Focal Dystonia: The Root Causes Underpinning the Yips

 Have you ever cracked under pressure, for a test, a championship game, or an interview? Most people can move on from that crack and do better the next time, but what if you were stuck in that moment forever? There have been countless world-class athletes who have done just this on the biggest stage. A recent and well-known case of cracking under pressure was that of Markelle Fultz in 2018. Fultz was drafted as the number one overall pick by the Philadelphia 76ers and was slated to have a profound impact on scoring for his team. However, shortly into his professional career, he had a completely broken jump shot and looked lost on the court. The team physician diagnosed Fultz with a case of the yips [1]. Cases of the yips have popped up from time to time in all different sports from MLB pitchers suddenly not being able to find the strike zone to professional golfers missing very short putts. A theory proposed by researchers to explain the yips is a motor dysfunction known as focal dystonia [2]. Dystonia describes a wide variety of movement disorders which are defined by intermittent or constant muscle contractions that create irregular and repeated movements [3]. It is worth noting that the yips affect not only gymnasts and golfers, but also a wide variety of skilled professionals, as the yips target fine motor skills and muscle memory [4]. The name of the phenomenon and the affected body regions vary depending on the area of expertise of the individual affected by this dystonia. Amongst golfers it is known as the yips, for professional gymnasts it is the twisties, and professional musicians call it musician’s dystonia [5]. What happens when the mind gets in the way of the body? Severe performance anxiety may be a catalyst for the yips. Psychological stress manifesting in muscular defects makes finding a treatment plan difficult and case specific. If the yips is not purely psychological, but is a motor control disorder, then how does a healthcare professional go about treating the symptoms?

Part One: “The Case of Simone Biles”

Simone Biles is arguably considered to be one of the greatest gymnasts of all time. She performs complex moves with precision, and has four skills that bear her name, solidifying her mark on the world of gymnastics [6]. However, when she was slated to take home gold in the all-around competition at the Tokyo Olympics, something happened that no one could have predicted. She withdrew from competition. One of her first events was the vault, in which athletes sprint toward and launch off of a springboard to perform flips, twists, and other techniques before landing with a dismount. In one of her first vault attempts, she aimed to flip two and a half times in the air, but she landed after only one and a half [6]. Simone was suffering from focal dystonia, sometimes called “the twisties” in gymnastics, and appeared to get lost in midair before landing. Competing in gymnastics with the twisties is inherently dangerous; this mid-air error could have easily resulted in a major injury or even death. While spinning in the air, she experienced a mental block that seemingly erased years of practice in one second, and was enough to force her to withdraw from competition. In an interview, Simone said that she felt a disconnection between her mind and body which may have been caused by the stress and anxiety of the Olympic games [6]. The perplexing aspect of her condition is that every athlete in the Olympics faces immense pressure, but what triggers the twisties or yips in certain athletes? Focal dystonia may be a contributing factor causing involuntary muscular spasms that impede an athlete from competing. For Simone Biles, focal dystonia resulted in a loss of spatial awareness and her getting lost in midair, but how does this translate to a more static sport like golf?

Part Two: “Comprehensive Review of Focal Dystonia in Golfers”

The sport of golf is highly competitive and demands the best fine motor skills and requires a sharply tuned mental fortitude, similar to gymnastics. Throughout the years there have been countless professional golfers who have been forced into retirement simply because they are unable to sink putts, drive the ball, or hit a green due to the yips. A detailed analysis of The ‘Yips’ in Golf outlined that there are two types of the yips that affect golfers. Type I is due to dystonia, while type II is labeled as ‘choking’ [2]. Extreme cases of performance anxiety are at the core of choking, which produces poor performance and emotional turmoil and can drastically affect decision making. This study found that performance anxiety also worsens dystonia by increasing cortisol levels and grip tension, manifesting irregular contractions in forearm muscles. Focal dystonia has been proposed to originate in golfers' forearm muscles, making it increasingly difficult to swing a golf club [2]. The thousands of hours necessary to achieve professional status in golf may also be at the forefront of this phenomena. One theory is that the yips could manifest due to a loss in confidence to perform successfully, however it is also plausible that this condition could arise due to disrupted musculoskeletal systems controlling motor function because of their prolonged training [7]. Repeated training of the same fine motor skill for years disorganize the neural circuits that control the motions needed to swing a golf club, which phenotypically resembles focal dystonia [7]. There is further speculation in scientific literature that the yips develop due to excessive repetition and damage to the reward-motivation system. This system revolves around the basal ganglia and dopamine circuits to regulate movement [8]. The cause of the yips is far from clear, but the perfectionist mindset that many professional golfers employ seems to be a main driving force underpinning their demise [9]. 

