Golf and Reducing the Risk of Falls in Parkinson’s

“The harder you work, the luckier you get.” Gary Player

“The only thing a golfer needs is more daylight.” Ben Hogan

Précis: The sport of golf provides a low-impact all-around form of exercise that improves balance and flexibility and promotes a range of motion by activation of muscles in the upper and lower body. If you have followed this blog for any time, you know how I value hitting golf balls. This post further discusses the merits of playing golf to reduce the risk of falls in Parkinson’s.

“The value of routine; trusting your swing.” Lorii Myers

Background: The story behind this blog dates back a few years. It starts with my playing golf, having Parkinson’s, and a scientist’s wonder about whether playing golf might alter (either positively or negatively) the outcome of the disorder? Then I heard the story of Gary Smith. Gary has Parkinson’s; and is using golf as part of his exercise therapy (Golf Channel, https://www.golfchannel.com/video/comeback-smith-battles-parkinsons-disease-golf/). Gary started by hitting 100 golf balls/day at a Top Golf facility, and over the past several years, his medical therapy has not advanced. Typically, increases in medication dosages imply disease progression. And I had one of those “oh my” moments. So for the past three years, I have tried very hard to get to a golf driving range and hit ~100 golf balls/day (sometimes I’ve done it 6 days/week; usually, it is 3-4 days/week). I feel good doing it because it is such great fun hitting golf balls. I have never gotten bored.

Going back to 2019, my initial idea for a research proposal pairing together PWR! Moves and golf. Then the research idea was simplified to golf alone. The final concept was the potential for golf to reduce the risk of falls in Parkinson’s. I am a very visual person; thus, to help me focus on the idea, I’d make small posters to print out and think about the idea. From here, we tried to generate a small amount of grant money, and I was very fortunate to recruit a former collegiate golfer turned medical student to help with the clinical aspects of the study. We got some money, spent time writing, and approved an IRB clinical protocol for our golf study (see the poster below). And then, just like that, it was over before it ever started, the COVID-19 pandemic shut us down entirely during the summer of 2020.

Thus, we were forced to change directions and turned our attention to writing a review article on exercise, Parkinson’s, and COVID-19. This collaboration produced a really nice paper:
Hall,M.-F.E., and F.C. Church. Exercise for Older Adults Improves the Quality of Life in Parkinson’s Disease and Potentially Enhances the Immune Response to COVID-19. Brain Sciences 10.9 (2020): 612.  https://www.mdpi.com/2076-3425/10/9/612.

That left me with an uncertain future for the golf project and no ending in sight for COVID-19. From here, I turned to one of the local physical therapists that I work with, Rebecca Bliss. I asked her if she had any interest in writing a review article on the potential role of golf to prevent falls in people with Parkinson’s. In other words, bypass the clinical study and write a review article instead. She said yes, and that she enjoyed writing. The result was the following paper, which in my opinion, turned out really nice:
Bliss, R.R. and F.C. Church. Golf as a Physical Activity to Potentially Reduce the Risk of Falls in Older Adults with Parkinson’s Disease. Sports (2021), 9, 72. hticelt:tps://doi.org/10.3390/sports9060072 (What is included below is a general overview of this paper; however, several major sections are not presented. To gain the full picture of the review, you are encouraged to read the article, it is Open Access).

Medical Advisory Statement: The benefits of a new exercise program will only work if you have talked with your Neurologist, and worked out a plan with your physical therapist or personal trainer that includes stretching exercises for pre -and post-golf and discussion on the optimal dose and frequency as you prepare for a new exercise. Definitely, please consult with your Neurologist before beginning any new exercise routine, like golf.

Additionally, like any form of exercise being used by someone with Parkinson”s to ‘help’ with your disorder, golf is not a ‘perfect’ fit for all. However, golf has several aspects that contribute some ‘benefit’ to your health based on the information given below.

“The older I get, the better I used to be.” Lee Trevino

Could Playing Golf Reduce Falls in Older Adults with Parkinson’s?: Older adults are at increased risk for falls. Furthermore, people-with-Parkinson’s (PwP) have an even greater risk of falls than age-matched non-Parkinson’s people. In the article mentioned above, we suggest that older adults with Parkinson’s who routinely hit golf balls could lower their risk of falling (The scheme below describes the study ).

