performance. Presumably, task requirements related to body positioning provided adequate sensory cues for successful performance.

Personality Predictors of Yips and Choking Susceptibility

The ability to perform under heightened levels of pressures is one of the largest discriminators of those who achieve success in competition and those who do not. There are several phenomena associated with breakdowns in an athlete's performance in a high-pressure environment, collectively known as paradoxical performances. The two most prevalent and researched forms of paradoxical performance are the yips and choking. The aim of the current study is to investigate a range of psychological traits (fear of negative evaluation, individual differences, anxiety sensitivity, self-consciousness, perfectionistic self-presentation, and perfectionism) and their ability to predict susceptibility to choking and the yips in an experienced athlete sample. 155 athletes (Golfers n = 86; Archers n = 69) completed six trait measures and a self-report measure of yips or choking experience. The prevalence rate for choking and yips in both archers and golfers was 67.7 and 39.4%, respectively. A 2 × 2 × 2 MANOVA and discriminant function analysis revealed that a combination of 11 variables correctly classified 71% of choking and non-choking participants. Furthermore, analysis confirmed that a combination of four variables correctly classified 69% of the yips and non-yips affected participants. In this first study to examine both paradoxical performances simultaneously, these findings revealed that for the yips, all predictors stemmed from social sources (i.e., perfectionistic self-presentation), whereas choking was associated with anxiety and perfectionism, as well as social traits. This important distinction identified here should now be tested to understand the role of these traits as development or consequential factors of choking and the yips.

Acupuncture for Treatment of the Yips? - a Case Report

A 65 year old golfer with the yips was treated with acupuncture at GV20, EX-HN-1 ( Si Shen Cong) and TE5. The symptoms disappeared after one treatment and no relapse has occurred in the 24 months’ follow up. Although it cannot be determined whether the effect in this case occurred from neurological stimulation or was the result of expectation, acupuncture may be worth trying in patients with the yips since this condition is otherwise difficult to treat.

Neurologic Injuries in Noncontact Sports

Noncontact sports are associated with a variety of neurologic injuries. Concussion, vascular injury (arterial dissection), and spinal cord trauma may be less common in noncontact sports, but require special attention from the sports neurologist. Complex regional pain disorders, muscle injury from repetitive use, dystonia, heat exposure, and vascular disorders (patent foramen ovale), occur with similar frequency in noncontact and contact sports. Management of athletes with these conditions requires an understanding of the neurologic consequences of these disorders, the risk of injury with return to play, and consideration for the benefits of exercise in health restoration and disease prevention.

Task-specific kinetic finger tremor affects the performance of carrom players

We aimed to determine the effect of task-specific kinetic finger tremor, as indexed by surface electromyography (EMG), on the accuracy of a carrom stroke. Surface EMG of extensor digitorum communis muscle of the playing arm was recorded during rest, isometric contraction and stroke execution in 17 male carrom players with clinically observed finger tremor and 18 skill- and age-matched controls. Log-transformed power spectral densities (LogPSDs) of surface EMG activity (signifying tremor severity) at a 1-s pre-execution period correlated with angular error of the stroke. LogPSDs in 4-10 Hz range were higher in players with tremor than controls during pre-execution (P < 0.001), but not during the resting state (P = 0.067). Pre-execution tremor amplitude correlated with angular deviation (r = 0.45, P = 0.007). For the first time, we document a task-specific kinetic finger tremor in carrom players. This finger tremor during the immediate pre-execution phase appears to be a significant determinant of stroke accuracy.

Some unusual sports-related neurologic conditions

PURPOSE OF REVIEW

This article reviews some of the unusual sports-related neurologic disorders within the new and rapidly growing field of sports neurology that neurologists may encounter.

RECENT FINDINGS

Surfer's myelopathy is a potentially tragic disorder predominantly affecting novice surfers, leaving many who are affected by this condition with permanent paralysis. Neck-tongue syndrome is a rare primary headache disorder that can occur in athletes and nonathletes, and consists of paroxysmal neck and occipital pain and transient ipsilateral tongue numbness, triggered by sudden rotation of the neck. Athletes are also at risk for cervical arterial dissections, with golfers especially prone to vertebral rather than carotid dissections. Finally, "the yips" likely represents a form of occupational dystonia described in golfers.

