The prevalence and impact of low back pain in pre-professional and professional dancers: A prospective study

The role of muscle function and pointe shoe characteristics in Arabesque movement among ballet dancers with non-specific low back pain

This study aimed to investigate posterior chain muscle function and the influence of pointe shoes in ballet dancers with and without low back pain (LBP) in the Arabesque. Twenty-nine young professional ballet dancers (17 with LBP and 12 healthy controls) were recruited. Muscle strength and mechanical properties of the erector spinae and hamstrings were assessed. The displacement of centre of mass (COM) during Arabesque under different shoe conditions (R-class, Chacott, and own shoes) was measured with a motion capture system. The LBP group exhibited greater dynamic stiffness and decreased mechanical stress relaxation time in the lateral hamstring compared to the control group. During Arabesque, the LBP group demonstrated significantly greater anterior-posterior displacement of the COM and a larger percentage of time to achieve maximal trunk extension angle. The COM displacement in vertical and medial-lateral directions was smaller in the R-class than in their own shoes. LBP impacts muscle mechanical properties, particularly in the lateral hamstring. The compromised muscle function resulted in a longer time to spinal extension during Arabesque, signifying that reduced trunk control contributed to greater COM displacement. Hence, it is essential to emphasise that evaluating muscle properties and dynamic postural control is imperative for dancers experiencing LBP.

An Exploration of Low Back Beliefs of Male Pre-Professional and Professional Dancers

BACKGROUND

Globally, male dancers are affected by low back pain (LBP) up to 2.5 times more than female dancers. While female dancers' beliefs around LBP and dance-specific low back movements exist, no research has explored male dancers' beliefs. This study aimed to (1) examine the low back beliefs of Australian male professional and pre-professional dancers, and (2) determine if beliefs toward common low back movements and lifting differed when current LBP or history of disabling LBP (DLBP) were considered.

METHODS

40 male dancers (mean age [SD] 26.9 years [7.9]) from a range of dance backgrounds (all participating in ballet) were recruited to complete a cross-sectional survey comprising a beliefs questionnaire considering dance-specific movement and lifting tasks, the Back Pain Attitudes Questionnaire (Back-PAQ) and the Athletic Fear Avoidance Questionnaire (AFAQ). Primary analysis included initial descriptives, a repeated measures ANOVA for movement-specific beliefs and visual thematic analysis for written responses within the belief's questionnaire. Secondary subgroup analysis included independent T-tests for those with/without current LBP and those with/without a history of DLBP.

RESULTS

Fourteen dancers reported current LBP and 30 reported a history of DLBP. Dancers held generally negative beliefs toward the low back (Back-PAQ mean 123.1 ± 9.7) with neither subgroup demonstrating significant between-group difference (P < .05). Dance-specific flexion movements were seen as safer than extension movements (P < .05), and more extended-spine lifting was seen as safer than more flexed-spine lifting (P < .05). Dancers experiencing current LBP held less positive beliefs surrounding some dance-specific movements.

CONCLUSIONS

Dancers hold negative general beliefs toward the low back irrespective of current or historical DLBP, however their beliefs surrounding dance-specific movements were relatively positive. Dancers' beliefs surrounding some movements were affected by the presence of current LBP, in particular an arabesque and a fish dive.

Dancers Show Significant Improvement in Outcomes and Favorable Return-to-Dance Rates After Primary Hip Arthroscopy With Femoral Head Cartilage Status Being a Predictor of Secondary Surgical Procedures at Mid-Term Follow-Up

PURPOSE

To report minimum 5-year follow-up patient-reported outcome measurement (PROM) scores and return-to-dance rates in dancers who underwent primary hip arthroscopy and to identify predictors of secondary surgical procedures.

METHODS

Prospectively collected data from patients who underwent hip arthroscopy between May 2010 and June 2016 were retrospectively reviewed. Patients were included if they participated in dance at any level 1 year prior to surgery and had preoperative and minimum 5-year follow-up scores consisting of the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale pain score. The exclusion criteria were previous hip conditions, previous ipsilateral hip surgery, Tönnis grade greater than 1, or lateral center-edge angle less than 18°. The minimal clinically important difference (MCID) was reported. Dancers who discontinued dance for reasons other than pain in the operative hip were excluded from the return-to-dance analysis. A logistic regression model was used to identify predictors of secondary surgical procedures.

