Golfer’s yips

The case of the curious golf affliction – the “yips”

A lot of my patients come to me because of chronic pain. So it’s no surprise that I see a lot of athletes – bikers, runners, tennis players –seeking help in restoring their performance levels. However, nobody has come to me, yet, with the specific request that I help their golf game. I’ve helped some here and there, but it’s always been a secondary consequence of treatment.

Well, thanks to an article in the journal of the British Medical Acupuncture Society (BMAS), I’m now ready to be of more direct help. Seems there is a condition that uniquely attacks golfers – the oddly named “yips.” It’s not really painful. Unless you’re a golfer. Adding about five strokes per round can hurt a lot.

Little did I know that this condition has been the subject of intense research (cf. A Multidisciplinary Study of the ‘Yips’ Phenomenon in Golf, Sports Medicine, 2000, 30(6) 423-437, and The ‘Yips’ in Golf, Sports Medicine, 2003, 33(1) 13-31). And now, thanks to BMAS (and their generous presentation of many articles through their website), a role for acupuncture is revealed: Acupuncture for Treatment of the Yips, a Case Report, by Palle Rosted (Acupuncture in Medicine, 2005, 23(4): 188-189).

What are the “yips”?

Many amateur golfers, and more than a small number of professional ones, lose control of the muscles in their arms in such a way that they can’t smoothly move a putter to and fro. Their arms can cramp or sometimes make involuntary movements. Aggravating if you’re an amateur, a catastrophe if you’re a professional.

A continuum of causes

The subtitle of the 2003 article in Sports Medicine is “A Continuum Between a Focal Dystonia and Choking.” It turns out that the yips are a psychoneuromuscular impediment. Yikes. Multiple causes here. From a localized neuromuscular problem to a psychosocial one – choking in common parlance.

The article on treating with acupuncture

Why do I like this article so much? First, it’s based on a sample size of one. That’s right, one golfer. One 65 year old Brit with a handicap of 14. Who would ever take seriously a study of sample size one? Well, me. If you read my blog on sample sizes in research and practice you’ll know why. Suffice it to say here that in an encounter between caregiver and patient, the sample size is always one. What I learn about one golfer today can help one golfer tomorrow.

Second, because it encompasses what acupuncture and Chinese medicine in general are so good at. The yips are a symptom. And we don’t attack symptoms willy-nilly. What is the cause of this symptom? Discovering this will take both rational evaluation and intuitive diagnosing. It takes listening. Same for the treatment. Rationality and intuition. Science and art. From sample sizes of N=1031 and N=72 describing the phenomenon in the two Sports Medicine articles, one golfer (N=1) gets treated in such a manner that he overcomes an impediment. I love it.

The cure for the N=1 golfer

Whatever physical muscular problems are involved with the yips, they are exacerbated by performance anxiety. The patient of this study did not clearly present physical or anxiety-related symptoms, so Rosted chose a combination of points to address the condition. (The details: GV20, EX-HN-1 [Si Shen Cong: four points one cun from GV20], and TE5.) The symptoms were gone after one treatment (a total of five were given), and there were no relapses by the 24-month follow-up.

Final thoughts

Performance anxiety and repetitive motor skills are important in lots of people’s lives. Maybe this isn’t so unique to golfers, after all. So, OK, I’m ready. Bring on the golfers, musicians, and poker players and let’s see what kinds of psychoneuromuscular impediments we can resolve. One at a time.

We’re all N = 1

There is a ton of interesting acupuncture research being conducted these days, and there is no doubt that we all will benefit from this work, practitioners and patients alike. Our aims are the same – bringing about healing. As I’ve been thinking about the actual research itself, though, I’ve become aware of a kind of disconnect between medical researchers and the patients they recruit for their work. These researchers are most interested in “Does treatment/drug X have a measurable effect on symptom Y?” And as a matter of good research protocol, they have to remain as neutral as possible about the outcome. That is to say, they can’t bias their work by hoping for one result or another.