SUMMARY

The syndromes described in this article range from relatively minor syndromes that cause discomfort or abnormal movement to potentially devastating cerebrovascular or myelopathic syndromes. Although the disorders described in this article are not common, they can affect individuals involved in sports at all levels, from the novice to the elite athlete, and may present to any neurologist. Neurologists should be aware of the potential for these syndromes to occur as a consequence of athletic activities in order to provide the most appropriate diagnosis, management, and counseling.

We Are Able, We Intend, We Act—But We Do Not Succeed: A Theoretical Framework for a Better Understanding of Paradoxical Performance in Sports

Paradoxical performance can be described simply as a sudden decrease in a top athlete’s performance despite the athlete’s having striven for superior performance, such as the lost-skill syndrome in trampolining or “the yips” in golf. There is a growing amount of research on these phenomena, which resemble movement disorders. What appears to be missing, however, is a clear phenomenology of the affected movement characteristics leading to a classification of the underlying cause. This understanding may enable specific diagnostic methods and appropriate interventions. We first review the different phenomena, providing an overview of their characteristics and their occurrence in sports and describing the affected sports and movements. We then analyze explanations for the yips, the most prominent phenomenon, and review the methodological approaches for diagnosing and treating it. Finally, we present and elaborate an action theoretical approach for diagnosing paradoxical performance and applying appropriate interventions.

Reinvestment--the cause of the yips?

The yips is a multi-etiological phenomenon consisting of involuntary movements during the execution of a skill (e.g., a golf putt). Reinvestment, the conscious control of a movement that detrimentally affects automated movements, is thought to be a potential mechanism leading to the yips. Preventing yips-affected golfers from consciously controlling their movement, therefore, should be beneficial. The aim of the study was to be the first to empirically test in a laboratory whether reinvestment causes the yips and to explore if the tendency to reinvest can explain yips behavior. Nineteen yips-affected golfers participated in a lab experiment. They putted with the dominant arm in a skill-focus and an extraneous condition, in which they had to perform different dual tasks designed either to direct their focus on their own skill or to distract them from it. The tendency to reinvest was estimated via the Movement-Specific Reinvestment Scale. Yips behavior was assessed by putting performance and movement variability. Although the dual-task performance showed that the attentional manipulation worked, the tendency to reinvest did not predict the behavior of the yips-affected golfers in either putting condition. The yips-affected golfers also showed no difference in yips behavior between the skill-focus and the extraneous condition. In other words, the attentional manipulation did not change yips behavior. The data do not support the assumption that there is a link between the yips and reinvestment, likely because of the multi-etiological nature of the yips. Other psychological or neurological mechanisms such as conditioned reactions may better explain the yips and should be investigated.

How to detect the yips in golf

The yips is a multi-aetiological phenomenon that is characterized by an involuntary movement that can affect a golfer's putting performance. Diagnostics are crucial for a better understanding of what causes the yips but are still lacking. The purpose of the present study was therefore to identify sensitive methods for detecting the yips and evaluating its aetiology. Forty participants, 20 yips-affected golfers and 20 nonaffected golfers, completed a psychometric testing battery and performed a putting session in the laboratory. They answered questions about their golfing and yips experience and filled in standardized questionnaires measuring trait anxiety, perfectionism, stress-coping strategies, somatic complaints, and movement and decision reinvestment. In the laboratory, they had to putt in five different conditions that might elicit the yips: as usual with both arms, under pressure, with one (the dominant) arm, with a unihockey racket, and with latex gloves. Measures included putting performance, situational anxiety, kinematic parameters of the putter, electromyography of the arm muscles, and electrocardiography. The groups were separated only by putting performance and kinematic parameters when putting with the dominant arm. Future research should use kinematics to investigate the aetiology of the yips and possible interventions.

Focal task-specific lower extremity dystonia associated with intense repetitive exercise: a case series

BACKGROUND

Focal task-specific dystonia of the lower extremity associated with intense repetitive exercise has recently been recognized. The clinical course, treatment response and prognosis remain poorly understood.