RESULTS

Fifty-one hips (48 female dancers) were included. The average age and average follow-up period were 29.8 ± 17.2 years and 79.1 ± 23.2 months, respectively. Improvement in all PROM scores (P < .001) was reported. Achievement rates of the MCID for the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale pain score were 83.3%, 85.7%, and 85.7%, respectively. Revision hip arthroscopy was performed in 5 dancers (9.8%). Conversion to total hip arthroplasty was performed in 4 dancers (7.8%). The return-to-dance rate was 78.6%, with 57.6% returning to the preinjury performance level or a higher level. Higher femoral head Outerbridge grade was identified as a predictor of secondary surgical procedures (P = .045; odds ratio, 6.752 [95% confidence interval, 1.043-43.688]).

CONCLUSIONS

After primary hip arthroscopy, dancers experienced significant improvement in all PROM scores collected and achieved the MCID at a high rate at minimum 5-year follow-up. The return-to-dance rate in dancers who did not discontinue dance because of lifestyle transitions was 78.6%, with 57.6% returning to the preinjury performance level or a higher level. Higher femoral head Outerbridge grade was found to be a predictor of secondary surgical procedures.

LEVEL OF EVIDENCE

Level IV, case series.

Incidence, prevalence and risk factors for low back pain in adolescent athletes: a systematic review and meta-analysis

OBJECTIVE

To investigate the incidence, prevalence, risk factors and morphological presentations of low back pain (LBP) in adolescent athletes.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Medline, Embase, CINAHL via EBSCO, Web of Science, Scopus.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies evaluating the incidence and/or prevalence of LBP in adolescent athletes across all sports.

RESULTS

There were 80 studies included. The pooled incidence estimate of LBP in adolescent athletes was 11% (95% CI 8% to 13%, I²=0%) for 2 years, 36.0% (95% CI 4% to 68%, I²=99.3%) for 12 months and 14% (95% CI 7% to 22%, I²=76%) for 6 months incidence estimates. The pooled prevalence estimate of LBP in adolescent athletes was 42% (95% CI 29% to 55%, I²=96.6%) for last 12 months, 46% (95% CI 41.0% to 52%, I²=56%) for last 3 months and 16% (95% CI 9% to 23%, I²=98.3%) for point prevalence. Potential risk factors were sport participation, sport volume/intensity, concurrent lower extremity pain, overweight/high body mass index, older adolescent age, female sex and family history of LBP. The most common morphology reported was spondylolysis. Methodological quality was deemed high in 73% of cross-sectional studies and in 30% of cohort studies. Common reasons for downgrading at quality assessment were use of non-validated survey instruments and imprecision or absence of LBP definition.

SUMMARY/CONCLUSION

LBP is common among adolescent athletes, although incidence and prevalence vary considerably due to differences in study methodology, definitions of LBP and data collection.

PROSPERO REGISTRATION NUMBER

CRD42020157206.

Comparing Lumbar Lordosis in Functional Dance Positions in Collegiate Dancers With and Without Low Back Pain

Limited research has explored the relationship between lumbar lordosis and incidence of low back pain in dancers. The purpose of this study was to investigate the relationship between lumbar lordosis in functional dance positions and low back pain (LBP). Thirty full-time undergraduate ballet and modern collegiate dancers (28 female, 2 male) from three university dance programs participated in this study. Functional lumbar lordosis, hip passive range of motion, and core endurance were measured in a single session. Dancers participated in weekly follow-up surveys over a 4-month period to track the presence and severity of LBP. Primary analysis was performed using independent t-tests between groups who did and did not develop pain. Secondary analyses were performed using Pearson's r correlation. Eleven dancers reported no pain during the follow-up period, 16 reported pain, and three did not respond to follow-up surveys. Lumbar lordosis in right developpé á la seconde and right retiré was significantly greater (p < 0.05) in the group who reported pain compared to the group who reported no pain. Increased hold times in the supine bridge position was shown to be fairly correlated (p < 0.05) to reduced lumbar lordosis in first position (Pearson's r = 0.381), left retiré (Pearson's r = 0.396), and right developpé á la seconde (Pearson's r = 0.365). The results of this study suggest a relationship between increased lumbar lordosis in the retiré and developpé á la seconde dance positions and development of LBP. Increased endurance of posterior core musculature and gluteal muscles was inversely related to the magnitude of lumbar lordosis in some dance-specific positions. The measurement of lumbar lordosis during functional dance positions, particularly those requiring single leg stances, may help identify collegiate dancers with increased risk of developing low back pain.

Movement quantity and quality: How do they relate to pain and disability in dancers?

Objective

This field-based study aimed to determine the association between pre-professional student dancers’ movement quantity and quality with (i) pain severity and (ii) pain related disability.

