Impact of touring, performance schedule, and definitions on 1-year injury rates in a modern dance company

Prevalence and risk factors of musculoskeletal injuries in modern and contemporary dancers: a systematic review and meta-analysis

Background

A large number of studies have found that the musculoskeletal injury of modern and contemporary dancers has a high incidence. Previous publications have indicated that there are many potential factors that are related to dancing injury; however, they have not been proven, and even some data are conflicting in different research.

Results

The search yielded 18 prospective studies reporting on professional and pre-professional modern or contemporary dancers from companies and schools. The prevalence of modern and contemporary dancers was 0.82 (95% CI: 0.74~0.90). The injury proportion of trauma, overuse, ankle and foot, lower extremity, joint and ligaments, muscle and tendons, and time-loss were 0.40, 0.26, 0.49, 0.34, 0.33, and 0.29 in the total number of injuries. There was no evidence of a significant difference in sex, age, and education program. The factors of BMI and injury history achieved statistical significance, and the p-values were less than 0.01.

Conclusion

Based on the results of this article, BMI and injury history may be risk factors for injury in contemporary and modern dancers. Modern and contemporary dancers have a high prevalence of musculoskeletal injuries. Lower extremity injuries are the most common in the whole body, with injuries to the foot and ankle being more frequent. The mechanism of injury is mostly overuse injury, and the injured tissues are mostly muscle tendons and joint ligaments.

Don't stop me now: A qualitative study of how Brazilian dancers and staff perceive injury and its prevention

OBJECTIVE

To investigate how Brazilian dancers and dance staff perceive and deal with injury and its prevention in professional and non-professional contexts.

DESIGN

Qualitative study.

SETTING

Semi-structured interviews conducted using an online platform.

PARTICIPANTS

Thirteen participants (8 women, 5 men) from four different dance styles (classical ballet, jazz, contemporary and urban): 6 dancers, 6 staff and 1 classified as both.

MAIN OUTCOME MEASURES

Interviews were recorded, transcribed and analyzed based on Grounded Theory principles using comparative data analysis.

RESULTS

The main themes and findings were: 1) Injury definition: Injury was defined and classified based on pain, structural damage and consequent limitations and restrictions. 2) Dealing with injury: Dancers' fear of having to stop dancing justifies different behaviours facing injury. 3) Injury factors: Overload and many personal and environmental factors were perceived as related to injury. 4) Injury prevention: it is linked with physical preparation and additional measures and influenced by communication, trust, experience, time, access to preventive programs, dancers' personalities and environmental factors. Responsibility for injury prevention should be shared by all stakeholders.

CONCLUSIONS

To improve injury prevention, we need to acknowledge the dancers' drive to keep dancing, consider the multiple factors that influence their behaviours, and develop education and self-efficacy to help them make better decisions to reduce the risk of injury.

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.

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.

Injury epidemiology in professional ballet: a five-season prospective study of 1596 medical attention injuries and 543 time-loss injuries

OBJECTIVES

To describe the incidence rate, severity, burden and aetiology of medical attention and time-loss injuries across five consecutive seasons at a professional ballet company.

METHODS

Medical attention injuries, time-loss injuries and dance exposure hours of 123 professional ballet dancers (women: n=66, age: 28.0±8.3 years; men: n=57, age: 27.9±8.5 years) were prospectively recorded between the 2015/2016 and 2019/2020 seasons.

RESULTS

The incidence rate (per 1000 hours) of medical attention injury was 3.9 (95% CI 3.3 to 4.4) for women and 3.1 (95% CI 2.6 to 3.5) for men. The incidence rate (per 1000 hours) of time-loss injury was 1.2 (95% CI 1.0 to 1.5) for women and 1.1 (95% CI 0.9 to 1.3) for men. First Soloists and Principals experienced between 2.0-2.2 additional medical attention injuries per 1000 hours and 0.9-1.1 additional time-loss injuries per 1000 hours compared with Apprentices (p≤0.025). Further, intraseason differences were observed in medical attention, but not time-loss, injury incidence rates with the highest incidence rates in early (August and September) and late (June) season months. Thirty-five per cent of time-loss injuries resulted in over 28 days of modified dance training. A greater percentage of time-loss injuries were classified as overuse (women: 50%; men: 51%) compared with traumatic (women: 40%; men: 41%).

CONCLUSION

This is the first study to report the incidence rate of medical attention and time-loss injuries in professional ballet dancers. Incidence rates differed across company ranks and months, which may inform targeted injury prevention strategies.

Epidemiology of Patients with Dance-Related Injuries Presenting to Emergency Departments in the United States, 2014-2018

BACKGROUND

Updated rates and patterns associated with patients with dance-related injuries reporting to US emergency departments (EDs) is needed.

HYPOTHESIS

Between the years 2014 and 2018, there will be an observed rise of patients with dance-related injuries seen within US EDs.