Double blind research protocol

More importantly, some sort of randomized trial has to be set up and a placebo chosen. In the case of acupuncture studies, some type of “sham acupuncture” is employed (either inserting needles at random points disregarding established meridians, or only pretending to insert needles). Controls such as these are needed to ascertain whether the main treatment variable is the one responsible for any positive effects that might ensue. And then, in an attempt to remove bias from the gathering of data, a double-blind situation is set up whereby neither the doctor nor the patient is aware of which group he/she is in. (A real hurdle, for obvious reasons – the acupuncturist knows what group the patient is in, but at least the recording of results can be performed by someone who is unaware of treatment group assignments.)

A conundrum – two different views of sample size

The medical researcher is interested in the statistical results of the test. Does the treatment group differ significantly from the placebo group(s)? Statistics are based on samples of patients, and the larger the sample, the better. Sample sizes are referred top as “N,” so a sample size of 100 patients would be N = 100. The patients, on the other hand, are interested in their own personal health. Each is a sample of one. Hence the N = 1 in the title of this blog. How does the perspective of N = 1 relate to the perspective of the N = 100? Here’s where it gets interesting.

Lots of studies have failed to establish a statistically significant difference between treatment and control groups. So the researchers must conclude that the treatment is not effective. But there may be many individual patients who experienced significant individual benefits! It’s just that the significant individual benefits in the treatment group did not exceed the benefits of the control group.

The researcher, in a sense, has to dismiss the treatment’s effectiveness as being no better than the placebo’s. But each patient that responded positively has to be delighted, right? Nobody ever claims that their symptoms were less severe or that their recovery was less real. From their perspective the treatment (even if it was the placebo, and I’ll have more to say about placebos in a later blog) was successful.

What this means to me as a practitioner

As I treat patients, I have to be aware of what research has revealed about the kind of medicine I practice, and it certainly informs my treatment options, but every patient I see is a sample size of one. And what that means is that I look for unique, individual avenues to explore, and these avenues are not constrained by statistical evidence. I find this liberating in a way because it allows me to be creative in my practice; but also because it reminds me that my goals and my patients’ are the same – healing. And it really doesn’t matter if the exact same treatment given to another patient would not have the same result.

Significant individual benefits are not dependent on statistical significance in a clinical setting. I’ll have to talk to my family doctor the next chance I get and see if she has come to this same conclusion.

Unexpected outcomes

Want to know one of my favorite things about being an acupuncturist? Watching people experience healing in unexpected ways. Someone comes in for shoulder pain, right? I treat her for a few weeks with LI 4, LI 11, TB 14, SI 10, TB 10, SI 11, and a few ashi points and her shoulder gets better. She’s happy about this, obviously, but then as we’re chatting about preventive care and other things, she says “Look at the nail on my index finger! It’s finally better.” This nail had been a nuisance to her for a long time because of a really gnarly crack right down the middle. Now it was growing normally. What a treat to share in her excitement. What a treat to watch people walk away with more healing than they had thought possible

And, of course, fellow professional acupuncturists will just nod their heads, because although the details of unexpected outcomes such as this can’t be predicted beforehand, the occurrence is by no means a surprise. I never explicitly said this to her, but I wasn’t directly treating her main symptom, shoulder pain. I was treating qi and blood stagnation in the TB, SI and LI channels for her shoulder but also liver qi stagnation, which is a common diagnosis and if treated properly will create a lot of change for the patient. Sometimes this is referred to as the root and the branch. The root cause is a fundamental imbalance that needs addressing, the branch is the specific symptom. If I am successful in resolving the root cause, the “main complaint,” or branch, will respond. But removing the root cause unleashes the possibility of an effect on any number of symptoms for which the patient wasn’t seeking treatment.