Methods

Pre-professional female ballet and contemporary dance students (n = 52) participated in 4 time points of data collection over a 12-week university semester. At each time point dancers provided self-reported pain outcomes (Numerical Rating Scale as a measure of pain severity and Patient Specific Functional Scale as a measure of pain related disability) and wore a wearable sensor system. This system combined wearable sensors with previously developed machine learning models capable of capturing movement quantity and quality outcomes. A series of linear mixed models were applied to determine if there was an association between dancers’ movement quantity and quality over the 4 time points with pain severity and pain related disability.

Results

Almost all dancers (n = 50) experienced pain, and half of the dancers experienced disabling pain (n = 26). Significant associations were evident for pain related disability and movement quantity and quality variables. Specifically, greater pain related disability was associated with more light activity, fewer leg lifts to the front, a shorter average duration of leg lifts to the front and fewer total leg lifts. Greater pain related disability was also associated with higher thigh elevation angles to the side. There was no evidence for associations between movement quantity and quality variables and pain severity.

Discussion

Despite a high prevalence of musculoskeletal pain, dancers’ levels of pain severity and disability were generally low. Between-person level associations were identified between dancers’ movement quantity and quality, and pain related disability. These findings may reflect dancers’ adaptations to pain related disability, while they continue to dance. This proof-of-concept research provides a compelling model for future work exploring dancers’ pain using field-based, serial data collection.

Effect of low back pain on clinical-functional factors and its associated potential risk of chronicity in adolescent dancers of classical ballet: cross-sectional study

BACKGROUND

Low back pain (LBP) is a common symptom in classical ballet dancers, which can limit their daily activities and dance training routines. The purpose of the study was to verify the association and comparison of clinical-functional outcomes (spine flexibility and foot posture) between different levels of intensity low back pain in adolescents of classical ballet and the potential risk of chronicity using the STarT back tool.

METHODS

Cross-sectional study.

PARTICIPANTS

78 adolescent girls who practice classical ballet were evaluated and divided into groups according to level of low back pain: mild (n = 21), moderate (n = 17), and high (n = 20), and a control group (n = 20).

MAIN OUTCOME MEASURES

Pain, flexibility of the spine (thoracic and lumbosacral), risk of chronicity for low back pain, and foot posture were assessed using the visual analogue scale, clinical tests, STarT back screening tool (SBST) questionnaire, and foot posture index (FPI), respectively.

RESULTS

Dancers with high-intensity low back pain showed a potential risk of chronicity by the SBST. The spine pain intensity was not different considering thoracic and lumbosacral flexibility in the sagittal plane, but was different with greater supine FPI when compared to control dancers. Mild low back pain was associated with greater supine FPI. The SBST score was associated with higher exposure time-frequency and time of dancing.

CONCLUSION

Adolescents of classical ballet with high-intensity low back pain showed a potential risk of chronicity by the SBST. The level of intensity low back pain did not influence the clinical-functional aspects of spine flexibility in the sagittal plane, but the level of intensity moderate pain promoted changes in foot posture (more supinated). The potential risk of chronicity using the SBST was also associated with higher exposure time-frequency and time of dancing, in adolescents of classical ballet.

Cognitive, emotional, and somatosensory behavior in professional dancers with acute and chronic pain

BACKGROUND

Dance has been linked in a complex manner to pain and the physical and psychological peculiarities of this discipline could influence pain perception and chronicity of pain.

OBJECTIVE

To determine the differences in cognitive, emotional, and somatosensory symptoms between dancers with acute versus chronic pain.

DESIGN

A cross-sectional study of professional dancers with pain.

SETTING

Higher conservatory of dance.

PARTICIPANTS

Thirty-four professional dancers experiencing pain were included. The cohort was divided into two subgroups: those with acute pain (<3 months duration) and those with chronic pain (>3 months duration).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Pain intensity (as measured by the visual analogue scale or VAS), pressure pain threshold (PPT), Pain Catastrophizing Scale (PCS), pain-related fear of movement (Tampa Scale of Kinesiophobia [TSK-11]), fear avoidance beliefs (Fear-Avoidance Beliefs Questionnaire [FABQ]), self-efficacy (Chronic Pain Self-Efficacy Scale [CPSS]). and chronic pain severity (Chronic Pain Graded Scale [CPGS]).