“A good golfer has the determination to win and the patience to wait for the breaks.” Gary Player

Increased Risk of Falling in Older Adults, the Risk Increases for Those with Parkinson’s, and the Role of Exercise in Reducing the Risk: These major sections are presented in detail in the review article cited above, but not here below. However, it is essential to note that older adults increase their risk of falls as we age, while older adults with Parkinson’s have an even more substantial increased risk of falling. Interestingly, exercise has been shown to help reduce the risk of falling in both groups of older adults.

Some of the many risk factors that increase this risk of falls in Parkinson’s are lower muscle weakness, balance-mobility issues, rigidity, and gait problems. Although many exercise routines have been created to help with falling, I thought how valuable the golf swing could be to help lower this risk of falling. In addition, excellent exercise routines developed explicitly for Parkinson’s have been shown to improve physical and neurological symptoms.

“For this game you need, above all things, to be in a tranquil frame of mind.” Harry Vardon

The Game of Golf: Golf is widely accepted, with >28 million individuals in the USA over the age of 6 playing golf; interestingly, participation by older persons (>50 years of age) is growing at an even faster rate. A correctly performed golf swing works muscles in the upper and lower body. Golf requires strength, flexibility, and a lot of coordination; there is also a cognitive component to the game. 

“As you walk down the fairway of life you must smell the roses, for you only get to play one round.” Ben Hogan

The Golf Swing ( excerpt from an early version of the paper): Golf is a sport that offers an all-around low-impact exercise.  The golf swing is a whole-body goal-oriented task that requires an extension, axial mobility, weight shift, coordination, the transition of the body (over the base of support), and focuses on visual-motor integration to allow the golf club to hit the golf ball. The golf swing can be split up into five sections: (i) backswing (ball address to the top of backswing); (ii) forward swing [top of the swing to club horizontal (early part of downswing)]; (iii) forward swing acceleration [horizontal club to impact (late part of downswing)]; (iv) early follow-through (impact to the horizontal club); and (v) late follow-through (horizontal to completion of swing). The complete golf swing not only promotes a full range of bodily motion and axial rotation flexibility but activates many muscles and joints in the body.

The figure below demonstrates the muscles used to perform the golf swing, the work was performed by McHardy and Pollard (see Figure below).

“Golf is a science, the study of a lifetime, in which you can exhaust yourself but never your subject.” David Forgan

Playing Golf Promotes Wellness and Reduces Falls in Older Adults: If you followed me this far, here is the published evidence that hitting golf balls in older adults can reduce the risk of falling (references are included at the bottom).

•Tsang and Hui-Chen found that older golfers had better static and dynamic balance control compared to the control group of older healthy non-golfers. 

•Gao et al. suggested that the combined precision and repetitive nature of the golf swing and walking the golf course favored older golfers to have better balance and more confidence when compared to the control group of older healthy non-golfers.

•Comparing experienced older golfers to older Tai Chi practitioners, Tsang and Hui-Chen found that both groups had better joint proprioception and balance control during weight shifting compared to aged-match controls. Furthermore, both older golfers and Tai Chi test subjects were comparable in balance control to healthy college-aged control subjects.   

•Du Bois et al. gave golf lessons to two older adults who were non-golfers and they measured a significant increase in strength and power along with improved balance and posture. 

•Martinez-Bustelo et al. measured quadriceps symmetry inactive, sedentary, and institutionalized lifestyles in females over 80 years of age. The active group was golfers and they had increased muscular function compared to the other groups. 

•Du Bois et al. used a 12-week comprehensive golf training program to study the physical abilities, dynamic balance, and hip muscle performance of older military Veterans.  They found that the older military Veterans showed improved physical performance and dynamic balance from playing golf. 

•In a direct comparison of golf to Tai Chi for patients with moderate PD, Johnson et al. reported golf was associated with greater improvements in balance and mobility than Tai Chi. 

•Murray et al. reviewed golf and health.  Besides finding improved physical health and mental well-being in golfers, they also suggested that playing golf contributes to muscle strengthening, improved balance, and fall prevention.

Collectively, these studies reinforce the hypothesis that golf [(a) repetitively hitting golf balls; (b) playing a round of golf; and (c) walking while you play golf] strengthens the body, improves posture, coordination, and axial rotation, and increases balance.  These studies imply that older adults who routinely practice/play golf should be less likely to fall.

