Improving performance in golf: Current research and implications from a clinical perspective

Abstract

Golf, a global sport enjoyed by people of all ages and abilities, involves relatively long periods of low intensity exercise interspersed with short bursts of high intensity activity. To meet the physical demands of full swing shots and the mental and physical demands of putting and walking the course, it is frequently recommended that golfers undertake golf-specific exercise programs. Biomechanics, motor learning, and motor control research has increased the understanding of the physical requirements of the game, and using this knowledge, exercise programs aimed at improving golf performance have been developed. However, while it is generally accepted that an exercise program can improve a golfer's physical measurements and some golf performance variables, translating the findings from research into clinical practice to optimise an individual golfer's performance remains challenging. This paper discusses how biomechanical and motor control research has informed current practice and discusses how emerging sophisticated tools and research designs may better assist golfers improve their performance.

Full text

http://dx.doi.org/10.1590/bjpt-rbf.2014.0122
1
Braz J Phys Ther.
Improving performance in golf: current research and
implications from a clinical perspective
Kerrie Evans
1
, Neil Tuttle
1
ABSTRACT
| Golf, a global sport enjoyed by people of all ages and abilities, involves relatively long periods of low‑intensity
exercise interspersed with short bursts of high‑intensity activity. To meet the physical demands of full‑swing shots
and the mental and physical demands of putting and walking the course, it is frequently recommended that golfers
undertake golf-specic exercise programs. Biomechanics, motor learning, and motor control research has increased the
understanding of the physical requirements of the game, and using this knowledge, exercise programs aimed at improving
golf performance have been developed. However, while it is generally accepted that an exercise program can improve a
golfer’s physical measurements and some golf performance variables, translating the ndings from research into clinical
practice to optimise an individual golfer’s performance remains challenging. This paper discusses how biomechanical
and motor control research has informed current practice and discusses how emerging sophisticated tools and research
designs may better assist golfers improve their performance.
Keywords: golf swing; kinematics; exercise programs; movement variability; biomechanics.
HOW TO CITE THIS ARTICLE
Evans K, Tuttle N. Improving performance in golf: current research and implications from a clinical perspective. Braz J Phys Ther.
http://dx.doi.org/10.1590/bjpt‑rbf.2014.0122
1
School of Allied Health Sciences, Menzies Health Institute Queensland, Grifth University, Gold Coast campus, Queensland, Australia
Received: Mar. 17, 2015 Revised: June 12, 2015 Accepted: June 25, 2015
Introduction
The inclusion of golf in the 2016 Summer Olympic
Games for the rst time since 1904 is an indicator
of the increasing globalisation of the sport. It is
estimated that worldwide between 55 and 80 million
people from at least 136 countries play golf
1‑3
, with
the more avid golfers playing more than once a week,
every week of the year. The vast majority of people
who play golf are amateur golfers, with only a very
small proportion being considered elite amateurs and
fewer still are professional golfers. Irrespective of
whether a golfer is an amateur or a professional, the
goal is the same – to complete a round of golf in as
few strokes (shots) as possible and, from a longevity
perspective, continue to enjoy the game as pain and
injury free as possible.
The game of golf
Golf is a sport that involves a relatively long duration
of low‑intensity activity interspersed with short bursts
of high‑intensity activity. Golf courses vary in length
and terrain, so a round of 18 holes can take between
3.5 and 6 hours to play and, if the players are walking,
results in a low‑moderate intensity form of aerobic
exercise
4,5
. However, as much as 60% of the time
taken to play a round of golf is spent preparing and
performing swings, and of this time, 25% is spent
putting on the green
6
. In contrast to the relatively
low‑intensity demand of the rest of the game, a full
swing action requires a rapid expenditure of energy.
For example, professional golfers perform a swing with
a driver in 1.09 seconds
7
, with the club head reaching
speeds of more than 160 km/hour
8
. Overall muscle
activity when using a 5‑iron reaches 90% of maximal
voluntary contraction (MVC) for amateurs and 80%
for professionals
9
, and golfers perform an average
of 30‑40 swings every round with these high levels
of intensity
10
. In contrast to full swings, the putting
stroke requires minimal body movement but involves
the greatest degree of sustained trunk inclination and
sagittal exion compared with shots with other clubs
6
.
It has been suggested that, particularly when practised
for prolonged periods, putting may challenge a golfer’s
postural endurance
11,12
. Researchers and clinicians
wanting to optimise performance and prevent golf
injury have hypothesised that specic golf exercise
programs are necessary to meet the physical demands