RESULTS

Dancers with chronic pain reported higher levels of pain intensity in daily activities (p < .01; t = 3.42; d = 1.17) and during exercise/dance (p = .02; t = 2.82; d = 0.82), as well as lower PPT in lumbar (p = .03; t = 3.22; d = 1.1) and tibialis regions (p = .01; t = 2.51; d = 0.86). Dancers with acute pain experienced worse psychological symptoms indicated by the fear of harm subscale of TSK-11 (p = .04; t = -2.08; d = 0.72), physical activity subscale of FABQ (p = .03; t = -2.27; d = 0.78), and pain management subscale of CPSS (p = .01; t = -2.76; d = 0.94) and lower scores for CPGS scale (p = .01; t = 2.99; d = 0.7 to 1.26).

CONCLUSIONS

The results showed differences in pain intensity and PPT revealing higher values in dancers with chronic pain. It is possible that the physical and psychological characteristics of dancers, as well as the sociocultural aspects of this discipline, could influence the way in which this population interprets pain.

Sagittal Integral Morphotype of Female Classical Ballet Dancers and Predictors of Sciatica and Low Back Pain

The aims of this study were to describe the sagittal integral morphotype (SIM) of classical ballet (CB) dancers, and to establish predictor factors and their cut off values for high risk of experiencing sciatica or low back pain (LBP). This retrospective cohort study was performed in 33 female professional CB dancers. Data related to anthropometric parameters, CB dance experience, sciatica or LBP history, and sagittal spine curvatures were collected. A binary logistic regression and receiver-operating characteristic analysis were performed. The main spine misalignments observed in the SIM of CB dancers were thoracic functional hyperkyphosis, hypomobile kyphosis, and hypokyphosis, and those for the lumbar curvature were hyperlordotic attitude and functional hyperkyphosis. The lumbar curvature in slump sitting and trunk forward bending positions, together with the stature, were significant predictor factors of sciatica history, while the years of dance experience was a significant predictor factor of LBP history. The cut off values analysis revealed that dancers with a stature of 161 cm or less, and those with 14 years of experience or more, have a greater probability of experiencing sciatica or LBP history, respectively.

Prevalence and risk factors for back pain in sports: a systematic review with meta-analysis

OBJECTIVES

We aimed to determine the prevalence of low back pain (LBP) in sport, and what risk factors were associated with LBP in athletes.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Literature searches from database inception to June 2019 in Medline, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus, supplemented by grey literature searching.

ELIGIBILITY CRITERIA

Studies evaluating prevalence of LBP in adult athletes across all sports.

RESULTS

Eighty-six studies were included (30 732, range 20-5958, participants), of which 45 were of 'high' quality. Definitions of LBP varied widely, and in 17 studies, no definition was provided. High-quality studies were pooled and the mean point prevalence across six studies was 42%; range 18%-80% (95% CI 27% to 58%, I2=97%). Lifetime prevalence across 13 studies was 63%; range 36%-88% (95% CI 51% to 74%, I2=99%). Twelve-month LBP prevalence from 22 studies was 51%; range 12%-94% (95% CI 41% to 61%, I2=98%). Comparison across sports was limited by participant numbers, study quality and methodologies, and varying LBP definitions. Risk factors for LBP included history of a previous episode with a pooled OR of 3.5; range 1.6-4.0 (95% CI 1.9 to 6.4). Statistically significant associations were reported for high training volume, periods of load increase and years of exposure to the sport.

CONCLUSION

LBP in sport is common but estimates vary. Current evidence is insufficient to identify which sports are at highest risk. A previous episode of LBP, high training volume, periods of load increase and years of exposure are common risk factors.

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.

Lumbar Spine Injuries in Sports: Review of the Literature and Current Treatment Recommendations

Low back pain is one of the most prevalent complaints of athletes at all levels of competition. The purpose of this literature review is to provide an overview of sport-specific injuries and treatment outcomes that can be used by healthcare providers to better recognize injury patterns and treatment options for different groups of athletes. To our knowledge, no prior comprehensive review of lumbar spine injuries in sports is currently available in the literature, and it is essential that healthcare providers understand the sport-specific injury patterns and treatment guidelines for athletes presenting with low back pain following an athletic injury. Injury mechanisms were found to vary significantly by sport, although some broad recommendations can be made with regards to optimal treatment for these injuries and return to play. Additionally, it was found that certain treatments were more beneficial and resulted in higher rates of return to play depending on the specific sport of the injured athlete. Healthcare providers need to be aware of the different injury patterns seen in specific sports in order to properly evaluate and treat these injuries. Furthermore, an individualized treatment plan needs to be selected in a sport-specific context in order to meet the needs of the athlete in the short and long term.

Multi-segment spine range of motion in dancers with and without recent low back pain

BACKGROUND

Altered spine kinematics are a common in people with LBP. This may be especially true for populations such as dancers, who are required to perform repetitive movements of the spine, although this remains unclear.

