Musculoskeletal injuries and pain in dancers: a systematic review

Step type is associated with loading and ankle motion in tap dance

Tap dance generates forces and joint motions that can lead to injury; however, little is known about the magnitude of load across different tap steps. The purpose of this study was to calculate peak vertical forces, average vertical foot velocities, and maximum/minimum ankle angles produced by tap dancers with different levels of experience performing the toe cannon, heel cannon, flap, and cramp roll. This prospective cross-sectional study included 14 female tap dancers aged ≥18 years with varying tap experience. Participants were recorded by three cameras while performing a choreographed tap combination containing four steps of interest on a force platform. Adjusting for experience and dancer-level clustering, we identified the steps-cramp roll and toe cannon-that had the highest peak vertical ground reaction force, angles, and velocities compared to flap and heel cannon. There was no effect of experience. The results supported our hypothesis and provide new insights into step production. Over time, the larger forces associated with these steps could pose an increased risk of injury to bones and joints when compared to smaller forces, which may suggest the importance of adjusting routines to reduce or avoid injury.

Flexor hallucis longus tendon morphology in dancers clinically diagnosed with tendinopathy

PURPOSE

The unique demands of dance technique make dancers more prone to certain pathologies especially of the foot and ankle. Flexor hallucis longus (FHL) tendinopathy, colloquially known as "dancer's tendinopathy," is common in dancers and not well studied. The purpose of this study was to assess if morphological alterations in tendon structure occur as an adaptive response to dance activity by comparing the FHL tendon in dancers to non-dancers, and if pathology further alters tendon morphology in dancers clinically diagnosed with tendinopathy.

METHODS

Three groups of ten participants were recruited (healthy non-dancers, healthy dancers, and dancers with FHL tendinopathy). Ultrasound images of the FHL tendons were analyzed for macromorphology by measuring the tendon thickness. The micromorphology was analyzed by determining the peak spatial frequency radius of the tendon. Our study did find increased tendon proper and composite tendon thickness in dancers with tendinopathy but no difference between asymptomatic dancers and non-dancers.

RESULTS

There was no significant difference in micromorphology found between any of the groups. As expected, dancers with tendinopathy demonstrated increased composite tendon and tendon proper thickness however, there was no evidence of adaptive thickening of the FHL tendon as might be expected for the dance population. There was also no evidence of micromorphological changes in the presence of clinically diagnosed FHL tendinopathy.

CONCLUSION

Because of the limited normative data for this pathology, these results can help improve diagnosis and therefore treatment for dancers to decrease the impact of this injury on their careers.

Umbrella review of musculoskeletal injury burden in dancers: implication for practice and research

BACKGROUND

Dancers are susceptible to injury. Nevertheless, injury epidemiology research in dancers is inconsistent. Furthermore, ballet dancing has dominated the huge body of reviews analyzing the epidemiology of musculoskeletal injuries in a variety of artistic dance forms, making it challenging to acquire a thorough, comprehensive, and understandable reporting of the available data.

PURPOSE

The overview and reanalysis of dancers' musculoskeletal pain and injury load across artistic dance forms.

STUDY DESIGN

Systematic review of systematic reviews and meta-analysis.

METHODS

A search was conducted online for literature written in English using PubMed and Google Scholar (2012-2021). The data gathered was then analyzed using predetermined qualifying criteria.

RESULTS

12 reviews were determined to be qualified, the majority of which had moderate to low confidence and raised concerns about bias based on JBI-URARI and ROBIS. The prevalence of dance-related musculoskeletal injuries ranged from 26% to 84% in any artistic dancers and 42% to 343% in ballet dancers. The incidence was less than 5 per 1000 dance hours in both groups, with lower extremities and back being the commonly reported sites. Reviews themselves stated that the quality of the reviews was often poor. Due to the study's heterogeneity and methodological inconsistency, data pooling and meta-analysis were not possible.

CONCLUSION

The current review emphasizes the gaps and restrictions in the dance epidemiology literature that make it challenging to quantify and report a single overall injury rate for dancers. These results underline the need for better primary investigations and evidence synthesis. As injury epidemiology is a critical component of the overall injury-prevention puzzle, there is a need for standardization in future research, particularly with active and prospective injury surveillance, injury classification, injury evaluation, and injury reporting.

LEVEL OF EVIDENCE

Systematic Review, Level III.

Injury incidence and severity in Chinese pre-professional dancers: A prospective weekly monitoring survey

OBJECTIVES

To determine dance injury incidence and severity in full-time Chinese pre-professional dancers.

STUDY DESIGN

Prospective weekly online monitoring survey.

METHODS

Respondents were asked to record all dance-injury incidences between September 2020 and July 2021 using a remote weekly self-report injury monitoring tool. An inclusive definition of injury was used in this study to record all injuries, even if they didn't cause a cessation of training. Data were excluded if respondents completed <90 % of the survey period and had over 3 consecutive weeks of missing data.

RESULTS

450 individuals from 11 different schools were included in the analyses. A total of 1157 injuries were reported over a 30-week academic year. Injury prevalence was 64.9 % and injury incidence was 5.51 injuries per 1000 h. Forty-eight percent of the injuries were minor severity and 41 % were of moderate severity, and the main injury sites were knees (0.89/1000 h), lower back (0.80/1000 h), feet (0.58/1000 h) and groin (0.56/1000 h). Female dancers reported significantly higher injury prevalence and injury incidence, and higher rates of moderate to severe injuries than males. The university group reported higher injury incidence than the adolescent group (p < 0.05), whereas the latter reported higher rates of moderate to severe injuries than the former (p < 0.001).

CONCLUSIONS

The injury incidence found in this study (5.1 injuries/1000 h) is higher than most previous sets of data. Female dancers are at a higher risk of injury and reported higher levels of injury severity than male dancers, especially for the female adolescent group.

Injuries in Ballroom DanceSport: A Retrospective Study on Prevalence and Relation With Demographic Data

BACKGROUND

DanceSport is a variant of Ballroom dancing, a style that is performed as a couple dancing together. Although there are many participants worldwide, the amount of research on injuries done in this style of dancing is limited.

OBJECTIVE

The aim of this study was obtaining information about the DanceSport Athletes in the Netherlands including anthropometrics, level, frequency and duration of dance training per week. Our second objective was to investigate injury prevalence and type of injuries.

STUDY DESIGN

Retrospective questionnaire study.

METHODS

All 816 registered active dancers within the Dutch DanceSport Association received an online questionnaire with questions on anthropometrics, level of dancing, frequency and duration of dance training, and questions on injuries. The Chi-Square test was used to calculate differences between categorical variables.

RESULTS

A total of 218 dancers (33.7%) completed the questionnaire, 107 males (49.1%), and 111 females (50.9%). The mean age for men was 42 ± 15.9 and 36 ± 15.1 for women. 176 dancers (80.7%) reported 1 or more injuries. Foot, ankle, and lower leg injuries were reported most frequently, 49 males (45.8%), and 60 females (54.1%). No significant difference was found in the total number of injuries for the variables sex (P = .761) and discipline (P = .225). Significantly more head and neck injuries were identified in female Standard dancers (P < .001) compared to male dancers. Also, Standard dancers have more back injuries compared to dancers in both disciplines (P < .009).

CONCLUSION

With the described anthropometrics and an 80% lifetime prevalence of injuries, this group can be compared to other dance forms. Significant differences in injuries of the head and neck for female Standard dancers compared to male dancers and significantly more back injuries in Standard dancers compared to dancers in both disciplines were found. Future studies need to translate and validate existing questionnaires in Dutch for use in this population.

Validity and Reliability of the Pre-Adolescent Dance Injury and Participation Questionnaire (PADIP-Q)

INTRODUCTION

Dancers generally begin training in a variety of styles at a young age. Across ages and levels of participation, dancers are at high risk for injury. Most available injury surveillance tools, however, have been developed for adult populations. Valid, reliable tools that monitor injury and exposure of pre-adolescent dance populations are limited. Therefore, the purpose of this study was to determine the validity and reliability of a dance injury and participation questionnaire specifically for pre-adolescent private studio dancers.

METHODS

Four stages of validity and reliability testing assessed a novel questionnaire: initial design based on previous literature, expert panel review, cognitive interviews, and test-retest reliability. The target population was 8 to 12-year-olds who participate in at least 1 class/week at a private studio. Feedback from a panel review and cognitive interviews was incorporated. Test-retest analyses included Cohen's kappa coefficients and percent agreement for categorical variables, and intraclass correlation coefficients [ICCs (3,1)], absolute mean difference (md) and Pearson's correlation coefficients (r) for numerical data.

RESULTS

The final questionnaire was comprised of 4 sections: demographics, dance training history, current dance participation (previous 1-year and 4-months), and dance-related injury history (previous 1-year and 4-months). Items with categorical responses estimated kappa coefficients from 0.32 to 1.00, and percent agreement between 81% and 100%. For items with numeric responses, ICC estimates ranged between .14 and 1.00, r values between .14 and 1.00, and the largest absolute md was 0.46. The 4-month recall sections revealed higher agreement than the 1-year sections.

