NEUROLOGICAL INSIGHTS FOR TEACHING GOLF TO TODAY S FITNESS CHALLENGED John Milton, MD, PhD, FRCP(C) Director, Golf Neurology Clinic The University of Chicago Golf is fun. It is a game that all can play. As a result of advances in medical science and therapeutics, many of today s golfers would not have been seen on the golf course just a few years ago. These golfers include those with physical disabilities (e.g. loss of limb, sight), those with neurological disabilities (e.g. strokes, Parkinson s disease, mental retardation), and those with medical disabilities (e.g. arthritis, heart disease, diabetes). Increasingly, physicians are being put under pressure by their patients to get them back on the golf course. It is good doctoring to want to keep our patients active and happy so that they can enjoy being with their family and friends. Moreover, numerous anecdotes describe patients who have successfully rehabilitated themselves through their love of the game. Golf teaching professionals must be prepared to respond to this demand by becoming knowledgeable about teaching golf to those with disabilities. There are two good reasons why golf teaching professionals need to become knowledgeable and comfortable working with those with disabilities. First, it s good business. The population of golfers with disabilities is large and growing everyday. These golfers often have lots of free time and are financially secure: just the type of golfing population to fill up those slow weekday tee times and teaching slots. Second, physicians and golf teaching professionals must begin to work together to make the game a healthy one. Estimates of the prevalence on golf related injuries in able bodied golfers range as high as 57 % (Batt, 1992; Jobe, 1988; McCarroll and Gioe, 1982; McCarroll, et al, 1990). The injury rate for golfers with disabilities is not known. Fortunately, most golfing injuries can be prevented by 1) attention to proper swing technique; 2) use of properly fitted equipment; 3) better physical fitness and flexibility of the golfer; and 4) avoidance of overuse. In order to teach golf to those with disabilities it is not necessary to know how to diagnose or treat medical and neurological conditions. However, it is necessary to understand how the human nervous system plays golf. This understanding provides a solid foundation upon which to build a teaching approach that can be applied to all golfers whether they are disabled or not. Control of skilled movements: The golf swing is a highly skilled movement. There are three aspects to the control of skilled motor movements: P : Planning B: Balance E: Execution 1
Once the brain has formulated a plan, almost every movement that a golfer makes has both 1) postural components, which stabilize the movements; and 2) prime mover components that relate to the movement goal. Irrespective of a golfer s ability, the golf teaching professional should assess them from the point of view of PBE. P: Planning: Golf is a mental game! However, there is very little understanding of the neurobiological aspects of the mental game. Consider the golf swing. Motion analysis studies demonstrate that the golf swing occurs in 790-1020 msec: the downswing occurs in only 200 msec (Cochran and Stobbs, 1968). Does the nervous system have time to make corrective adjustments during the course of the golf swing? Since golf is not possible without proper balance let us estimate the time to correct a change in balance during a golf swing. Estimates of the latency for postural sway range from 250-500 msec. An additional 500-1000 msec is required to activate muscles in order to overcome inertia and make a movement. Obviously the nervous system doesn t have enough time to make meaningful corrections during the golf swing. What do we mean by the term meaningful? Well suppose you were hitting a 7-iron to a target located 163 yards away. Is it possible during the golf swing to change your mind and hit a chip shot to a target located 33 yards to your right with the same success as if this had been the original intention? I think that the answer is no. Is it possible to make a very small correction which did not significantly shift the center of mass and which involves the same target? Maybe. But, this topic is quite controversial and perhaps better left for discussion at the 19 th hole! It follows from these observations that the golf swing, in major part, must be preprogrammed. Golfers often refer to the importance of visualizing the shot before making it. From the neurobiological point of view visualization is absolutely necessary. Sufficient time must be given for the nervous system to pre-program all of the movements (plus the necessary corrective movements) for the golf swing. How much time is required for pre-shot programming of the nervous system? The length of the pre-shot routine for the professional LPGA golfers is typically about 12-13 seconds and the shot to shot variation in this time is surprisingly small (no more than ± 0.5 seconds). On the hand, the length of the pre-shot routine for the amateurs was considerably shorter (less than 5 seconds) and there was more shot to shot variability (greater than 1 second). These observations suggest that it likely takes the brain longer to visualize the shot than most people realize. The more difficult question is determining what regions of the brain are involved in the pre-shot routine. As a first step towards answering this question the following experiment was conducted by the LPGA and The University of Chicago in conjunction with the 50 th Women s US Open. LPGA professional golfers were asked to visualize their pre-shot routine to a pin location 100 yards away while 2
images of brain activity were measured using functional magnetic resonance imaging (fmri) techniques. When a region of the brain becomes active there is a local change in blood flow that can be measured using fmri. Thus this technique provides a very precise and objective way (accuracy of a few millimeters) to determine which parts of the brain are important for the pre-shot routine. The results of this study will be presented during the session. Although studies of this type still have a long way to go before we can answer questions about the where and how of the pre-shot routine, there is a practical bottom line to all of this basic science. Many amateur golfers are not able to put in long hours at the practice tee. However, everyone can be taught the importance of a reproducible pre-shot routine. The simpler and better defined the task, the likely it is that the brain can better focus on it. It would be interesting to know how much an amateur golfer s game could be improved by simply emphasizing these points. B: Balance: What is the most important task faced by the nervous system during the golf swing? Answer: maintain balance. You can t hit a golf ball very well if you are flat on your back. It is pretty hard to hit a golf ball if your main concern is the fear of falling down. The task of maintaining balance throughout the golf swing is likely to be the major problem faced by golfers with disabilities. Maintaining balance means that the distribution of body weight must be such that the center of gravity projects to a point on the ground located inside the base of support, e.g. between the two legs. During the golf swing, body geometry is continually changing in order to maintain the center of gravity within this constraint: 1) the set-up: e.g. maintaining the proper posture; 2) back swing: e.g. upper trunk movement; and 3) downswing and follow through: e.g. the fast postural reactions that occur. Another way of thinking about this is to realize that every planned movement during the golf swing is accompanied by additional movements by other body parts that occur in the opposite direction and which are designed to maintain balance. It is important in analyzing the swing of a golfer with a disability to distinguish between those movements designed to hit the ball and those movements (or postures) that represent the corrective movements necessary to maintain balance. It is mandatory in teaching golf to persons with disabilities never to correct an apparent swing flaw without first considering what the effects of this correction on balance might be. E: Execution: All is said and done, how far a golf ball travels and in what direction depends on five laws, as first articulated by Gary Wiren: 1) club head speed; 2) centeredness of contact; 3) club head path; 4) angle of approach; and 5) loft of the club face. These 3
laws, and the concepts of principles and preferences that derive from them, apply equally well to all golfers whether they are disabled or not. However, it is important to remember that from the point of view of the nervous system it is the maintenance of balance that is the primary task. The more disabled the golfer, the greater this challenge. The bottom line is not whether a golf swing looks good, but whether it works. I think that it is impossible for an able bodied golf teacher to ever understand the difficulties that the nervous system of a golfer with a disability faces in order to swing a golf club. Obviously the one person in the world who best understands the consequences of disabilities is the disabled golfer. Therefore a sound approach to teaching golf to those with disabilities is to first thoroughly teach the laws and principles of the golf swing. Once this has been accomplished the golf teacher and player must form a team in order to find out, on a trial and error basis, what works. Remember that a funny looking swing might actually be a very elegant solution that a damaged nervous system has devised in order to play golf. Assessing a golfer with a disability Let me illustrate the application of PBE by analyzing the swing of a paraplegic golfer. This means that both legs are missing and replaced by a prosthetic device. Many of these golfers have a golf swing in which the back swing is almost vertically up with a downswing across the body with a limited and awkward follow through. Lots of problems, right! Before jumping in and making corrections let us consider this golfer s problems from the point of view of PBE (note that under each heading a golfer has strengths (+) and weaknesses (-)). P: + healthy brain - perhaps nervous about playing in front of people B: - limited possibility for weight shifts - no sensory information from lower extremities E: + strong upper body and arms - minimal hip turn - poor weight shift Analysis: Why does this golf swing work? The verticality of the golf swing is likely a consequence of the fact that the golfer has very little ability to compensate for shifts in the center of gravity. Consequently the golf swing must be performed in such a way as to minimize the displacement in the center of gravity. Obviously confining the swing to a vertical plane results in little significant shift in the center of gravity. However, a purely vertical downswing is not a very effective way to hit a golf ball down the fairway. The across the body downswing and follow through results from trade-offs between the position at the top swing (necessitated by trying not to fall down) and the effort to generate sufficient club head speed. 4
Solution: A golf ball can be hit a pretty long way using a shortened swing which takes advantage of a good wrist cock and strong forearms. This type of swing draws on the main asset that a paraplegic golfer has, namely, upper body and forearm strength. Combine this swing with a good short game and solid putting and we ve got game! Play sheets: Some examples of golfers with different disabilities are provided in the play sheets. Think about the problems that these golfers might face and solutions to them from the point of view of PBE. Remember that very little is known about the best way to teach golf to those with disabilities. Thus, I ll enjoy discussing your answers with you! References: Batt ME (1992). A survey of golf injuries in amateur golfers. Brit. J. Sports Med. 26: 63-65. Cochran A and Stobbs J (1968). Search for the Perfect Swing. Triumph Books: Chicago. Jobe FW (1988). The dark side of practice. Golf 30: 22. McCarroll JR and Gioe TJ (1982). Professional golfers and the price they pay. Phys. Sports Med. 10: 64-70. McCarroll JR, Rettig AC and Shelbourne KD (1990). Injuries in amateur golfers. Phys. Sports Med. 18: 122-126. Wiren G (1997). The PGA Manual of Golf: The Professional s Way to Play Better Golf. MacMillan: New York. 5
GOLFER 1 A golfer with a right handed swing has Parkinson s disease. He has a rest tremor that makes it difficult to have a reproducible grip on the golf club. He has a poor weight shift due to problems with balance and stiffness. There are problems with timing and the golfer just can t seem to get the rhythm of the swing correct. Planning: Balance: Execution: Analysis: Solutions: 6
GOLFER 2 A golfer with a right handed swing has a below the knee amputation of the left leg. He lost his leg as a result of diabetes. Planning: Balance: Execution: Analysis: Solutions: 7
GOLFER 3 A golfer with a right handed swing has a below the knee amputation of the right leg. He lost his leg as a result of diabetes. Planning: Balance: Execution: Analysis: Solutions: 8
GOLFER 4 A golfer with a right handed swing has left arm paralysis as the result of a stroke. Planning: Balance: Execution: Analysis: Solutions: 9
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