Part Three: “Musician’s Dystonia”

It may seem like focal dystonia only affects athletes, but this disorder reaches far beyond sports. Imagine that you are attending a grand symphony orchestra. The awe-inspiring sounds produced by hundreds of talented musicians fills the room - but one performer is out of sync with the ensemble. That musician, who has honed their craft after thousands of hours of practice, is unable to correctly flow with the orchestra because of musician’s dystonia, which, in many cases, ends their career. Musician’s dystonia manifests in a similar way to that of athletes because it is a task-specific movement disorder that causes involuntary muscle contraction in repetitively trained motions [10]. Repetitive use of the same muscle groups creates a network disease, meaning that there is a short circuit in the motor pathways of the basal ganglia, limbic system, cerebellum, and somatosensory cortex as well as disrupting neuronal plasticity [11]. All of that is to say that the neurons affected are “forgetting” how they are meant to function because of overuse and extensive repetition just like professional athletes. Although this disorder is detrimental to the career of the musician affected, there is some hope regarding possible treatments. Possible therapies are complicated and not well studied, but one theoretical therapy that has offered relief of symptoms for some musicians was botulinum toxin injections (Botox) paired with muscular rehabilitation [12]. Botox injections can be fickle and are experimental. The doses administered and injection site differ based on the specific clinical phenotype of focal dystonia [12]. Furthermore, anxiety plays a large role in the development of musician’s dystonia and cognitive therapy has been beneficial in finding relief [13]. The loss of the ability to perform for a musician must be horrifying and devastating, but the upside is that the research regarding musician’s dystonia is currently exploding and new treatments are underway.

Part Four: “Treating the Mind to Cure the Body”

Symptoms caused by focal dystonia arise from a complex combination of anxiety and motor dysfunction. This makes treating the yips a difficult task because relieving the mental aspect may not alleviate the physical aspect. As the symptoms exist at the intersection of the mind and the body, treating either the mental anxiety or the muscular manifestation alone may not return the individual back to peak performance. Instead, overarching methods that target both cognition and musculature or combined approaches might serve as the most effective treatment package for focal dystonia [14]. In cognitive behavioral therapy, the source of an individual's anxiety is explored with a therapist in order to identify the negative thought patterns which result in anxious beliefs and behaviors. A more radical way to treat focal dystonia is to use deep brain stimulation (DBS) in targeted brain regions. One of these brain regions is the Globus Pallidus which functions to control conscious and proprioceptive movements [8]. Proprioception is one's awareness of their bodily orientation in space and are a sort of unconscious movements like being able to touch your nose with your eyes closed. For professionals, these movements are trained until they become second nature, allowing them to swing a golf club, play an instrument, or any trained autonomic function that requires muscle memory. Targeting the ventroposterolateral Globus Pallidus with DBS has been used to treat the physical symptoms of the yips with recovery after six months [15]. Another surgical procedure that has been hypothesized to treat focal dystonia is a series of botulinum toxin (botox) injections in the affected site. It is proposed that the botox will work to disrupt the nerve’s signals to a muscle which will relax the muscle and thus reduce spasms [16]. All in all, this condition involves many simultaneous working aspects of the mind and body which makes it an intricate problem to solve, but far from impossible with a multilevel treatment plan.

Conclusion

Becoming a highly skilled professional in anything takes dedication and countless hours committed to becoming the best possible at it. This love for perfecting a craft can become an obsession, yet in an instant it can be ripped away because of focal dystonia. Focal dystonia is a physical disease producing uncontrollable muscular movements which is exacerbated by high levels of performance anxiety to succeed. The true cause of the yips is far from conclusive, but due to an increase in research on the topic it is becoming less of a mystery.

References:

1. Marcin, T. (2018). Markelle Fultz’s jump shot, the yips and explaining the sports phenomenon through past cases. Newsweek. https://www.newsweek.com/2018/09/07/markelle-fultz-yips-jump-shot-fix-explaining-past-cases-1055214.html

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6. Park, A. (2021). Simone Biles has the twisties. why are they so dangerous? Time. from https://time.com/6085776/simone-biles-twisties-gymnastics/.

7. Gon, Y., Kabata, D., Kawamura, S., Mihara, M., Shintani, A., Nakata, K., et al. (2021). Association of the yips and musculoskeletal problems in highly skilled golfers: A large scale epidemiological study in japan. Sports, 9(6). https://doi.org/10.3390/sports9060071

8. Lanciego, J. L., Luquin, N., & Obeso, J. A. (2012). Functional neuroanatomy of the basal ganglia. Cold Spring Harbor perspectives in medicine, 2(12). https://doi.org/10.1101/cshperspect.a009621.

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13. Jabusch, H-C., Muller, S. V., Altenmuller, E., (2004). Anxiety in musicians with focal dystonia and those with chronic pain, Movement Disorder, 19(10), 1169-1175. https://doi.org/10.1002/mds.20110

14. Borza, L., (2017). Cognitive-behavioral therapy for generalized anxiety. Dialogues Clinical Neuroscience, 19(2), 203-208, https://doi.org/10.31887/DCNS.2017.19.2/lborza

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16. Nunez, K. (2021). Yips: Do they exist or are they just sports mythology? Healthline. https://www.healthline.com/health/yips#summary.