CONCLUSION

This valid pre-adolescent dance injury and participation questionnaire demonstrates good to excellent reliability across all items. To support participant completions, assistance from a parent/guardian is suggested. To move dance epidemiology research forward among private studio dancers aged 8 to 12 years, employment of this questionnaire is therefore recommended.

Relationships Between Common Preseason Screening Measures and Dance-Related Injuries in Preprofessional Ballet Dancers

OBJECTIVE: To examine modifiable and nonmodifiable factors for associations with dance-related injury among preprofessional ballet dancers over 5 academic years. DESIGN: Prospective cohort study. METHODS: Full-time preprofessional ballet dancers (n = 452; 399 female; median age [range], 15 years [11-21]) participated across 5 academic years at a vocational school. Participants completed baseline screening and online weekly injury questionnaires including dance exposure (hours/week). Zero-inflated Poisson regression models were used to examine associations between potential risk factors measured at baseline and self-reported dance-related injury. RESULTS: In count model coefficients, left one leg standing score (log coefficient estimate, -0.249 [95% CI: -0.478, -0.02]; P = .033) and right unipedal dynamic balance time (log coefficient estimate, -0.0294 [95% CI: -0.048, -0.01]; P>.001) carried a protective effect with increased years of training when adjusted for Athletic Coping Skills Inventory (ACSI) score. A significant association was found for left unipedal dynamic balance time and dance-related injury (log coefficient estimate, 0.013 [95% CI: 0.000, 0.026]; P = .045) when adjusted for years of training and ACSI score. There were no significant associations between dance-related injury and ankle and hip range of motion, active straight leg raise, or Y Balance Test measures. CONCLUSION: When adjusted for years of previous dance training and psychological coping skills, there was a significant association between limb-specific lumbopelvic control and dynamic balance tasks, as well as self-reported dance-related injury in preprofessional ballet. J Orthop Sports Phys Ther 2023;53(11):703-711. Epub 3 October 2023. doi:10.2519/jospt.2023.11835.

Dance-related musculoskeletal injury leading to forced time-loss in elite pre professional dancers - a retrospective study

OBJECTIVES

Describe the epidemiology of dance-related musculoskeletal injury leading to forced time-loss in elite pre-professional dancers and provide descriptive data on the prevalence concerning diagnoses, location, and injury type, stratified by gender and skill level.

METHODS

Retrospective cohort, over a 3-year period on a full-time pre-professional Portuguese dance school featuring 70 both gender students with a mean age of 14.87 years. A total of 110 injuries were analyzed. Non-parametric statistics were used.

RESULTS

The most prevalent diagnosis leading to forced time-loss in female dancers were Medial Tibial Stress Syndrome (MTSS), 14.29%, and Posterior Ankle Impingement Syndrome (PAIS), 7.14%, whereas in male dancers these were Hallux Sprain, 17.50%, and Lumbar Spine Joint Injuries, 7.50%. Differences were found in injuries' anatomical location between genders and in Incidence Proportion and Clinical Incidence between skill levels. 72.20% of the chronic injuries and 50.00% of the acute injuries occurred in Level III students.

CONCLUSIONS

With respect to forced time-loss injuries, male dancers were found to sustain more acute traumatic injuries and female dancers overuse, respectively, sprains and MTSS and PAIS. Identifying which injuries are most likely to lead to forced time-loss may be useful for helping health-care professionals in clinical decision-making and in developing more effective injury prevention and management strategies.

Pediatric Dance-Related Injuries Treated in Emergency Departments in the United States, 2000-2020

OBJECTIVE

This study investigated the characteristics and trends of children aged 3 to 19 years treated in US emergency departments for dance-related injuries.

METHODS

Retrospective analysis of data from the National Electronic Injury Surveillance System from 2000 through 2020 was conducted.

RESULTS

An estimated 489,119 children received emergency treatment for a dance-related injury, averaging 23,291 children annually, and the rate of injury increased 68.1% during the 21-year study period. Girls accounted for 80.3% and children aged 15 to 19 years accounted for 46.5% of cases. Sprains/strains were the most frequent diagnosis (44.4%), and lower extremities were the most commonly injured body region (56.4%). Compared with other body regions, patients aged 3 to 10 years were more likely to sustain head/neck injuries (odds ratio, 3.94, 95% confidence interval, 3.42-4.52) than 11- to 19-year-olds. Falls and noncontact mechanisms of injury accounted for 35.6% and 32.1% of injuries, respectively. Unstructured dance activity was associated with 30.8% of dance-related injuries overall and 67.0% among children aged 3 to 5 years. Ballet/pointe dancers frequently sustained lower extremity sprains/strains (39.2%). Compared with other dance types, break dancing was more commonly associated with injuries to an upper extremity than other body regions (odds ratio, 4.76, 95% confidence interval, 3.66-6.19).

CONCLUSIONS

The rate of pediatric dance-related injuries treated in US emergency departments is increasing. Unstructured dance activity was an important source of dance-related injury, especially among children aged 3 to 5 years. The injury diagnosis and body region injured varied by child age and type of dance. Additional targeted prevention efforts should be implemented that address the injury characteristics of dancer subgroups.

Female Collegiate Dancers' Physical Fitness across Their Four-Year Programs: A Prospective Analysis

Dance is physically demanding, requiring physical fitness (PF) that includes upper body, lower body, core fitness, and balance for successful performance. Whether PF changes as dancers advance from when they enter (freshmen) to when they graduate from their collegiate program (seniors) is unclear. We prospectively compared collegiate dancers' freshman-to-senior PF. We recorded PF in regard to upper body strength endurance (push-ups), core strength endurance (front, left-side, right-side, and extensor plank hold times), lower body power (single leg hop-SLH-distances % height; Leg Symmetry Index: LSI = higher/lower × 100, %), and balance (anterior reach balance, % leg length, LL; LSI balance = higher/lower × 100, %) in 23 female collegiate dancers (freshman age = 18.2 ± 0.6 years). Repeated measures ANOVAs (p ≤ 0.05) were used to compare measures from freshman to senior years. Across their collegiate programs, dancers' PF remained unchanged. Specifically, their upper body strength endurance push-up numbers (p = 0.93), their core strength endurance plank times (left: p = 0.44, right: p = 0.67, front: p = 0.60, p = 0.22), their SLH distances (left: p = 0.44, right: p = 0.85), and their symmetry (p = 0.16) stayed similar. Also, dancers' right leg (p = 0.08) and left leg balance (p = 0.06) remained similar, with better balance symmetry (p < 0.001) in seniors. Overall, dancers' PF did not change across their collegiate programs. Thus, female dancers' freshman PF may be an adequate baseline reference measure when devising rehabilitation programs and determining readiness-to-return-to-activity post injury.

Joint Hypermobility and Fatigue Are Associated With Injuries in a Group of Preprofessional Ballet Dancers

INTRODUCTION

Strenuous preprofessional ballet training places young students at an increased risk of injury. This represents a major concern for aspiring dancers since a link has been described between injury and dropping out. It is therefore important to identify physical and psychological factors related to injuries in dance for prevention purposes.

METHODS

In this cross-sectional study, we explored the frequency and characteristics of injuries, as well as their physical and psychological determinants in preprofessional ballet dancers. Seventy-three participants (women = 75.6%; mean age = 13.7; SD = 1.8) were evaluated with the Beighton criteria for joint hypermobility and self-questionnaires assessing injuries in the last 18 months, fatigue, fear of injury, and motivation.

RESULTS

Most of participants (61.6%) experienced injuries in the last 18 months, mainly in the lower limbs, and due to overuse. Multivariate analyses showed that joint hypermobility and fatigue predict injury status in this sample.

CONCLUSION

These results confirm previous reports suggesting that physical factors such as fatigue and joint hypermobility, that are frequent in ballet dancers, should be taken into account in order to prevent injuries.

Pain Perceptions, Suffering and Pain Behaviours of Professional and Pre-Professional Dancers towards Pain and Injury: A Qualitative Review

Limited data exist that describe the experiences of pain and injury in dancers. The purpose of the current study was to understand pain perceptions, suffering and pain behaviours associated with pre-professional and professional dancers and to consider the psychosocial factors that influence suffering, behaviour and perceptions of pain. A thematic synthesis review was undertaken in three stages: (1) A systematic search using pre-defined search terms was conducted until 17 November 2022. Qualitative studies were included if they captured dancers’ perceptions, experiences, or the behaviour of dancers towards pain and injury. (2) Quality appraisal and certainty assessments was performed. (3) A five-phase synthesis generated themes that included a certainty assessment score. Twelve studies with 290 dancers met the inclusion criteria. The aggregated mean age was identified as 28.5 years. No studies were excluded following the quality appraisal stage. Nine studies included professional ballet dancers. Three themes were developed: (1) developing positive and adapted perceptions and behaviours towards pain, (2) the impact and danger of embracing pain and the risk of injury and (3) factors that influenced the response to injury and the ability to perform. This review has highlighted the experiences of pre-professional and professional dancers towards pain and injury. Practical implications for healthcare professionals, employers, choreographers and dancers are provided. Further research is required given the limited evidence base.