Evans K , Tuttle N
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Braz J Phys Ther.
of both full‑swing shots and the potential fatigue
associated with putting or walking
13,14
.
Biomechanical investigations of the golf
swing
The landmark work of Cochran and Stobbs
15
in
1968 employed high-speed lming techniques to
examine the components of the golf swing, ball
aerodynamics, and equipment dynamics. Since then,
there has been a vast range of biomechanical studies
that have examined the highly complex, multi‑joint
movements involved in the golf swing. Researchers
have used 2D and 3D methods, including high‑speed
video
16
, optoelectronic
12,17‑19
and electromagnetic
motion tracking systems
20,21
, computer modelling
22
,
force plates
23‑25
, wireless inertial sensors
26
, and
electromyography
27‑31
to gain insight into and quantify
the fundamental elements of the swing. The majority
of studies have been conducted in laboratory settings
and most have employed indirect measures of golf
performance such as club head velocity (CHV) and
ball launch characteristics
18,23,32,33
. Laboratory‑based
studies have clear advantages, including ease of
standardisation, greater environmental control, and the
degree of accuracy possible with some indoor motion
analysis systems. On the other hand, swinging a golf
club indoors surrounded by expensive equipment
may not reect what happens on the golf course,
and there is concern that the indirect measures of
performance used in laboratory conditions may
provide incomplete information about actual golf
performance. Some studies have been conducted
outdoors and on golf courses
6,34
; however, more
research is needed to examine how golfers perform
their swing on the course, over a round of golf, and
under competition conditions and how these ndings
relate to what occurs in laboratory settings. Not only
will these types of studies provide ecologically valid
biomechanical information, but they will also provide
more specic information about the physical demands
of the sport and how environmental or other factors,
such as pressure or fatigue, affect golf performance.
Due to the importance of the full swing, particularly
in driving performance
32
, and perhaps because of the
fact that this stroke could be considered as having
the most repeatable intention ‑ to hit the ball as far
and straight as possible ‑ most kinematic studies
have concentrated on full‑swing kinematics. In
spite of the golf swing being dynamic by nature,
many of these studies have measured parameters
(e.g. segmental orientation) at discrete time points
during the swing, such as address, top of backswing,
ball contact. Collectively, ndings have provided
valuable insights into, for example, the magnitude
of thorax and pelvis movement when high CHV
are produced
7,35,36
, differences in segmental angular
velocities between skilled and less skilled golfers
37,38
,
and the importance of the magnitude, sequencing,
and timing of segmental motion
35,39,40
. The results
have helped inform research investigating physical
characteristics required for skilled golf performance.
With the increasing awareness of the importance
of movement variability in skilled performance
41‑43
,
there has been growing interest in investigating the
complex segment and intersegmental coordination that
occurs during the full swing
44‑47
. Movement variability
can be described as the normal variations that occur
in motor performance across multiple repetitions of
a task
48
. Historically, movement variability observed
in skilled sporting tasks was considered “noise” or
error and therefore undesirable. It is now recognised
that variability has a functional role and does not
necessarily result in outcome variability
41,45,49
. That is,
there is greater understanding of the large number of
constraints that interact to shape movement behaviours
during sporting endeavours, including body properties,
environmental conditions, and tasks, and that highly
skilled performers demonstrate the necessary exibility
and adaptability to operate prociently in a variety of
learning and performance contexts
42,50
.
Movement variability in the downswing of skilled male
and female golfers was investigated by Horan et al.
51
.
Despite variability in the kinematics of the thorax and
pelvis as well as variability in thorax‑pelvis coupling
at the midpoint of the downswing and at ball contact,
both males and females achieved highly consistent
club and hand trajectories at ball contact. Interestingly,
females were found to have greater variability in
thorax‑pelvis coupling than males. While physiological
measures were not directly measured, the differences
may have been due to differences in factors such as
strength or exibility or that male and female golfers
adopted different motor control strategies to achieve
consistent performance. Gender‑related differences in
golf swing kinematics have been observed by other
authors
38,39,52
supporting the notion that a number of
characteristics will inuence a golfer’s pattern of
movement and coordinative strategies.
The concept that movement variability in individual
segmental trajectories during a specic task may
not be detrimental to outcome performance as long
as the critical ‘end point parameters’ (in the case of
the golf swing, club head parameters at ball contact)

