Golf as therapeutic exercise for older adults: a biomechanical analysis of golf swing demands and the effects of a golf training program on older adult balance and strength

2019-04-28Older adults experience physiological declines, including decreases in muscle performance and balance, that increase the risk for falls and impair the ability to perform activities of daily living. Laterally-directed falls more frequently occur during changes in posture and increase the risk for a hip fracture; therefore, dynamic mediolateral (ML) postural control and the physiological factors that mediate ML postural control are important for the aging individual. ❧ Multimodal physical activity is recommended to attenuate the physical declines associated with aging and to reduce fall risk. Golf is a popular recreational activity that contains multiple components and can be played across the lifespan. A round of golf consists of moderate to vigorous intensity walking, bending, precise putts, and high velocity golf swings that require dynamic balance and high hip demand. Cross-sectional analysis reveals that older golfers have better static and dynamic balance, proprioception, and balance confidence than older non-golfers and similar balance performance to older adult Tai Chi practitioners. Current research primarily investigates golf from a performance perspective and there is limited research investigating golf as a health intervention for older adults. Therefore, the primary objective of this dissertation was to characterize the golf swing as therapeutic hip and balance exercise and evaluate the effects of comprehensive golf training program on the balance and strength of older adults. ❧ Previous golf research has focused on the cardiovascular demands of walking the golf course and the associated adaptations in cardiovascular health. In stroke survivors, golf has been used as part of a rehabilitation program, resulting in beneficial adaptations in balance, strength, coordination, and quality of life. Golf has also been used as an intervention to improve cognition in older adults. With limited research on the effects of golf on the overall health of healthy, older adults, the purpose of Chapter III was to describe the design and implementation of a comprehensive golf training program and the assessed outcomes to evaluate the demands and the efficacy of the program. Detailed in the report is the description of a 12-week comprehensive golf training program aimed at safely introducing current non-golfing, older adults to golf play. Chapter III also includes a brief overview of the outcome measures assessing changes in physical, cognitive, and psychosocial health following participation in the golf training program. Information from this report will provide beneficial insight to the study and program design, allowing for a complete interpretation of published study results. ❧ Given the current research, it is plausible that the golf swing could be used as therapeutic hip and balance exercise in older adults. Therefore, the purpose of Chapter IV was to evaluate the hip and weight shift demands of the golf swing in novice, older golfers as compared to older adult balance, strengthening, and walking exercises. Average internal net hip joint extensor, abductor, external rotator, and triplanar (sum) moments and power during the golf swing were compared to the hip demands during semi-tandem stance (balance), a chair stand (strength), and self-selected gait (walking). Additionally, the magnitude of the weight shift as assessed by ML center of pressure (COP) range was compared between the golf swing and the exercises. Generally, the average internal net hip joint extensor, abductor, external rotator, and triplanar moments during the golf swing were similar or greater than the demands during the exercises. However, the average net hip joint abductor moment during self-selected gait was greater than the golf swing, likely attributed to the single limb support phase during gait. The golf swing is a rapid movement; thus, average net hip joint extensor, abductor, external rotator, and triplanar power during the golf swing was greater than semi-tandem stance and similar to self-selected gait. The average net hip joint extensor power was greater in the chair stand, a primarily sagittal plane exercise; however, when all three planes were analyzed, demands during the golf swing were greater in the remaining two planes and there were no differences in the average net hip joint triplanar power between the two movements. The ML COP range during the golf swing was greater than the chair stand and semi-tandem stance and tended to be greater than self-selected gait with a large effect size. The results of this study support the golf swing as a viable hip and dynamic balance exercise in novice, older golfers. ❧ Given the multimodal nature of golf, the purpose of Chapter V was to evaluate the effects of a comprehensive golf training program on 1) hip abductor muscle performance, 2) ML dynamic postural control, and 3) functional strength and balance in older adults. Current, non-golfing older military Veterans participated in a two-times per week, twelve-week comprehensive golf training program. The 90-minute training sessions consisted of complimentary exercise training aimed at preparing the participants for the demands of golf play, a dynamic warm-up, golf skill training, and progressive golf play. As the training program progressed, complimentary exercise time decreased and time in golf play increased with golfers playing a full 9-holes by the last training session. Before and after the golf training program, strength and balance were assessed. Hip abductor peak force and rate of force development were assessed during a weight-bearing rapid isometric hip abductor assessment. ML postural control was assessed via a rapid step test and consisted of measures of temporal performance including weight shift, step, and total movement time and COP dynamics including ML COP range and average ML COP velocity during the weight shift phase and average ML COP displacement during the step phase. Functional strength and balance were assessed via a 30-second chair stand and 8-foot-up-and-go test, respectively. Participants were able to safely complete the golf training program with a high adherence rate (91%). Following the comprehensive golf training program, there were no changes in hip abductor peak force or rate of force development. During the rapid step test, participants had a significantly reduced step time and movement time, with a trend towards a reduced weight shift time with a small to medium effect size following the golf training program. There were no changes in ML COP dynamics during any portion of the rapid step test. Finally, participants significantly improved their functional strength and balance. These results indicate beneficial effects of a comprehensive golf training program on dynamic balance, functional balance, and functional strength. ❧ These studies describe a novel comprehensive golf training program aimed at improving the overall health and well-being of older adults and indicate that participation in this program resulted in beneficial changes in balance and strength. Results from Chapter IV support the golf swing as therapeutic hip and balance exercise for older adults. Given the high hip demand of the swing, it is important that older golfers are prepared for the demands of the golf swing through complimentary exercise training and a dynamic warm-up to reduce injury risk. It is also important that older adults are gradually introduced to the golf swing through limits on swing count and a gradual introduction to golf play. Following participation in the comprehensive golf training program, older adults improved temporal performance on a rapid step test, and functional strength and balance (Chapter V). ML COP dynamics during the step test did not change indicating that the decreased step time did not come at the cost of ML postural control. Contrary to our hypotheses, there was no change in hip abductor peak force or rate of force development. It is possible that either 1) the golf training program did not provide a sufficient stimulus, or 2) the static nature of the test limited the ability to detect changes in muscle performance following a dynamic training program. It is likely that all facets of the golf training program including the complimentary exercise training, walking the golf course, bending, putting, and golf swings contributed to the observed changes in dynamic balance and functional measures. Our study results are limited in their applicability to the general population as all participants were older male, military Veterans; therefore, future research should investigate the effects of a comprehensive golf training program on the balance and strength non-Veteran community-dwelling older adults (male and female)