Injury epidemiology in Chinese undergraduate classical dance students: A 14-week prospective study

OBJECTIVES

The aim of this study was to investigate the injury prevalence, incidence rate, injury proportions, and characteristics of injuries in Chinese undergraduate classical dance students by using the modified Oslo Sports Trauma Research Centre Questionnaire on Health Problems.

DESIGN

Prospective study.

SETTING

Online survey.

PARTICIPANTS

63 Chinese classical undergraduate students (female: 40, male: 23; median age: 20 years, range: 17-20 years) completed the survey.

MAIN OUTCOME MEASURES

The injury prevalence (proportions) and incidence rate were calculated. The characteristics (severity, locations, injury type) of injuries were investigated.

RESULTS

During the 14-weeks, 84% students reported injury occurrence more than one time. The injury incidence rate was 3.28 injuries per 1000h across 14-weeks. Weekly proportion for all injuries ranged from 38.2% to 61.9% and substantial injuries ranged from 7.5% to 22.7%. The lower back was the most frequently injured body location (38.9%), followed by the knee (17.3%) and the ankle (12.9%). In all reported injuries, overuse injury was the most prevalent type (78.9%, 95% CI: 73.2%-81.1%).

CONCLUSIONS

Chinese classical dance students are at a relatively high risk for injuries. Injury prevention programs in Chinese classical dance students should focus on the lower back and lower extremity.

Effects of a specific injury prevention neuromuscular training program for young female dancers. A randomized-controlled trial

To assess the effects of a specific injury prevention neuromuscular training programme (IPP) on balance and lower-limb asymmetry in female competitive dancers (age 12-20 years; height 1.57 ± 0.06 m; weight 24.27 ± 2.79 kg) were randomly allocated to an active general control (GIPP, n = 7) and specific (SIPP n = 7) group. Both programmes were conducted for 6 weeks, with a frequency of three sessions per week. Dynamic balance and lower-limb asymmetry were assessed before and after the intervention. A greater improvement in right-leg total balance (86.6[84.0-90.5] vs 93.8[86.7-99.4];p = 0.035), left-leg total balance(87.8[81.0-89.1] vs 93.6[90.6-100.0];p = 0.013), left-leg anterior balance (71.9[69.1-72.2] vs 74.6[72.0-77.3];p = 0.041), left-leg posteromedial balance (80.5[72.9-83.3] vs 85.9[83.0-94.0];p = 0.048), and left-leg posterolateral balance (79.5[70.4-84.5] vs 85.0[80.0-88.5];p = 0.048) was observed in the SIPP group compared to the GIPP group. No other significant intra-group changes nor inter-group differences were noted. Therefore, compared to a GIPP, a SIPP induced greater improvements in lower-limb dynamic balance in female dancers, potentially leading to greater reduction in lower-limb injury risk.

The Efficacy of Physical Fitness Training on Dance Injury: A Systematic Review

Greater levels of physical fitness have been linked to improved dance performance and decreased injury incidence. The aim was to review the efficacy of physical fitness training on dance injury. The electronic databases CINAHL, Cochrane Library, PubMed, Web of Science, MEDLINE, China National Knowledge Infrastructure were used to search peer-reviewed published articles in English or Chinese. Studies were scored using Strength of the Evidence for a Conclusion and a risk bias checklist. 10 studies met the inclusion criteria from an initial 2450 publications. These studies offered physical fitness training for professional (n=3) and pre-professional dancers (n=7), participant sample size ranged between 5 to 62, ages from 11 to 27 years, and most participants were females. Assessment scores were classified as Fair (n=1), Limited (n=7), and Expert Opinion Only (n=2) and risk of bias scores ranged from 22.7-68.2%. After physical fitness training, 80% of studies reported significant benefits in injury rate, the time between injuries, pain intensity, pain severity, missed dance activities and injury count. This review suggests that physical fitness training could have a beneficial effect on injury incidence in dance. The evidence is limited by the current study methodologies.

(Low) Energy Availability and Its Association with Injury Occurrence in Competitive Dance: Cross-Sectional Analysis in Female Dancers

Background and objectives: The risk of low energy availability is related to various health problems in sports. This cross-sectional study aimed to identify a possible association between various dance factors, anthropometrics/body build, and energy availability with injury occurrence in contemporary dancers. Materials and Methods: The participants were 50 female competitive dancers (19.8 ± 4.1 years of age). The independent variables included age, dance factors (amount of training and competitions per week–exposure time, experience in dance), anthropometrics/body composition (body height, mass, BMI, body fat percentage (BF%), and fat-free mass (FFM)), and energy availability score (EAS; evaluated by accelerometer-based measurement of energy expenditure and Dance Energy Availability Questionnaires). The dependent variables were the occurrence of (i) soft-tissue injuries and (ii) bone injuries. The measurements were obtained by experienced technicians during the pre-competition period for each specific dance discipline. Univariate and multivariate logistic regressions were calculated to identify the associations between independent variables and injury prevalence. Results: The results showed that EAS (OR = 0.81, 95% CI:0.65–0.91), age (OR = 1.65, 95% CI: 1.1–2.46), higher BF% (OR = 1.23, 95% CI: 1.04–1.46) and BMI (OR = 1.61, 95% CI: 1.05–2.47) were correlated with soft-tissue injuries. Dancers who suffered from bone injuries reported higher exposure time (OR = 1.21, 95% CI: 1.05–1.37) and had lower values of FFM (OR = 0.73, 95% CI: 0.56–0.98). Multivariate regression analyses evidenced a higher likelihood of soft-tissue injuries in older dancers (OR = 1.75, 95% CI: 1.21–2.95) and the ones who had lower EAS (OR = 0.84, 95% CI: 0.71–0.95) while the exposure time was associated with a higher likelihood of bone injuries (OR = 1.21, 95% CI: 1.05–1.39). Conclusions: In order to decrease the injury prevalence among dancers, special attention should be paid to maintaining adequate nutrition that will provide optimal available energy for the demands of training and performing. Additionally, the control of training volume should be considered in order to reduce traumatic bone injuries.

Injury Rates and Characteristics Associated with Participation in Organized Dance Education: A Systematic Review

INTRODUCTION

Several studies and recent systematic reviews have investigated injury in dance settings and have largely focused on specific concert dance genres (i.e., ballet, contemporary) and elite levels (i.e., pre-professional, professional) of dance. Less is known about the health of those who participate in dance education settings, namely teachers and students from private dance studios. Given that these individuals constitute a large proportion of the dance community, greater clarity of risks in the dance training environment could benefit an underserved majority by informing the development of effective injury prevention strategies.<br/> Objective: The primary objective was to describe injury rates and characteristics associated with participation in organized dance education settings.<br/> Methods: Six electronic databases were searched to April 2021 (Medline, EMBASE, SportDiscus, CINAHL, SCOPUS, Cochrane). Selected studies met a priori inclusion criteria that required original data from dance teacher and student samples within formal dance education settings. All genres of dance were eligible. Studies were excluded if no injury outcomes or estimates of dance exposure were reported, if injuries occurred during rehearsal and performance, or if dance was used as a therapeutic intervention or exercise. Two reviewers independently assessed each paper for inclusion at abstract and full text screening stages. The quality of included studies was assessed using the Joanna Briggs Institute Level of Evidence tool.<br/> Results: The initial database search identified 1,424 potentially relevant records, 26 were included and scored. Most studies (n = 22) focused on dance students only, three included only dance teachers, and one study included both. Among both dance students and teachers, the majority of injuries reported were overuse or chronic and involved the lower limb. For studies that reported injury rates (n = 14), estimates ranged from 0.8 to 4.7 injuries per 1,000 dance hours, 4.86 per 1,000 dancer-days, and 0.21 to 0.34 per 1,000 dance exposures.<br/> Conclusions: Based on the current research, dance students and teachers experience a similar rate of injury to concert and professional dancers, and their injuries are most commonly overuse injuries involving the lower extremity. There have been few high-quality investigations of injury specific to the dance training environment. Therefore, consensus around the burden of injury in the dance education settings remains difficult. Future dance epidemiological investigations that examine the burden of injury among dance teachers and students, include operational injury and exposure definitions, and utilize prospective designs are warranted.