Clinical perspective on improving performance in golf
3
Braz J Phys Ther.
remain consistent
49,53
was supported more recently by
Tucker et al.
54
. These authors found that a group of
highly skilled golfers maintained consistency of ball
speed despite variability in movement of individual body
segments during the swing. Variability of movement
of the individual body segments are integrated to
produce a reduced variability in the club head trajectory,
which in turn results in an even smaller variability in
the club head on contact with the ball. Additionally,
Tucker et al.
54
found that movement variability was
highly individual-specic with different golfers
adopting different performance strategies to preserve
shot outcome. Taken collectively, emerging evidence
supports the notions of 1) inter‑player variability, i.e.
that individual golfers have individualised swing
patterns that are different from the patterns of other
golfers (Figure 1), and 2) intra‑player variability, i.e.
that within their own swing pattern, each individual
has variation in the contributions from the many
different components (Figure 2).
Figure 1. Full swing by two golfers demonstrating between‑individual variations. From left: address position, top of backswing, impact,
and follow‑through.
Figure 2. The 3D trajectory of the club head of one golfer performing multiple swings demonstrating within‑individual variation.
The width and colour of the pathway indicate the magnitude and direction of variability. The width at the point of impact is narrower
indicating considerably less variability than the backswing and downswing that precede it.

Evans K , Tuttle N
4
Braz J Phys Ther.
Clinical implications
Golf has been described as one of the most complex,
technically demanding and high precision sports that
exist
55
. Clinicians that work with golfers should consider
that inter‑golfer and intra‑golfer variability in swing
performance will be affected by task, environment,
and organism constraints, all of which interact to
determine the patterns of motion that are observed
when a golfer swings a club
45
. Despite an increased
understanding of the swing from both biomechanics
and neuroscience research, the best way to optimise
both swing and outcome performance for an individual
golfer remains elusive. From a physical therapist’s
perspective, optimising performance in golf requires
knowledge of not only the technical and physical
requirements of the sport, but also how these domains
are interrelated with the elds of psychology, motor
learning, and motor control. While recognising the
importance of a multimodal approach to optimising
golf performance, the following sections focus on the
physical requirements of golf and evidence pertaining
to whether exercise programs can help golfers improve
their performance.
Physical requirements of the golf swing
Highly skilled golfers tend to have different physical
characteristics than less procient golfers
56
and factors
such age, gender, and history of injury also inuence
a golfer’s performance on physical tests as well as
swing parameters
39,57,58
. Nevertheless, a combination of
mobility, stability, strength, and cardiovascular tness is
frequently recommended for optimal ‘golf tness’
14,59
.
Kinematic studies have highlighted the importance of
adequate exibility, particularly in the trunk, hips, and
shoulders, to achieve the body positions required to
optimise CHV
52,56,60
. For example, reported averages
for torso rotation during the backswing for a driver
range from 78° to 109° with the pelvis rotating to a
lesser extent of between 37° and 64°
7,35,52
. EMG studies
have sought to identify the muscle groups important
for golf performance
28,29,61‑64
and several reviews
have been published on this topic
65,66
. From the
collated data, it is apparent that the trunk extensors,
hip extensors, and the abdominal muscles all play
an important role in producing a powerful efcient
golf swing. The efcient transfer of energy from the
lower body to the muscle groups of the chest and
arms and eventually the hands and club ‑ the “bottom
up phenomenon”
60
‑ is important for producing high
CHV, but similarly to swing kinematics, a number of
kinetic variables measured during the swing are also
highly individual-specic
22
.
Golfers spend many hours practising. Professional
golfers can perform up to 300 swings in a single
practice session and hit over 2000 shots per week
67,68
.
To ensure a golfer can meet both the physical and
mental demands of playing tournament golf and
avoid the detrimental effects that fatigue has been
shown to have on performance
11,69
, exercises aimed
at improving a golfer’s cardiovascular tness have
also been advocated
14
.
In summary, playing golf has very specic physical
requirements that have led many researchers, coaches,
and clinicians to suggest that physical preparation
programs should be undertaken by golfers of all ages
and abilities in order to improve performance and
prevent golf‑related injury. This paper will not focus
on the latter but on ndings from studies that have
investigated whether exercise programs can improve
golf performance.
Exercise programs to improve golf
performance
Golf-specic exercises have been advocated
for many years, with early attempts being largely
idiosyncratic and based on personal experience and
opinion. For example, three-time Open Championship
winner Sir Henry Cotton in 1948 said:
Let me add, that, as far as I know, no data on
this subject of specic golf muscle-building
has ever been given, and I have had to grope
my way along according to my own ideas and
following my own observations, endeavouring
to build up my golng muscles to the best of
my ability
70
.
Cotton’s statement reflects the predominant
understanding of human performance in the 1940’s:
increased muscular strength should result in improved
performance. A golf‑specific exercise program
would therefore be designed to target the specic
muscles used in the sport. In their review of strength
and conditioning programs for improving tness in
golfers, Smith et al.
71
dened golf-specic exercises
as those that activate muscles groups that are used in
golf in comparable patterns of motor coordination,
in similar planes and ranges of movements, with
similar speeds, and similar loads on postural muscles.
In addition to load, this denition adds coordination,
pattern specicity, and speed to the idea of what makes
exercises golf-specic. Interestingly, Smith et al.
71