METHODS

Individuals with lower extremity task-specific dystonia evaluated at UCSF's Movement Disorders Center (2004-2012) were eligible for this descriptive case study series if he/she had a history of strenuous and prolonged exercise involving the lower extremity and had no abnormal neurological or medical conditions to explain the involuntary movements. Data was gathered from the medical history and a self-report questionnaire. The findings were compared to 14 cases previously reported in the literature.

RESULTS

Seven cases (4M/3F) were identified with a diverse set of exercise triggers (cycling, hiking, long-distance running, drumming). The mean age of symptom onset was 53.7 ± 6.1 years. The median symptom duration prior to diagnosis was 4 (9.5) years. Several patients underwent unnecessary procedures prior to being appropriately diagnosed. Over a median of 2 (3.5) years, signs and symptoms progressed to impair walking. Seven patients had improvement in gait with treatment (e.g. botulinum toxin injections, benzodiazepines, physical therapy, bracing, body weight supported gait training and/or functional electrical stimulation of the peroneal nerve) and six returned to a reduced intensity exercise routine.

CONCLUSIONS

Isolated lower extremity dystonia associated with strenuous, repetitive exercise is relatively uncommon, but disabling and challenging to treat. The pathophysiology may be similar to task-specific focal dystonias of the upper limb. Prompt recognition of leg dystonia associated with extreme exercise could minimize unnecessary testing and procedures, and facilitate earlier treatment.

Yips and other movement disorders in golfers

Golf is a sport that requires perfect motor coordination and a balance between mobility and stability. Golfer's "yips," an intermittent motor disturbance manifested as transient tremor, jerk, or spasm that primarily occurs when the player is trying to chip or make a putt, is a movement disorder frequently encountered in both amateur and professional golfers. In addition, other movement disorders, such as tremors and dystonia, also can interfere with playing golf. Although the pathophysiology of the yips remains poorly understood, recent studies suggest that it may be a form of a task-specific, focal dystonia involving the hand and arm. Because task-specific dystonias and tremors are best treated by botulinum toxin injections, this also may be an effective therapy for the yips. The aim of this article is to systematically review the literature and our own experience with the yips and other movement disorders in golfers.

[Dystonia as a common status against a common belief]

Primary dystonia is believed to be rare, and its estimated prevalence is roughly around 10-20 per 100,000 in the general population. In middle-aged or elderly people, the prevalence is much higher, reported to be over 700 per 100,000. Dystonia also occurs secondarily in various conditions, as drug-induced (acute or tardive) dystonia or in association with neurological disorders. Reported prevalence values may be underestimate. The diagnosis of dystonia tends to be delayed for several years after the onset of symptoms, or the symptoms may be left unrecognized or misinterpreted. "Dry eye" is common in the modern society and is a frequent misdiagnosis of blepharospasm. "Stiff sensation of the neck", a ubiquitous symptom among Japanese, may actually be a phenotype of cervical dystonia. A subset of "essential tremor" and tremor in SWEDDs (Scans Without Evidence of Dopaminergic Deficits) reportedly have similar pathophysiology to dystonia. Occupational dystonia is common within a specific population. About 1% of musicians may suffer from musician's dystonia, and about one-third of professional or highly skilled golfers may have "yips", possibly a representation of dystonia. Dystonia is common against a general belief, and should be included among the differential diagnosis in patients with muscular hyperactivity and impaired voluntary movements.

Neural mechanisms underlying paradoxical performance for monetary incentives are driven by loss aversion

Employers often make payment contingent on performance in order to motivate workers. We used fMRI with a novel incentivized skill task to examine the neural processes underlying behavioral responses to performance-based pay. We found that individuals' performance increased with increasing incentives; however, very high incentive levels led to the paradoxical consequence of worse performance. Between initial incentive presentation and task execution, striatal activity rapidly switched between activation and deactivation in response to increasing incentives. Critically, decrements in performance and striatal deactivations were directly predicted by an independent measure of behavioral loss aversion. These results suggest that incentives associated with successful task performance are initially encoded as a potential gain; however, when actually performing a task, individuals encode the potential loss that would arise from failure.