“A routine is not a routine if you have to think about it.” Davis Love Jr.

Benefits of Golf for Parkinson’s: In our paper, we devoted a substantial amount of space to discussing the benefits of playing golf for those of us with Parkinson’s. This was my favorite part of the paper because it went into specific aspects of the golf swing and how facets of the swing could augment someone with Parkinson’s in their increased risk of falls. I am incredibly thankful for having recruited Dr. Bliss to this paper because her insight and expertise in physical therapy impacted these sections in the article. I encourage you to read these paragraphs entitled “Golf Could Improve Functional Ability in Older Adults with Parkinson’s Disease.”

“Golf is deceptively simple and endlessly complicated; it satisfies the soul and frustrates the intellect. It is at the same time rewarding and maddening – and it is without a doubt the greatest game mankind has ever invented.” Arnold Palmer

Hitting Golf Balls and Playing Golf to Reduce the Risk of Falls: While this article was focused on those with Parkinson’s, the evidence that golf reduces falls is primarily on healthy adults. Thus, the game of golf should help anyone lower their risk of falling as they get older. However, since the data does not exist in large amounts testing the benefits of golf to reduce falls in Parkinson’s, we provided a template for those interested in reducing their risk of falling. Reproduced below is the Table from the publication.

“You don’t have the game you played last year or last week. You only have today’s game. It may be far from your best, but that’s all you’ve got. Harden your heart and make the best of it.” Walter Hagen

Conclusions: The biomechanics of the golf swing supports the concept of strengthening the upper and lower body, increasing the process of balance, enhancing axial mobility, and improving coordination and posture, all of which should help to lessen falls in people with Parkinson’s. Although further study is needed, playing golf regularly may be beneficial in reducing the risk of falls in older adults with Parkinson’s.

References:
McHardy, A, and H Pollard. “Muscle Activity During the Golf Swing.” British Journal of Sports Medicine 39, no. 11 (2005): 799-804.

Tsang, William WN, and Christina WY Hui-Chan. “Static and Dynamic Balance Control in Older Golfers.” Journal of aging and physical activity 18, no. 1 (2010): 1-13.

Gao, Kelly L, Christina WY Hui-Chan, and William WN Tsang. “Golfers Have Better Balance Control and Confidence Than Healthy Controls.” European Journal of Applied Physiology 111, no. 11 (2011): 2805-12.

Tsang, WW, and CW Hui-Chan. “Effects of Exercise on Joint Sense and Balance in Elderly Men: Tai Chi Versus Golf.” Medicine and Science in Sports and Exercise 36, no. 4 (2004): 658-67.

Du Bois, A.M., Marcione, N.A., Castle, S.C., and Salem, G,J. . “Golf as Therapeutic Exercise for Older Adults. .” World Scientific Congress of Golf VIII (2018).

Bustelo, S Martinez, B Simon, Martin Warner, A Jácome, Jessica Wootton, Daniella Welch, and Dinesh Samuel. “Between-Side Symmetry of Quadriceps Thickness Using Ultrasound Imaging in Female Golfers and Non-Golfers Aged over 80 Years.” Osteoarthritis and Cartilage 24 (2016): S65.

Du Bois, A., Marcione, N., Powers, C., Flanagan, S., Schroeder, T., Castle, S., Moore, J., and Salem, G. J. . “The Effects of a Comprehensive Golf Training Program on Measures of Physical Performance and Dynamic Balance in Older Military Veterans.” International Journal of Golf Science 9, no. 1 (2021): in press.

Johnson, R., Plummer, L, Chan J., Willis, A.M. . “Feasibility and Tolerability Randomized Clinical Trial of Golf Versus Tai Chi for People with Moderate Parkinson’s Disease.” The American Academy of Neurology’s 73rd Annual Meeting (2021): Abstract to be presented.

Murray, AD, L Daines, D Archibald, RA Hawkes, C Schiphorst, P Kelly, L Grant, and N Mutrie. “The Relationships between Golf and Health: A Scoping Review.” British Journal of Sports Medicine 51, no. 1 (2017): 12-19. 90.       

“One reason golf is such an exasperating game is that a thing we learned is so easily forgotten, and we find ourselves struggling year after year with faults we had discovered and corrected time and again.” Bobby Jones

Cover Photo Credit: David Mark from Pixabay

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