Clinical perspective on improving performance in golf
5
Braz J Phys Ther.
concluded that the majority of studies included in their
review involved reasonably generic exercise programs
that did not full the criteria for being golf-specic.
The exercises employed ranged from free weights
and medicine ball plyometric training in young male
golfers (age: 29±7.4 yrs, handicap: 5.5±3.7)
72
to
strength and exibility exercises in older recreational
golfers (age: 65.1±6.2 yrs of all skill levels)
73
to a
proprioceptive neuromuscular facilitation stretching
program in golfers aged between 47 and 82 years with
handicaps ranging from 8 to 34
74
. Despite the fact
that several of the studies reviewed by Smith et al.
71
had low methodological scores, it is nevertheless
interesting to see that, seemingly irrespective of
the type of exercise approach, the duration of the
program, the age or skill of the golfer, the majority
of studies reported improvements in at least some of
the tness (e.g. muscular strength, exibility) and golf
performance variables (e.g. club head speed, driving
distance) that were measured.
Since Smith et al.’s
71
2011 review, as well as
that of Torres‑Ronda et al.
75
, further studies have
investigated the effects of different exercise approaches
on parameters, such as club head speed, ball spin, and
swing kinematic variables, thought to relate to golf
performance. These studies have again been diverse
in terms of the exercises prescribed (e.g. ‘isolated
core training’
76
, plyometric training
77
, combination
of maximal strength, plyometric and golf-specic
exercises
78
, different warm up programs
79
); duration of
the program (range 6 weeks
80
to 18 weeks
78
); age and
skill level of the golfers (e.g. ~24 years with handicap
<5
80
vs ~47 years with a mean handicap of 11.2±6.1
78
);
effect sizes; and methodological quality. Similar to
previous work, direct measures of golf performance (e.g.
strokes per round, performance during tournaments)
are lacking. Overall, the results support the notion
that it is more important that a golfer do some form of
exercise rather than no exercise, irrespective of what
particular type of exercise is undertaken.
Lessons from other areas of clinical research
Interestingly, the conclusion that exercise (generally)
has a benecial effect for golfers, regardless of the
type of exercise, is similar to ndings in other areas
of sports research
81,82
but most notably the low back
pain (LBP) eld. Historically, most reviews of exercise
therapy for patients with LBP conclude that when
different types of exercise are compared directly,
exercise in general is effective
83‑85
. That is, there does
not appear to be one form of exercise that is superior
to another for patients with LBP. What the studies do
not tell us, however, by reporting group means, is
whether one program is better for a given individual
and if so, which one. More recently, studies comparing
interventions based on subgrouping of patients and
development of clinical prediction rules have been
conducted with the aim of more specically tailoring
interventions based on a set of patient characteristics.
However, it has proven extremely challenging to
develop theoretical and practical frameworks that
consider enough of a patient’s biological as well as
psychosocial characteristics to determine effective
treatment strategies
86
. Nevertheless, there is preliminary
evidence supporting the notion that patients who
receive a more individualised treatment approach
achieve better outcomes
87
.
To date, when studies of the effects of exercise
programs on golf performance have subgrouped
participants, the grouping criteria have been according
to handicap, age, or gender. Grouping a golfer based
on handicap intuitively makes the most sense – skilled
golfers have more consistent swing kinematics
than unskilled golfers and therefore any changes
post‑intervention are more likely to be as a result of the
intervention than due to measurement error. However,
one only has to look at the player anthropometrics of
the Ladies Professional Golf Association’s (LPGA)
Top 10 female golfers to recognise that even the best
players in the world are reasonably heterogeneous.
Where to from here?
There is still much to understand about how to
assist golfers improve their game and avoid injury.
It will be important to ensure the validity of the
measurements that are being made, consider more
sophisticated measures or methods of analysis, and
ensure that the outcomes being considered are true
indicators of the desired outcomes. Perhaps most
importantly, however, is to use measures that reect
the dynamic nature of golf and are capable of taking
into consideration individual variation in strategies
and responses.
New tools such as a variety of wearable sensors,
marker-less motion tracking, and wide eld-of-view
electromagnetic tracking systems are becoming
available that can assist to improve our understanding
of the biomechanics and by enabling studies to be
carried out on the golf course instead of the laboratory.
Alternatively, if laboratory studies continue to be used,
it will be important to cross‑validate the methodologies
to ensure what occurs in the lab actually reects what