Applications of Biomechanical Foot Models to Evaluate Dance Movements Using Three-Dimensional Motion Capture: A Review of the Literature

Dance movement requires excessive, repetitive range of motion (ROM) at the foot-ankle complex, possibly contributing to the high rate of injury among dancers. However, we know little about foot biomechanics during dance movements. Researchers are using three-dimensional (3D) motion capture systems to study the in vivo kinematics of joint segments more frequently in dance-medicine research, warranting a literature review and quality assessment evaluation. The purpose of this literature review was to identify and evaluate studies that used 3D motion capture to analyze in vivo biomechanics of the foot and ankle for a cohort of dancers during dance-specific movement. Three databases (PubMed, Ovid MEDLINE, CINAHL) were accessed along with hand searches of dance-specific journals to identify relevant articles through March 2020. Using specific selection criteria, 25 studies were identified. Fifteen studies used single-segment biomechanical foot models originally created to study gait, four used a novel two-segment model, and six utilized a multi-seg- ment foot model. Nine of the studies referenced common and frequently published gait marker sets and four used a dance-specific biomechanical model with purposefully designed foot segments to analyze the dancers' foot and ankle. Description of the biomechanical models varied, reducing the reproducibility of the models and protocols. Investigators concluded that there is little evidence that the extreme total, segmental, and inter-segmental foot and ankle ROM exerted by dancers are being evaluated during dance-specific movements using 3D motion capture. Findings suggest that 3D motion capture is a robust measurement tool that has the capability to assist researchers in evaluating the in vivo, inter-segmental motion of the foot and ankle to potentially discover many of the remaining significant factors predisposing dancers to injury. The literature review synthesis is presented with recommendations for consideration when evaluating results from studies that utilized a 3D biomechanical foot model to evaluate dance-specific movement.

Perceived Severity and Management of Low Back Pain in Adult Dancers in the United States

INTRODUCTION

Low back pain (LBP) lifetime prevalence in dancers reportedly ranges from 17% to 88%. Low back pain can have negative secondary consequences on dancers' lives and careers. Still, how LBP impacts dancer function and medical care-seeking behaviors and whether these issues differ across dance genres, is understudied.

MATERIALS AND METHODS

Two hundred and eight-nine ballet, modern, and hip-hop dancers and teachers (median age: 20.3 years; range: 18 to 69 years) in the United States completed an online 24-question survey assessing LBP related self-reported injury history, impact on their lives, and management strategies. We defined LBP as occurrence of acute or chronic pain in the lumbar or sacral regions of the back.

RESULTS

Two hundred and fifty-seven participants (88.9% of 289 total) reported at least one instance of LBP during their lifetime and 220 participants reported LBP in the prior 4 weeks. Of these 220, 72 (32.7%) had LBP severe enough to limit their activities of daily living. Of the 213 who had LBP and danced during that time, 89 (41.8%) reported that LBP limited their dancing. Pain intensity (median: 4 on a 0 to 10 scale, IQR: 3.0) and LBP prevalence were similar across dance genres. Dancers sought multiple medical professionals, most often chiropractors (n = 94, 33.8%), medical doctors (n = 77, 27.7%), and physiotherapists (n = 60, 21.6%). Ninety dancers (35.0% of those with LBP) never sought medical care. Dancers who did seek care reported higher pain intensities (median: 4, IQR: 3.8) than those who did not (median: 3, IQR: 3.0).

CONCLUSION

Overall, most participants did suffer from LBP. Low back pain negatively impacts dancers' everyday activities and dancing. Pain intensity and loss of function may impact care-seeking. Our findings highlight the need for all dance stakeholders to educate dancers about their health, provide resources for dancer health care, and proactively create an environment that supports injury reporting behaviors in dancers.

Biomechanical Risks Associated with Foot and Ankle Injuries in Ballet Dancers: A Systematic Review

Professional ballet dancers can be classified as dance artists and sports performers. This systematic review aims to consider the biomechanical risk factors for foot and ankle injuries in ballet dancers, as this could potentially reduce the impact that ‘cost of injury’ may have on ballet companies. An additional outcome was to examine the effects of injury on the career of ballet dancers. This study searched articles in four electronic databases for information in peer-reviewed journals. The included articles examined the relationships between biomechanical factors and the relationship between ballet shoes and foot performance. There were 9 articles included in this review. Among these articles, two focused on the peak force of the foot using two types of pointe shoes, three focused on overuse injuries of the ballet dancer’s foot, one article focused on the loading of the foot of a dancer, and three articles focused on the function and biomechanics of the foot in dancers. This review also found that the pointe shoe condition was the most important factor contributing to a foot injury; overuse injury related to high-intensity training and affected both the ankle and the foot; and metatarsophalangeal joint injury related to the function and structure of the foot. Finally, strengthening the lower extremity muscle is also a recommendation to improve muscle coordination and reduce injuries.

Substance Use in the Performing Artist with Chronic Pain

OBJECTIVES

To evaluate how performing artists (PAs) with chronic pain may differ on measures of substance use compared to non-PA controls.

METHODS

157 participants reporting chronic pain (89 PAs, 68 non-PA controls) completed an online cross-sectional survey. Participants were assessed for self-reported current pain severity using the Brief Pain Inventory Short-Form, opioid misuse risk using the Screener and Opioid Assessment for Patients with Pain-Revised, opioid withdrawal using the Subjective Opiate Withdrawal Scale, and symptoms of opioid use disorder (OUD) using a modified version of the DSM-V checklist.

RESULTS

PAs had lower pain severity (p <0.05, t=2.196, df=155) and lower pain interference (p <0.05, t=2.194) than non-PA controls. 24% of PAs and 13% of controls reported using opioids within the past month. Among PAs, the number of days using opioids in the past month was positively associated with hours spent practicing per week (r=0.508, p <0.05). PAs (66%) were more likely to endorse current alcohol use than controls (44.1%, t= -2.136, X2=7.72, p <0.01). Importantly, PAs (19%) were more likely than controls (3%) to endorse symptoms of at least mild OUD (X2(3)=11.3, p <0.01) and higher ratings of opioid misuse risk (t=-2.166, p <0.05). Past month opioid withdrawal was also greater in PAs than controls (t=-2.136, p <0.05), and 5.6% of PAs and 1.5% of controls reported at least one prior incidence incident of opioid overdose in their lifetime (X2 =1.80, NS).

CONCLUSIONS

Among persons with chronic pain, PAs may have higher risk for opioid-related consequences, including OUD, and should be screened during health care encounters.

Prevalence and Risk Factors of Dance Injury During COVID-19: A Cross-Sectional Study From University Students in China

Objectives: Although coronavirus disease 2019 (COVID-19) has transformed the training environment of dancers worldwide, little is known on how this has affected injury prevalence, causes, and risk factors. Methods: An online investigation involving Chinese full-time dance students was conducted (September-November 2020), which covered two 6-month periods just before and during the first COVID-19 lockdown. Results: 2086 students (19 ± 2.4 years) responded to the investigation. Injury prevalence dropped from 39.6% (before the lockdown) to 16.5% (during the lockdown) (p < 0.01). It was noted that a significant increase in injury severity during the lockdown was caused due to a 4.1% increase in moderate-to-severe injuries (p < 0.05). During the lockdown, the injuries on the lower back, feet, and shoulders decreased significantly (p < 0.01), but the knee, ankle, and groin/hip joint injuries remained the same. Fatigue and the recurrence of an old injury remained as the top two perceived causes of an injury between the two periods with the increase in an unsuitable floor (p < 0.01), a cold environment (p < 0.05), and set/props (p < 0.05). The fatigue degree of students decreased (p < 0.01) and their hours of sleep increased (p < 0.01) during the lockdown. Binary Logistic Regression analysis indicated that dance injury is associated with fatigue, the hours of sleep, and the actions taken if they suspect an injury during the lockdown (p < 0.05), but is only related to the time set aside for a cooldown and age before the lockdown period (p < 0.05). Conclusion: Although injury prevalence dropped significantly during the first COVID-19 lockdown in Chinese dance students, the main dance injury characteristics remained the same. Decreased fatigue and longer hours of sleep could explain the aforementioned drop in injury prevalence during the lockdown.

A Comprehensive Summary of Systematic Reviews on Sports Injury Prevention Strategies

Background

A large volume of systematic reviews and meta-analyses has been published on the effectiveness of sports injury prevention programs.

Purpose

To provide a qualitative summary of published systematic reviews and meta-analyses that have examined the effectiveness of sports injury prevention programs on reducing musculoskeletal injuries.

Study Design

Systematic review; Level of evidence, 4.

Methods

We searched the PubMed, CINAHL, EMBASE, and the Cochrane databases for systematic reviews and meta-analyses that evaluated the effectiveness of sports injury prevention programs. We excluded published abstracts, narrative reviews, articles not published in English, commentaries, studies that described sports injury prevention strategies but did not assess their effectiveness, studies that did not assess musculoskeletal injuries, and studies that did not assess sports-related injuries. The most relevant results were extracted and summarized. Levels of evidence were determined per the Oxford Centre for Evidence-Based Medicine, and methodological quality was assessed using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews, revised version).