Table tennis dystonia

Focal task-specific dystonia (FTSD) occurs exclusively during a specific activity that usually involves a highly skilled movement. Classical FTSD dystonias include writer's cramp and musician's dystonia. Few cases of sport-related dystonia have been reported. We describe the first four cases of FTSD related to table tennis (TT), two involving professional international competitors. We also systematically analyzed the literature for reports of sport-related dystonia including detailed clinical descriptions. We collected a total of 13 cases of sport-related dystonia, including our four TT players. Before onset, all the patients had trained for many years, for a large number of hours per week. Practice time had frequently increased significantly in the year preceding onset. As TT is characterized by highly skilled hand/forearm movements acquired through repetitive exercises, it may carry a higher risk of FTSD than other sports. Intensive training may result in maladaptive responses and overwhelm homeostatic mechanisms that regulate cortical plasticity in vulnerable individuals. Our findings support the importance of environmental risk factors in sport-related FTSD, as also suggested in classical FTSD, and have important implications for clinical practice.

Implicit overcompensation: the influence of negative self-instructions on performance of a self-paced motor task

According to Wegner's (1994) theory of ironic processes of mental control, self-instructions not to perform in a certain way, together with mental loads, can induce thoughts, emotions, and behaviours that are precisely the opposite of intention. Wegner's theory was tested against the implicit overcompensation hypothesis, which states that movement direction and magnitude are implicitly dictated by self-instruction, irrespective of load, promoting overcompensation of action. Two experiments were conducted using a golf-putting task. In Experiment 1, 48 participants were randomly assigned to one of four load conditions: cognitive, visual, auditory, and self-presentation/incentive. In the experimental trials, participants were instructed to make the putt, but it was emphasized that the putt should not be left short of the target. Following the instructional strategy, putts landed significantly longer than at baseline, irrespective of load. In Experiment 2, 36 participants were divided into one of three groups, without load, in which different instructional sets (control, not putting long, and not putting short) were emphasized. A significant interaction emerged, as participants putted significantly longer or shorter than controls depending on the instructional set given. Overall, our findings support the implicit overcompensation hypothesis. Theoretical and practical considerations are discussed.

Task-specific dystonias: a review

Task-specific dystonias are primary focal dystonias characterized by excessive muscle contractions producing abnormal postures during selective motor activities that often involve highly skilled, repetitive movements. Historically these peculiar postures were considered psychogenic but have now been classified as forms of dystonia. Writer's cramp is the most commonly identified task-specific dystonia and has features typical of this group of disorders. Symptoms may begin with lack of dexterity during performance of a specific motor task with increasingly abnormal posturing of the involved body part as motor activity continues. Initially, the dystonia may manifest only during the performance of the inciting task, but as the condition progresses it may also occur during other activities or even at rest. Neurological exam is usually unremarkable except for the dystonia-related abnormalities. Although the precise pathophysiology remains unclear, increasing evidence suggests reduced inhibition at different levels of the sensorimotor system. Symptomatic treatment options include oral medications, botulinum toxin injections, neurosurgical procedures, and adaptive strategies. Prognosis may vary depending upon body part involved and specific type of task affected. Further research may reveal new insights into the etiology, pathophysiology, natural history, and improved treatment of these conditions.

Secondary motor disturbances in 101 patients with musician's dystonia

OBJECTIVE

Musician's focal dystonia is usually considered to be task specific but secondary motor disturbances have been reported also. We carried out a detailed evaluation of the incidence of these secondary motor problems in 101 patients.

METHOD

Symptoms were assessed using clinical histories, neurological examinations and observation of instrumental manoeuvres.

RESULTS

53.5% of patients reported secondary motor disturbances in activities other than playing their main instrument, with the onset delayed in some cases by up to 12 years from the awareness of dystonic symptoms. 46.5% suffered from simple, 19.8% from complex and 33.7% from progressive cramps. Plucked string players (guitarists) mainly suffered from simple cramps while keyboardists more frequently displayed the progressive form. In all patients, symptoms were focal, and the type of cramp was unrelated to the severity of the perceived symptoms. Those patients playing a second instrument similar to their main instrument showed symptoms which worsened to a higher degree than those playing either only one instrument or whose second instrument was different.