RESEARCH QUESTION

Do dancers with recent LBP display altered spine kinematics compared to their asymptomatic counterparts?

METHODS

A cross-sectional study of multi-segment spine kinematics was performed. Forty-seven pre-professional and professional female dancers either with LBP in the past two months (n = 26) or no LBP in the past 12 months (n = 21) participated. Range of motion (ROM) during standing side bending, seated rotation, and walking gait were compared.

RESULTS

Female dancers with LBP displayed reduced upper lumbar transverse plane ROM in seated rotation (Effect Size (ES)= -0.61, 95% Confidence Interval (CI): -1.20, 0.02, p = 0.04), as well as reduced lower lumbar transverse plane ROM (ES=-0.65, 95% CI: -1.24, -0.06, p = 0.03) in gait. However, there was increased lower thoracic transverse plane ROM (ES = 0.62, 95% CI: 0.04, 1.21, p = 0.04) during gait. No differences in the frontal plane were observed.

SIGNIFICANCE

Altered transverse plane spine kinematics were evident in dancers with recent LBP for select segments and tasks. This may reflect a protective movement strategy. However, as the effect sizes of observed differences were moderate, and the total number of differences between groups was small, collectively, it seems only subtle differences in spine kinematics differentiate dancers with LBP to dancers without.

The Epidemiology of Low Back Pain and Injury in Dance: A Systematic Review

BACKGROUND

Dance is a physical pursuit that involves loading the spine through repetitive dynamic movements and lifting tasks. As such, low back pain (LBP) and low back injury (LBI) have been identified as common health problems in contemporary and classical ballet dancers. However, clarity regarding the experience of LBP and LBI in dance is lacking.

OBJECTIVES

To systematically review and synthesize the epidemiology of LBP and LBI in dance populations.

METHODS

A comprehensive search of 6 electronic databases, back catalogs of dance science-specific journals, and reference lists of relevant articles and a forward citation search were performed.

RESULTS

Fifty full-text articles were included in the final systematic review. There was considerable methodological heterogeneity among the included studies. The median (range) point, yearly, and lifetime prevalence of LBP was 27% (17%-39%), 73% (41%-82%), and 50% (17%-88%), respectively. The lower back contributed to 11% (4%-22%) of time loss and 11% (5%-23%) of medical-attention injuries.

CONCLUSION

Dancers are vulnerable to LBP and LBI. The use of definitions that are sensitive to the complexity of LBP and LBI would facilitate improved understanding of the problem within dance, inform health care strategies, and allow for monitoring LBP-specific intervention outcomes. J Orthop Sports Phys Ther 2019;49(4):239-252. Epub 18 Jan 2019. doi:10.2519/jospt.2019.8609.

Multi-segment spine kinematics: Relationship with dance training and low back pain

BACKGROUND

Spine posture, range of motion (ROM) and movement asymmetry can contribute to low back pain (LBP). These variables may have greater impact in populations required to perform repetitive spine movements, such as dancers; however, there is limited evidence to support this.

RESEARCH QUESTION

What is the influence of dance and LBP on spinal kinematics?

METHODS

In this cross-sectional study, multi-segment spinal kinematics were examined in 60 female participants, including dancers (n = 21) and non-dancers (n = 39) with LBP (n = 33) and without LBP (n = 27). A nine-camera motion analysis system sampling at 100 Hz was used to assess standing posture, as well as ROM and movement asymmetry for side bend and trunk rotation tasks. A two-way ANOVA was performed for each of the outcome variables to detect any differences between dancers and non-dancers, or individuals with and without LBP.

RESULTS

Compared to non-dancers, dancers displayed a flatter upper lumbar angle when standing (p < 0.01, ηp² = 0.15), and achieved greater frontal plane ROM for the upper lumbar (p = 0.04, ηp² = 0.08) and lower thoracic (p = 0.02, ηp² = 0.09) segments. There were no differences between dancers and non-dancers for transverse plane ROM (p > 0.05) or movement asymmetry (p > 0.05). There was no main effect for LBP symptoms on any kinematic measures, and no interaction effect for dance group and LBP on spinal kinematics (p > 0.05).

SIGNIFICANCE

Female dancers displayed a flatter spine posture and increased spine ROM compared to non-dancers for a select number of spine segments and movement tasks. However, the overall number of differences was small, and no relationship was observed between LBP and spinal kinematics. This suggests that these simple, static posture, ROM, and asymmetry measures often used in clinical practice can provide only limited generalisable information about the impact of dance or LBP on spinal kinematics.