Results

A total of 507 articles were retrieved, and 129 were included. Articles pertaining to all injuries were divided into 9 topics: sports and exercise in general (n = 20), soccer (n = 13), ice hockey (n = 1), dance (n = 1), volleyball (n = 1), basketball (n = 1), tackle collision sports (n = 1), climbing (n = 1), and youth athletes (n = 4). Articles on injuries by anatomic site were divided into 11 topics: general knee (n = 8), anterior cruciate ligament (n = 34), ankle (n = 14), hamstring (n = 11), lower extremity (n = 10), foot (n = 6), groin (n = 2), shoulder (n = 1), wrist (n = 2), and elbow (n = 1). Of the 129 studies, 45.7% were ranked as evidence level 1, and 55.0% were evidence level 2. Based on the AMSTAR-2, 58.9% of the reviews reported a priori review methods, 96.1% performed a comprehensive literature search, 47.3% thoroughly described excluded articles, 79.1% assessed risk of bias for individual studies, 48.8% reported a valid method for statistical combination of data (ie, meta-analysis), 45.0% examined the effect of risk of bias on pooled study results, and 19.4% examined the risk for publication bias.

Conclusion

This comprehensive review provides sports medicine providers with a single source of the most up-to-date publications in the literature on sports injury prevention.

Association between pre-participation characteristics and risk of injury amongst pre-professional dancers

STUDY DESIGN

Prospective Cohort Study.

BACKGROUND

Few investigations utilize evidence-informed pre-participation evaluation, inclusive injury definitions, and prospective surveillance to identify risk factors for dance-related injuries.

OBJECTIVE

To evaluate pre-participation characteristics that may be associated with greater odds of dance-related musculoskeletal complaints in pre-professional dancers.

METHODS

Full-time pre-professional ballet [n = 85, 77 females, median (range) age 15-years (11-19)] and contemporary [n = 60, 58 females, 19-years (17-30)] dancers underwent pre-participation evaluation: baseline questionnaire, coping skills, body mass index, bone mineral density, ankle range-of-motion, active standing turnout, lumbopelvic control, and balance tests. Self-reported complaints (any physical problem making dance participation difficult, irrespective of medical attention or time-loss) were captured weekly via online questionnaires for one academic year. Self-reported musculoskeletal complaints were recorded weekly (yes/no). Potential risk factors were identified a-priori through systematic review. Associations between potential risk factors and musculoskeletal complaints were examined with generalized linear mixed method regression models.

RESULTS

Response rate was 99%, with 81% of dancers reporting at least one musculoskeletal complaint. Of 1521 complaints (19% first-time, 81% ongoing), the ankle (22%), knee (21%), and foot (12%) accounted for the majority. Injury history [odds ratio (OR) 7.37 (95% CI 3.41, 15.91)] and previous week's dance hours [OR 1.02 (1.01, 1.03)] were associated with dance-related musculoskeletal complaints.

CONCLUSIONS

Prevalence of musculoskeletal complaints amongst pre-professional dancers is high and associated with injury history and training volume. Further understanding of the relationship between training load and injury is needed, with particular consideration of the dynamic and recursive nature of dance injury etiology.

LEVEL OF EVIDENCE

Therapy / Prevention, Aetiology / Harm, level 2b.

Prevalence of overuse injuries in athletes from individual and team sports: A systematic review with meta-analysis and GRADE recommendations

BACKGROUND

Overuse injuries result from the cumulative process of repetitive microtrauma and overload on the musculoskeletal system, which causes tissue damage. Therefore, these injuries may have long-term negative consequences that decrease an athlete's performance.

OBJECTIVE

To estimate the prevalence of overuse injuries in individual and team sports.

METHODS

Searches on MEDLINE, EMBASE, SPORTDiscus, and CINAHL from the first registration to February 2021 and hand-searching identified studies investigating the prevalence of overuse injuries in athletes from individual and team sports. Meta-analysis was conducted and the GRADE system summarized the overall quality of evidence. This review was registered in PROSPERO (CRD42019135665).

RESULTS

Seventeen studies were included and pooling of 24 704 participants (22 748 of individual sports and 1.956 of team sports). Data from point- and period-prevalence of overuse injuries in individual and team sports were obtained. Pooled period-prevalence of overuse injuries in individual and team sports was 42.0% (95% CI: 30.0, 55.0) and 33.0% (95% CI: 21.0, 49.0), respectively. Another four studies investigated point-prevalence. The overall quality of evidence for the period-prevalence was of moderate quality. Sensitivity analyses suggested that different joints based in individual and team sports tended to increase the estimated prevalence of overuse injuries.

CONCLUSION

Athletes, clinicians, sport teams, and policymakers should be aware of the high prevalence of overuse injuries in athletes, especially, in athletes from individual sports. Current moderate-quality evidence shows that future high-quality studies are likely to impact on the estimated prevalence.

A Physiotherapeutic Approach to Musicians' Health - Data From 614 Patients From a Physiotherapy Clinic for Musicians (INAP/O)

Currently, the treatment of musicians is an interprofessional approach. Playing-related health complaints may impact the performance of a musician. In Germany, a medical consulting hour for musicians exists, but those for athletes in sports medicine are not so common. The diagnosing and treatment procedure within the physiotherapy consultation for musicians follows a specific concept-b and requires knowledge of instruments and musician-specific complaints. Based on the consulting hour in a clinic in Osnabrueck, 614 case reports were part of this sample, of which 558 data sets were complete. The focus of the analysis is the instrument and the primary complaint. Also, the type of therapy is characterized, and the amount is calculated. Primary complaints of musicians, in general, are found most frequently in the spine and upper extremity. Musician complaints are different between instruments. Instrumentalists have a significantly higher chance to suffer from a primary complaint in the area of the upper extremity. Furthermore, the groups without an instrument (e.g., singing or dancing) are developing complaints in the anatomical area which they primarily use. Therefore, these types of therapy were used: physiotherapy, manual therapy, and osteopathy with an average of 5.9 treatment units. This study underpinned the importance of musician-specific physiotherapy as a profession to treat musicians. Also, an interdisciplinary approach is necessary to treat all aspects of complaints.

Hip Instability in Ballet Dancers: A Narrative Review

BACKGROUND

Dancers possess a large degree of hip range of motion that results from a combination of innate and acquired osseous morphology and permissive soft tissues. Generalized hypermobility in dancers may predispose them to a spectrum of hip instability. The objective of this narrative review is to discuss the anatomical characteristics, pathogenesis, risk factors, clinical signs and symptoms, management, and outcomes of hip instability treatments in dancers.

METHODS

A retrospective search was performed beginning November 1, 2017, for English language articles regarding hip stability in the dancer. Key words used included but were not limited to: dance(r), ballet, hip, hypermobility, range of motion, instability, microinstability, and laxity. PubMed, Scopus, and MEDLINE databases were used.

RESULTS

Forty-three studies were analyzed. Groin pain was found to be the most common presenting symptom of hip instability. A variety of impingement and instability signs may be elicited during physical examination. Hypermobility is frequently observed and is thought to be a necessity for participation in elite levels of ballet. Radiographs and advanced planar imaging (magnetic resonance imaging and computed tomography) should be scrutinized to evaluate for dysplasia, cam, pincer, subspine, and rotational morphologies. Dysplasia (low volume acetabulum), cam morphology, femoral retroversion, and coxa valga are common findings in the ballet dancers' hip. Labral injuries and ligamentum teres tears are common and may potentiate instability in the hip. Management options include education, oral non-opioid medications, activity modification, exercise prescription, and surgery. Reported outcomes of these treatments in ballet are limited.

CONCLUSION

Hip hypermobility is prevalent in the ballet population and is a clear advantage. However, it may increase the risk of instability. It is important to identify the multifactorial osseous and soft tissue etiology of hip or groin pain in dancers. Practitioners should have a high level of suspicion for hip instability in the dancer presenting with hip pain and treat accordingly. There is a significant need for increased quantity and quality of investigation into the outcomes of treatment for hip instability in the dancer.