The phenomenon of fingernail healing

The patient’s surprise became my surprise when I was reading an article by Daniel Schulman in The Journal of Alternative and Complementary Medicine (abstract; sorry, you’ll have to go to the library to see the entire article). His article is titled The Unexpected Outcomes of Acupuncture: Case Reports in Support of Refocusing Research Designs. His main focus is on research (and I’ll get back to that myself in a minute), and he describes two clinical cases of unexpected results. Guess what one of them is. You’re right, a fingernail healed. This time, a thumbnail. A woman who had come in for treatment of acid reflux and headaches, among other things, never mentioned her thumbnail until one day she happily reported that this longstanding problem was gone.

Unexpected outcomes as a challenge in research methods

The existence of unexpected results such as these points to one of the difficulties that the scientific community is having in designing relevant tests – particularly when comparing the results of acupuncture to conventional biomedical treatments – for the effects of acupuncture. If either my patient or Daniel Schulman’s had been in a clinical trial for effectiveness of acupuncture in the treatment of their “main complaint,” would unexpected outcomes such as these even be documented? I haven’t read a case in which they have. Even more of a puzzle presents itself if a clinical trial reveals no statistical difference between treatment and no-treatment for a symptom. What if my patient still experienced shoulder pain, but slept better, was happier in general, and experienced any number of other unexpected outcomes?

I’m not a scientist, but I’m aware that the so-called “gold standard” of clinical research, randomized, controlled trials (RCT’s) have their inherent limitations and there are many challenges facing those in the research community who are interested in comparing different treatment modalities. I’ve just begun reading some of what Ted Kaptchuk has been writing about all of this (here’s his amazing bibliography) and look forward to learning more.

Until then, what to make of this fingernail phenomenon? How common is it?

Healing alliances

How can I optimize the treatment of my patients? How can I provide the best healing experience possible? It begins with a partnership with each patient – a unique healing alliance. How does this alliance develop?

Listening

It begins with listening. Listening for a patient’s personal understanding of whatever symptoms brought him or her to me. Dealing with illness or pain can be as emotionally draining as it is physically trying. So I also ask about expectations and anxieties. I listen for small details that might convey meaning. It isn’t uncommon for a patient’s needs to be greater than what can be objectively diagnosed. How else to discover this than by listening?

What follows

The result is shared communication. Shared attention. Shared concern. And how could it stop there? Compassion follows automatically. As does a shared vision of what this person’s life would be like without whatever symptom has initiated this interaction.

This is what it means to say I strive to treat the person, rather than the symptom. This is certainly one of the things that drew me to Chinese medicine in the first place.

The unexpected power of the therapeutic alliance

What I now realize is that this interaction has healing power in and of itself. Progress on the road to healing can begin even before acupuncture, before herbs, or before any kind of treatment. Several clinical studies have demonstrated that there is therapeutic value to this healer-patient interaction. This is why randomized clinical trials are needed, after all. Researchers attempt to control for this phenomenon when testing the efficacy of a new drug or treatment. Otherwise, how would we know when a new treatment was effective beyond this important baseline?

All of this is true for Western medicine, too. There even have been instances in which once-orthodox drugs and treatments were abandoned later because subsequent controlled studies demonstrated that the main variable bringing about the positive outcome was the interaction with the doctor, not the treatment itself. Isn’t that amazing? It’s even true for some surgical procedures, believe it or not. Patients were experiencing healing for reasons other than the specifics of the operation. Doctor and patient expectations can have such dramatic effects on treatment outcomes.

A humble suggestion regarding medical research priorities

Dear mainstream and alternative medicine researchers, please focus more investigative energy on that part of your research that is normally referred to only by way of comparison with a main treatment group — that phenomenal baseline of healing. Please discover more about how all practitioners can be better healers, regardless of the types of treatment involved. What mind-body phenomena are at work when patients and doctors interact, and how can we enhance these effects? What physiological interactions between the nervous, immune, and endocrine systems are taking place when a healer and a patient establish an alliance?

Until we’ve discovered more, I’ll keep listening for clues from my patients.