Evans K , Tuttle N
6
Braz J Phys Ther.
occurs on the course. Similarly, it will be important to
determine how the surrogate measures of performance
typically used in the lab relate to performance on
the course.
The systems that are currently used in most
biomechanics laboratories are able to determine location
of points on the body and ground reaction forces at
rates of hundreds or even thousands of samples per
second and create a 3D reconstruction of the entire
movement pattern through time. In spite of the dazzling
complexity and accuracy of the data, much of the
analyses use simplied variables such as maximum
or minimum values of locations, angles, speeds, or
accelerations or the values of these parameters at
predetermined time points during the swing. One of
a relatively small number of studies that evaluated
data across the time course of the swing was that of
Tucker et al.
54
. The authors recorded the locations of
14 points on the golfer’s body and club at 400 Hz for
10 swings by each of 16 golfers. For each normalised
time point for each marker, a virtual three‑dimensional
ellipsoid was constructed that would contain the mean
location +/‑ one standard deviation of the position
of that marker through the swing. Not only does this
type of methodology enable the swings of different
individuals to be compared in ways that were not
previously possible, but it also enables investigators to
evaluate the relative impact of different body locations
and/or time points on performance.
As more is understood about individual variation,
it may be possible to develop and assess the efcacy
of individualised programs for individual golfers.
Instead of the more common study design, which
compares two (or more) groups and have every
member of the group receiving the same intervention,
individualised programs could be assessed using a
parallel group design. For example, the intervention
in one group can be individualised according to an
algorithm while the other intervention uses a set
protocol
87
. Perhaps more appropriate, however, to
evaluate individual treatment responses would be the
use of so called “n‑of‑one trials”
88
. The power of this
design comes from each intervention option being
trialled more than once in a multiple crossover design
(e.g. as a minimum - an ABAB or ABBA sequence).
One type of intervention being consistently superior
in more than one comparison provides much stronger
evidence for it being actually superior. An advantage
of n‑of‑one trials is that they are also available to the
therapist in clinical practice. Consider for example if
two exercise programs have demonstrated benets,
but in a head‑to‑head comparison neither is superior.
One interpretation of the evidence would be to select
one and only change the program if the outcomes
were ‘very poor’
89
. However, by applying an n‑of‑one
design in clinical practice, the therapist no longer has
to rely on average results but can determine which
of the options is better for each individual golfer at
a given time.
Conclusions
Despite the growing body of research investigating
the golf swing, much remains unknown and translating
the ndings from the biomechanical, physiological,
motor learning, and motor control research into clinical
practice, where the aim is to assist golfers improve their
performance and prevent injury, remains challenging.
It is generally well accepted that, in order to improve
performance, a multimodal approach is required and
both researchers and clinicians need to consider the
aforementioned inter‑related dimensions in order to
help optimise golf performance. There are general
principles of exercise that are likely to be of benet
to all golfers, and the study designs employed to date
have provided a wealth of information and should
inform current and future practice. However, more
sophisticated tools and designs are available that are
capable of expanding our knowledge of golf and
practice, thereby potentially increasing our ability
to assist our clients improve their golf performance.
Acknowledgements
The authors wish to thank Dr Catherine Tucker
and colleagues for allowing use of this image which
illustrates some of the ndings from their research.
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Correspondence
Kerrie Evans
Grifth University
School of Allied Health Sciences
Gold Coast Campus
PMB 50, Gold Coast Mail Centre
QLD, 9726, Australia
e-mail: kerrie.evans@grifth.edu.au