Upper-Body Strength Endurance and Power Norms in Healthy Collegiate Dancers: A 10-year Prospective Study

ABSTRACT

Coogan, SM, Hansen-Honeycutt, J, Fauntroy, V, and Ambegaonkar, JP. Upper-body strength endurance and power norms in healthy collegiate dancers: A 10-year prospective study. J Strength Cond Res 35(6): 1599-1603, 2021-Dance is physically demanding and requires dancers to have adequate upper body (UB), core, and lower-body fitness to perform successfully. 50-85% of dancers suffer injury during a performance season. Although a large number of dancer's injuries are to the lower body, several dance genres (e.g., modern, hip hop, and salsa) use UB motions such as partner lifts and holds, which may result in a higher risk for UB injury. Health care practitioners often use baseline physical performance normative values to determine their clients' fitness levels and when planning training programs to prevent or rehabilitate postinjury. Still, little information exists regarding UB fitness norms among collegiate dancers. Thus, our purpose was to determine UB strength endurance and power norms in healthy collegiate dancers. We recorded UB muscular fitness in 214 healthy collegiate dancers (males: n = 26, 174.0 ± 6.7 cm, 71.3 ± 9.2 kg and females: n = 188, 163.0 ± 6.1 cm, 59.3 ± 6.8 kg) prospectively over a 10-year period (2008-2018) in a dance program that emphasizes modern and ballet dance. For UB strength endurance, we recorded the number of push-ups a dancer was able to perform without forcibly straining or losing form for 2 consecutive repetitions. For UB power, dancers sat with legs outstretched, backs flat against a wall, and threw a 3-kg ball horizontally from their chest as far as possible (distance thrown normalized to body height, *BH). The best attempt of 3 trials was used for statistical analyses. We report descriptive statistics, interquartile ranges (IQRs), and percentiles for both outcome measures. Dancers performed 20.4 ± 10.6 (range: 2-70, IQR: 12-24; males: 32.5 ± 14.4; females: 18.4 ± 8.4) push-ups and threw the medicine ball 1.8 ± 0.5 *BH (range: 45-3.9, IQR: 1.4-2.1; females: 1.7 ± 0.5; males: 2.3 ± 0.7). Overall, in this long-term prospective study, we developed UB fitness norms for dancers. The push-up test and medicine ball throw test are simple, low-tech, and inexpensive to test dancers UB fitness. Although dancers' UB muscular fitness was lower than previous reports among traditional sport athletes, these values may not necessarily indicate problems, as subjects were all healthy collegiate-level dancers. Rather, our findings reinforce the need to develop dance-specific norms so that practitioners can use these values to assess dancers' UB fitness and devise interventions appropriately. These results provide baseline UB muscular fitness norms among collegiate modern and ballet dancers, and further support the notion that differing norms are needed for different sports and dance genres. Specifically, future researchers should similarly develop norms across different dance genres for preprofessional and professional dancers and also examine whether these norms can predict dancers' injury risk or performance.

Determinants of pain occurrence in dance teachers

OBJECTIVES

Dance teachers are strongly dependent on their functional body in their professional practice. As yet, it has largely been unclear whether the musculoskeletal system is endangered by a dance teaching activity. Pain can be a warning signal for a health hazard. The aims of the study were (a) to determine the pain prevalence, location and assessment of dance teachers and (b) to identify determinants of pain occurrence over a 3-month period prior to the survey.

METHODS

The quantitative, retrospective cohort study was conducted with n=166 dance teachers by an anonymous online survey. The data on the study sample, professional practice and pain prevalence, location and assessment were presented descriptively. A binary logistic regression was used to identify determinants of pain occurrence in the last 3 months from the sample parameters and the data of professional practice.

RESULTS

In the 3-month period n=143 (86.1%) of dance teachers had been in pain, often localized in the lower back and lower extremities. In the binary logistic regression model, the Body mass index (BMI) (odds ratio (OR)=1.15, 95% CI: 0.93-1.42, p=0.18), age (OR=1.03, 95% CI: 0.99-1.08, p=0.11) and the presence of disease (OR=2.81, 95% CI: 0.78-10.15, p=0.12) were identified as determinants of pain occurrence (LR-Chi²=7.8, p<0.05, pseudo R²=0.06, n=160).

CONCLUSIONS

Pain occurs in dance teachers under multifactorial conditions. Pain occurrence seems to be favored by context factors, such as the BMI, age and the presence of diseases. However, none of these factors could be identified as a significant, clear risk factor for the occurrence of pain in this sample. Education and preventive measures, that consider pain as a warning signal, should take effect early in the dance career.

Risk Factors for Lower-Extremity Injuries in Female Ballet Dancers: A Systematic Review

BACKGROUND

Ballet dancers have a high prevalence of injuries to the lower extremity. Many studies have investigated the relationship between dance injury and risk factors. However, risk factors for lower-extremity injury comparing recreational- and elite-level ballet dancers are scarce.

OBJECTIVE

To systematically review available original studies to assess risk factors for lower-extremity injury in female ballet dancers between recreational and elite ballet dancers.

DATA SOURCES

Five online databases [Web of Science, PubMed, OVID (Medline), EBSCO, and ProQuest] were searched systematically.

STUDY SELECTION

Included studies had an analytic study design published in the past 11 years and investigated an association between potential risk factors and lower-extremity injury in female ballet dancers.

STUDY APPRAISAL

Assessed independently by 2 reviewers using the Downs and Black (DB) criteria and Oxford Centre of Evidence-Based Medicine.

RESULTS

Seventeen studies were included. Alignment was a risk factor for lower-extremity injury in both recreational and elite ballet dancers. In elite ballet dancers, poor lumbopelvic movement control, inappropriate transversus abdominis contraction, decreased lower-extremity strength, and poor aerobic fitness were risk factors for lower-extremity injury. In recreational ballet dancers, hypermobility of the hip and ankle and longer training hours were risk factors for lower-extremity injury. Mean DB score was 15.94 (SD 1.57). The majority of studies were retrospective cohort studies or had poor follow-up, with 7 level 2b studies, 6 level 3b studies (cross-sectional), and 4 level 1b studies (prospective cohort with good follow-up).

CONCLUSIONS

Alignment was identified as a common risk factor for recreational and elite ballet dancers. Other risk factors differed between recreational ballet dancers and elite ballet dancers. Future studies are warranted to use a prospective study design, identify dance level-specific risk factors, and implement evidence-based prevention strategies.

Determinants of Pain Intensity in Physical Education Teachers Focusing on Dance Teachers: A Cross-Sectional Study

(1) Background: Dance teachers (DT) are dependent on their functional body. Pain can hardly be avoided during the professional practice of dance. Pain can become so intense that it impairs, or even prevents, the professional practice. The aim of this study was to identify the determinants of pain intensity of the most severely affected body regions of DT in pain during the three-month period prior to the survey. (2) Methods: This cross-sectional study was conducted by an online survey. A total of 166 DT participated in the study; 143 of the DT were in pain during the three-month period and were included in the analysis. Using multiple linear regression, the determinants of pain intensity were identified from population parameters, occupational data, pain localisation, and temporal pain course. (3) Results: Regions of the lower extremity and head/trunk regions were most frequently indicated as the body regions with the most severe pain. The multiple regression model generated with the factors “functional impairment”, “biomechanical exposure”, and “pain at rest” explains a statistically significant, moderate proportion of the variance in pain intensity (R² = 0.22, F (3, 106) = 10.04, p < 0.001). (4) Conclusions: Intensity of pain in DT seems to be related to the physical demands of professional practice.

[Fatigue and quality of life among professional ballroom dancers in Brazil]

The scope of this study was to analyze the relationship between quality of life, fatigue and injuries among professional Brazilian ballroom dancers. A total of 320 professionals from the five regions of Brazil participated, and the data were collected through a self-administered online questionnaire concerning general information, WHOQOL-bref, Yoshitake Fatigue Questionnaire and Injury Identification in Dancers Questionnaire. For data analysis, descriptive statistics were used, followed by inferential analysis and the Multiple Linear Regression test. The results show that greater fatigue is associated with a negative quality of life, revealing that, for each additional increment in total fatigue, the quality of life is expected to decrease by 0.218 points in the physical domain; 0.226 points in the psychological domain; 0.420 points in the social domain; and 0.304 points in the environmental domain. In contrast, the incidence and intensity of injuries were not associated with quality of life. The conclusion drawn is that the context of professional ballroom dance can influence both the presence of fatigue and the quality of life. It is suggested that health professionals working with these dancers perform multifactorial interventions in order to reduce fatigue, attenuating its effects on quality of life.

Predicting Injury Status in Adolescent Dancers Involved in Different Dance Styles: A Prospective Study

The positive effects of dance on health indices in youth are widely recognized, but participation in dance is accompanied with a certain risk of injury. This prospective study aimed to investigate injury occurrence and to evaluate the possible influences of specific predictors on the occurrence of musculoskeletal problems and injuries in adolescent dancers. Participants were 126 dancers (21 males; 11–18 years), who were competitors in the urban dance, rock and roll, and standard/Latin dance genres. Predictors included sociodemographic factors, anthropometric/body build indices, sport (dance) factors, and dynamic balance. The outcome variable was injury status, and this was evaluated by the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC). Predictors were evaluated at baseline, and outcomes were continuously monitored during the study period of 3 months. During the study course, 53% of dancers reported the occurrence of a musculoskeletal problem/injury, and dancers suffered from an average of 0.72 injuries over the study period (95% CI: 0.28–1.41), giving a yearly injury rate of 280%. Gender and dance styles were not significantly related to the occurrence of injury. Higher risk for injury was evidenced in older and more experienced dancers. Dynamic balance, as measured by the Star Excursion Balance Test (SEBT), was a significant protective factor of injury occurrence, irrespective of age/experience in dance. Knowing the simplicity and applicability of the SEBT, continuous monitoring of dynamic balance in adolescent dancers is encouraged. In order to prevent the occurrence of musculoskeletal problems/injuries in youth dancers, we suggest the incorporation of specific interventions aimed at improving dynamic balance.