CONCLUSIONS

Longer follow-up assessments may reveal secondary motor symptoms that are not visible over shorter examination periods. Therefore, a thorough evaluation of everyday life motor activities should be considered in any clinical and treatment protocol. We speculate that the avoidance of movements that are similar to the main affected task may be of help in limiting symptoms. Consequently, focal dystonia may be considered more movement than task specific.

The yips in golf: multimodal evidence for two subtypes

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.

Psychophysiologic responses of invasive cardiologists in an academic catheterization laboratory

BACKGROUND

This study examined the psychophysiologic responses of invasive cardiologists during cardiac catheterizations. Because occupations are most stressful when one is not in control, the effect of a teaching versus an autonomous role on the psychophysiologic response of invasive cardiologists was investigated.

METHODS

The subjects were 9 invasive cardiologists. Psychophysiologic variables such as state anxiety and salivary cortisol levels were measured before and after each invasive cardiologist performed 7 cardiac catheterizations. Heart rate was measured before, during, and after procedures. Three procedures were studied while invasive cardiologists were in the primary operator (autonomous) role with full responsibility and control, whereas 4 were studied while the subjects were in the secondary assistant (teaching) role with full responsibility and no control.

RESULTS

There were no significant differences in physiologic arousal (heart rate and salivary cortisol levels) between catheterizations performed in the autonomous role versus those in the teaching role. However, the perceived anxiety scores were higher when in the teaching role versus when in the autonomous role. There were significant differences in psychophysiologic measurements of stress between less experienced cardiologists (out of training < 5 years) and more experienced cardiologists (out of training > 5 years). Less experienced invasive cardiologists had significantly higher trait anxiety (38.4 vs 31.7, P = .001), baseline salivary cortisol levels (0.51 vs 0.33, P = .01), and heart rate change (50.1 vs 27.4 beats/min, P = .001) during procedures compared with more experienced cardiologists.

CONCLUSIONS

Although there were no overall differences in the physiologic response to the autonomous and teaching roles, there was a higher perceived state of anxiety when in the teaching role. Less experienced invasive cardiologists had higher psychophysiologic measurements of stress during invasive procedures than did more experienced cardiologists.

The Sport Psychiatrist and Golf

The sport psychiatrist is well-positioned to consult to competitive golfers. The interrupted pace of play in golf provides ample time for the golfer's thoughts to go awry. The sport psychiatrist can work with competitive golfers in refining their strategies for dealing with these myriad distractions and stressors. The authors review pre-performance routine and methods for optimizing focus, and discuss the science behind being "in the zone." The authors also discuss how acute performance failure, or "choking," is best understood as being three separate disorders. The sport psychiatrist's unique role in competitive, professional golf is discussed by employing the concept of a sports mental health continuum and its relation to psychiatric disorders.

Self-consciousness and trait anxiety as predictors of choking in sport

The present study was designed to examine dispositional self-consciousness and trait anxiety as predictors of choking in sport. Sixty-six basketball players completed the Self-Consciousness Scale and the Sport Anxiety Scale prior to completing 20 free throws in low-pressure and high-pressure conditions. A manipulation check showed that participants experienced significantly higher levels of state anxiety in the high-pressure condition. A series of hierarchical multiple regression analyses supported the hypothesis that self-conscious athletes were more susceptible to choking under pressure. The best predictors of choking were private self-consciousness and somatic trait anxiety that together accounted for 35% of the explained variance. We discuss a number of possible explanations regarding the discrepancy between the present results and previous studies mainly relating to task characteristics, skill level of participants and manipulations of pressure.

Sports and performing arts medicine. 1. general considerations for sports and performing arts medicine11A commercial party with a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit upon the author or one or more of the authors. Nadler is a consultant for Proctor & Gamble

This self-directed learning module highlights general considerations in sports and performing arts medicine. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation.

OVERALL ARTICLE OBJECTIVE

To discuss similarities and differences of injuries sustained in sports and performing arts using case vignettes.