Analysis of Postural Risk and Pain Assessment in Bharatanatyam Dancers

Background:

Bharatanatyam dance form is an amalgamation of emotion, rhythm, expression, and sculpturesque poses that demand high levels of physical and psychological power during a performance.

Objectives:

To explore musculoskeletal pain and analyze risk factors in Bharatanatyam dancers. The level of injury risk for the “Natyarambham” posture adopted by dancers was also assessed.

Materials and Methods:

A cross-sectional study was conducted in forty female Bharatanatyam dancers who received a minimum of 5 consecutive years of formal dance training from a recognized dance institute. A self-designed questionnaire comprising of demographic profile, dancing characteristics, presence of musculoskeletal pain, and specific area of pain according to the body region was administered. The injury risk of the “Natyarambham” posture was evaluated using a rapid entire body assessment tool (REBA).

Results:

Among 40 female dancers, 75% dancers (n = 30/40, 75% [95% CI 0.61, 0.89] reported pain. The most common site of pain was the low back (n = 22/40, 55% [95% CI 0.39, 0.71]). Using Bonferroni correction for multiple independent comparisons, a significant difference was identified between dancers with and without pain for average performances per year (P = 0.028). As per REBA risk level scoring for Natyarambham posture, 62.5% (n = 25/40, 62.5% [95% CI 0.22, 0.53]) dancers were in the category of high-risk level.

Conclusion:

The findings of this study indicated that the point prevalence of pain in Bharatanatyam dancers is high. Natyarambham posture is considered high risk based on postural assessment.

The effects of acute physical fatigue on sauté jump biomechanics in dancers

Dancers spend large amounts of time practicing and performing, where fatigue may occur, resulting in adverse movement patterns. The purpose of this study was to compare sauté landings before and after acute physical fatigue in experienced female dancers. Twenty-one dancers completed 10 sauté jumps before and after a dance-specific fatigue protocol. A 12-camera motion capture system and a force plate were utilized to collect three-dimensional kinematic and kinetic data. After fatigue, dancers demonstrated an increase in mediolateral centre of mass displacement, pelvis excursion, peak knee abduction, peak ankle eversion and external rotation, as well as decreased peak metatarsophalangeal (MTP) joint extension, indicating less desirable movement patterns. Peak vertical ground reaction force was decreased after fatigue due to a softer landing strategy, demonstrated by increased peak hip flexion, knee flexion, and ankle dorsiflexion. There was some indication of shifting demands demonstrated by an increased peak knee extensor moment and decreased peak MTP flexor moment after fatigue. With jump landing kinematics and kinetics affected after only an average of 5 minutes of dancing, dancers may benefit from developing greater endurance and more eccentric strength to allow them to slow down properly while landing and to sustain the aesthetic demands throughout performance.

Nutrition Periodization in Dancers

Dancers' energy demands fluctuate across the season. Accordingly, dancers should adapt their training and nutrition. Still, how to periodize nutrition in dancers remains unclear. This article aims to (1) introduce nutrition periodization and (2) provide recommendations for nutrition periodization in dancers. During preseason, dancers design, rehearse, and train. During in-season, dancers have one or more daily performances. During postseason, dancers rest and prepare for the next season. Nutrition periodization is the strategic and timed nutrient intake to meet varying seasonal energy demands. Overall, nutrition periodization can support dancers' training goals, enhance their performance, and support optimal recovery.

Supplemental Training in Dance: A Systematic Review

Dancing, like athletics, is physically demanding, but dancing also involves aesthetics. Although athletes often use supplemental training, little information exists about its use in dancers. A review of types and effects of supplemental training on dancers' performance and injury risk indicates that, among largely female collegiate dancers, supplemental training enhances the dancers' performance, but limited evidence exists for injury risk reduction.

Choreography-Specific Cross-Training and Conditioning Programs

Because of increased choreographic demands, early specialization, multi-genre dancers, and high incidence of career-ending injuries, there is a need for enhanced training methodologies to address the unique needs of today's professional dancer. It is imperative for company directors, instructors, choreographers, and dance medicine practitioners to consider implementing the most specific conditioning and training programs to prepare their dancers to meet or exceed expectations without resultant injury. Quantifying effectiveness of choreography-specific training programs is an area for further research. The implementation of scientific principles can and should be used to enhance dancers' health, performance, athleticism, and artistry.

Access to Health Care Among Dancers

Dancers require a unique blend of artistry and athleticism, and have specific medical problems that require the expertise of health care professionals who understand the demands of the performing arts. There is often a lack of alignment between health care systems and dancers' perceptions of care. Factors including country of residence, socioeconomic status, and local infrastructure can affect dancers' access to health care. Efforts to improve access are evident, and specialized care for dancers has grown significantly in recent decades. By developing and refining systems of care delivery, there are opportunities to ensure optimal health of the dancer population.

Does forced or compensated turnout lead to musculoskeletal injuries in dancers? A systematic review on the complexity of causes

Injury prevalence in dancers is high, and misaligned turnout (TO) is claimed to bear injury risk. This systematic review aimed to investigate if compensating or forcing TO leads to musculoskeletal injuries. A systematic literature review was conducted according to the PRISMA Guidelines using the databases of PubMed, Embase, Emcare, Web of Science, Cochrane Library, Academic Search Premier, and ScienceDirect. Studies investigating the relationship between compensated or forced TO and injuries in all genders, all ages, and levels of dancers were included. Details on misaligned TO measurements and injuries had to be provided. Screening was performed by two researchers, data extraction and methodological quality assessment executed by one researcher and checked by another. 7 studies with 1293 dancers were included. Methodological quality was low due to study designs and a general lack of standardised definition of pathology and methods of assessment of misaligned TO. The studies investigating the lower extremities showed a hip-focus only. Non-hip contributors as well as their natural anatomical variations were not accounted for, limiting the understanding of injury mechanisms underlying misaligned TO. As such no definite conclusions on the effect of compensating or forcing TO on musculoskeletal injuries could be made. Total TO is dependent on complex motion cycles rather than generalised (hip) joint dominance only. Objective dual assessment of maximum passive joint range of motion through 3D kinematic analysis in combination with physical examination is needed to account for anatomical variations, locate sites prone to (overuse)injury, and investigate underlying injury mechanisms.

LOW BACK PAIN AND INJURY IN BALLET, MODERN, AND HIP-HOP DANCERS: A SYSTEMATIC REVIEW

Background

Low back pain is believed to be a common complaint among dancers; however, a comparison across recent research is needed to support or disprove this assertion across genres.

Purpose

To determine the prevalence of low back pain and low back injury in ballet, modern, and hip-hop dancers through a systematic literature review. A secondary goal was to identify trends amongst dance genres, level of mastery, gender, and age, if possible.

Study Design

Systematic Review of the Literature.

Methods

PRISMA search strategy of terms relating to dance and low back pain was conducted within the Pubmed, MEDLINE, SPORTDiscus, Web of Science, and the archives of the Journal of Dance Medicine and Science databases between November 2017 and March 2018. Inclusion criteria were published articles that addressed low back pain or injury in ballet, modern, or hip-hop dance population. Exclusion criteria included studies relating to specific pathologies or studies that did not report specific dance genre. All included articles were assessed for quality using a modified grading evaluation and a Modified Newcastle-Ottawa Risk of Bias assessment.

Results

Twenty-five ballet articles, five modern, and three hip-hop articles met the inclusion criteria, for a total of 33 articles. Twenty-five of the 33 studies relied on a questionnaire to gather data. Risk of bias results ranged from 3-7/10 and quality of studies ranged from Good I to Limited III. Prevalence of low back pain seems relatively high in ballet dance (range: 20.3%-79% of total dancers are affected). Little research exists on the prevalence of back pain in modern or hip-hop dancers, but hip-hop dancers also seem likely to have low back pain (range: 46.6%-85.7% of total dancers are affected). Low back injuries are also present in ballet (range: 2.1%-88% of total injuries), modern (range: 8.6%-21.6% of total injuries), and hip-hop (range: 26.3%-69.6%).

Conclusion

Ballet dancers seem to be at risk for low back pain or injury independent of gender, age or level of mastery; however, there is not enough evidence to draw any conclusions about modern dancers or hip-hop dancers and their risk for low back pain/injury currently. Future higher-level studies are needed with reduced risk of bias.

Level of Evidence

2a.

Injury Occurrence in Modern and Hip-Hop Dancers: A Systematic Literature Review

Introduction

Dance-related injuries have become a field of great interest to researchers, with the most commonly reported injuries being those sustained by ballet dancers. However, there is a lack of research into injuries sustained by those who perform modern and hip-hop dance.

Methods

A systematic literature review using the MEDLINE research database was performed and a search carried out for full-text studies that investigate injuries in modern and hip-hop dance.

Results

While a total of 74 hits were obtained from various searches, only nine studies were included in the systematic literature review. Six of them examined modern dancers, two examined break dancers and one examined hip-hop dancers. The results show that hip-hop dancers (and especially break dancers) sustain more injuries in comparison to modern dancers. The most common injuries are in the lower extremities, with studies revealing that overuse injuries occur in up to 71% of cases.

Conclusions

The injury incidence rate in hip-hop dance seems to be higher compared to modern dance, chiefly because of the more demanding biomechanics involved and the dance techniques employed. Prevention management can have a positive effect on the number of injuries.

Isokinetic ankle eversion and inversion strength profiling of female ballet dancers

Ankle injuries are highly prevalent in ballet, with strength highlighted as a primary risk factor. To profile ankle strength, fourteen female ballet dancers (age: 19.29 ± 1.59 years) completed an isokinetic testing protocol comprising concentric eversion (CON_EV) and inversion (CON_INV), and, eccentric inversion (ECC_INV) trials at four angular velocities (30° · s^-1, 60° · s^-1, 90° · s^-1, 120° · s^-1) for both the dominant and non-dominant limb. In addition to Peak Torque (PT) and the corresponding Dynamic Control Ratios (DCRs), angle-specific derivatives of strength (AST) and Functional Range (FR) were calculated. There was no evidence of any significant bilateral strength asymmetry (p = 0.90) across all metrics, and no significant interactions with limb and contraction mode or velocity. A significant main effect for contraction mode (p = 0.001) highlighted greater ECC_INV strength - which was maintained with increasing isokinetic velocity - in contrast to reductions in CON_EV and CON_INV strength. Specifically, dancers are ECC_INV dominant at angular velocities greater than 60° · s^-1, which is likely to be characteristic of most functional tasks. The lack of bilateral asymmetry may be attributed to dance training interventions that facilitate bilateral development, but ipsilateral mode and velocity-specific asymmetries have implications for injury risk and the training needs of female ballet dancers.

Surgical Outcomes of Os Trigonum Syndrome in Dancers: A Case Series

Background

Management of ankle pain in dancers can be challenging because of the repetitive stress and complex demands placed on this region. Despite the prevalence of ankle injuries in this population, literature on surgical outcomes and return to dance is limited.

Purpose

To retrospectively evaluate the efficacy and functional outcomes after surgical excision of a symptomatic os trigonum in dancers.

Study Design

Case series; Level of evidence, 4.

Methods

Between June 2006 and June 2016, a total of 44 dancers underwent surgical excision of a symptomatic os trigonum at a single institution and by a single surgeon. All patients presented with symptoms of posterior ankle impingement syndrome and subsequently failed nonsurgical treatment. Clinical analysis was conducted using various pre- and postoperative patient-reported outcome questionnaires, including the Veterans RAND 12-Item Health Survey (VR-12), Foot Function Index-Revised (FFI-R), and visual analog scale (VAS) for pain, as well as subjective patient satisfaction.

Results

A total of 44 patients (54 ankles; mean age, 18.2 years) were retrospectively evaluated at a mean follow-up of 33.4 months. The VR-12 Physical Health score improved from a mean score of 37.8 ± 11.9 to 51.2 ± 10.5 (P < .001). The cumulative FFI-R score improved from 46.45 ± 13.8 to 31.2 ± 9.7 (P = .044), with the subcategory of "activity limitation" representing the highest-scoring FFI-R subcategory at 65.28 ± 13.4 preoperatively and improving to 34.47 ± 12.4 at follow-up (P < .001). The mean VAS score for subjective pain improved significantly from 5.39 ± 2.84 to 1.73 ± 2.10 (P < .00044).

Conclusion

Overall, the findings of the present study demonstrate that dancers of varying style and level improved significantly according to various clinical measures. Patients included in this study reported that they returned to their previous level of dance upon completion of physical therapy and maintained thriving postoperative careers, which for several meant dancing at the professional level.

An Injury Prevention Program for Professional Ballet: A Randomized Controlled Investigation

BACKGROUND

Few investigations have examined dance-specific injury prevention programs (IPPs), and no published randomized controlled trials are available that evaluate IPPs for dance.

HYPOTHESIS

The implementation of an IPP will significantly reduce the risk of injury in professional ballet dancers.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A randomized controlled trial was designed that entailed a superiority model for the intervention group. All professional dancers from a single ballet company were eligible to participate. Randomization and allocation were performed before the start of the season. The control group practiced and performed without change to preexisting standard operating practice. The IPP group was instructed to perform a 30-minute exercise program 3 times per week over the 52-week study period. Injuries were recorded. Standard continuous and categorical data comparisons and correlations were used. Cox proportional hazards regression models for recurrent failures were used wherein the hazard ratio indicates the relative likelihood of injury in the control versus intervention groups.

RESULTS

Of the 52 eligible dancers, 75% (n = 39) participated. Of these 39 dancers, 19 (9 males, 10 females; mean age, 26.6 ± 4.0 years) were randomized to the control group and 20 (11 males, 9 females; mean age, 25.1 ± 5.1 years) to the IPP group. No significant (P > .05) difference was found in baseline demographics between groups. A total of 116 injuries were recorded for the entire study population (49 IPP; 67 control). Traumatic and chronic injuries accounted for 54% and 46% of injuries, respectively. The injury rate was 82% less (IPP hazard ratio, 0.18; z = -2.29; P = .022) in the IPP group after adjustment for confounding variables, and time between injuries was 45% longer (IPP hazard ratio, 0.55; z = -2.20; P = .028) than for controls.

CONCLUSION

The present study is the first prospective randomized controlled investigation of an IPP for professional ballet. The results showed an 82% decrease in injury rate for the intervention group and an extended period from previous injury to subsequent injury.

REGISTRATION

NCT04110002 (ClinicalTrials.gov identifier).

Injuries during transition periods across the year in pre-professional and professional ballet and contemporary dancers: A systematic review and meta-analysis

OBJECTIVE

To consider the association of injuries with transition periods in the dance year, i.e., when dancers return at the start of the year, and when they transition from rehearsal to performance periods.

METHODS

Six electronic databases were searched to November 2019. All English language peer-reviewed studies, of any study design investigating ballet and contemporary pre-professional and professional dance populations were included. Only those studies reporting on the timing of injury were included.

RESULTS

Fifteen cohort and two case-series studies were included. A meta-analysis of seven studies revealed the rate of injuries to be significantly higher for the second and third months (1.52; 95% confidence interval [CI]:1.11-2.08; 1.26; 95%CI:1.07-1.48 respectively) after the return to dance. Two further studies report more injuries up to Week 13 of the year. One study showed an increase in injured dancers at three and four weeks after transition from rehearsals to a performance season. Four studies show an increase in injuries at performance times.

CONCLUSIONS

Meta-analyses of seven studies shows the second and third months after returning to dance have a significantly higher rate of injuries. More research is needed to quantify training loads in dance. Practitioners should be cognisant of the higher injury rates during periods of transition and consider modifying load, as it is a potential contributing factor.

Risk Factors for Lower-Extremity Injuries Among Contemporary Dance Students

OBJECTIVE

To determine whether student characteristics, lower-extremity kinematics, and strength are risk factors for sustaining lower-extremity injuries in preprofessional contemporary dancers.

DESIGN

Prospective cohort study.

SETTING

Codarts University of the Arts.

PATIENTS

Forty-five first-year students of Bachelor Dance and Bachelor Dance Teacher.

ASSESSMENT OF RISK FACTORS

At the beginning of the academic year, the injury history (only lower-extremity) and student characteristics (age, sex, educational program) were assessed using a questionnaire. Besides, lower-extremity kinematics [single-leg squat (SLS)], strength (countermovement jump) and height and weight (body mass index) were measured during a physical performance test.

MAIN OUTCOME MEASURES

Substantial lower-extremity injuries during the academic year were defined as any problems leading to moderate or severe reductions in training volume or in performance, or complete inability to participate in dance at least once during follow-up as measured with the Oslo Sports Trauma Research Center (OSTRC) Questionnaire on Health Problems. Injuries were recorded on a monthly basis using a questionnaire. Analyses on leg-level were performed using generalized estimating equations to test the associations between substantial lower-extremity injuries and potential risk factors.

RESULTS

The 1-year incidence of lower-extremity injuries was 82.2%. Of these, 51.4% was a substantial lower-extremity injury. Multivariate analyses identified that ankle dorsiflexion during the SLS (OR 1.25; 95% confidence interval, 1.03-1.52) was a risk factor for a substantial lower-extremity injury.

CONCLUSIONS

The findings indicate that contemporary dance students are at high risk for lower-extremity injuries. Therefore, the identified risk factor (ankle dorsiflexion) should be considered for prevention purposes.