STUDY DESIGN

Retrospective analysis.

LEVEL OF EVIDENCE

Level 4.

METHODS

Utilizing the National Electronic Injury Surveillance System (NEISS) database, data were abstracted for all structured dance-related injuries for all people who presented to a NEISS participating hospital from January 1, 2014, to December 31, 2018. Data were abstracted on age, sex, race, disposition, location on the body where the injury happened, and free text box regarding the mechanism and nature of the injury. Each patient case was associated with a weight to provide national incidence rate (per 100,000) estimates. Descriptive statistics were used to summarize counts, percentages, and rates across patient cases.

RESULTS

Between years 2014 and 2018, 4152 patients reported to the NEISS EDs with a dance-related injury. Most injuries occurred in female patients (83.3%; n = 3459) and among those who were 10 to 18 years old (76.2%; n = 3164). The most common injuries were ankle sprain/strain (12.7%; n = 527) and knee sprain/strain (10.4%; n = 431). Almost all patients were treated and released (97.1%; n = 4033). These data yielded population-weighted estimates of 125,618 injuries for the study period, with an increasing trend over time (19.2% increase over 5 years). Incidence rates were over 4 times higher for female (12.4) than for male patients (3.0) and highest in the 10- to 18-year-old age group (incidence rate = 46.4).

CONCLUSION

Patients with dance-related injuries reporting to EDs increased over a 5-year period from 2014 to 2018. The majority of dancers in the study were female patients, between the ages of 10 and 18 years, nearly half of the patients reported to the ED with a sprain/strain, and almost all patients were treated and released.

CLINICAL RELEVANCE

An increase in access to proper injury prevention medical services and education should be provided to female dancers between the ages of 10 and 18 years.

STRENGTH OF RECOMMENDATION TAXONOMY

B.

Injury, Illness, and Training Load in a Professional Contemporary Dance Company: A Prospective Study

CONTEXT

Professional dance is a demanding physical activity with high injury rates. Currently, no epidemiologic data exist regarding the incidence of injury and illness together with training load (TL) over a long period of time.

OBJECTIVE

To provide a detailed description of injury, illness, and TL occurring in professional contemporary dancers.

DESIGN

Descriptive epidemiology study.

SETTING

A single professional contemporary dance company during a 1-year period.

PATIENTS OR OTHER PARTICIPANTS

A total of 16 male and female professional contemporary dancers.

MAIN OUTCOME MEASURE(S)

Injury data consisted of medical-attention injury (Med-Inj) and time-loss injury (Time-Inj). Illness was measured using the Wisconsin Upper Respiratory Tract Infection Survey. Training load was collected for each dance session using the session rating of perceived exertion and classified into 3 groups based on individual and group percentiles: low, medium, or high.

RESULTS

Reported injuries totaled 79 (86.1% new, 6.3% reinjury, and 7.6% exacerbation). The Med-Inj incidence rate was 4.6 per 1000 hours (95% confidence interval [CI] = 3.8, 5.8), and the Time-Inj rate was 1.4 per 1000 hours (95% CI = 0.8, 2.1). The median time until injury for Med-Inj and Time-Inj was 3 months. The number of days dancers experienced illness symptoms was 39.9 ± 26.9 (range = 1-96), with an incidence rate of 9.1 per 1000 hours (95% CI = 7.7, 10.7). Mean weekly TL was 6685 ± 1605 (4641-10 391; arbitrary units). Inconsistent results were found for the incidence of injury and illness based on individual and group categorizations of TL.

CONCLUSIONS

Professional dancing is associated with high injury and illness rates. This is worrying from a health perspective and underlines the need for further studies to understand how to decrease the risk. The TL is higher than in other sport disciplines, but whether the high incidence of injuries and illnesses is related to high training demands needs additional investigation, possibly conducted as international, multicenter collaborative studies.

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.

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.

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.

Performing artist and Athlete Health Monitor: user experience, content and conditions for use of an online dance-health surveillance system in a professional ballet company

Objectives

The user experience, content and conditions for use of an online dance-health surveillance system (Performing artist and Athlete Health Monitor, PAHM) was examined through a focus group interview with professional ballet dancers.

Methods

Nine professional dancers (56% female (n=5), average age=27.56± 5.17) completed biweekly questionnaires using the PAHM, including questions on health problems, injuries, mental complaints and illnesses. After 6 weeks, nine dancers participated in a focus group interview to investigate the user experience, content and conditions for use of the PAHM. Data were analysed using thematic analysis.

Results

25 of the 27 questionnaires were completed (response rate of 93%). Dancers were positive about using the PAHM. They recommend to clarifying the questions about pain and injury, expanding items on mental health, including items on workload, sleep, rest and nutrition, and receiving feedback regarding their own results. Dancers were reluctant regarding sharing their personal data with others. Data on an aggregated level can be shared because this might gain insight into the association between scheduling, workload and injury risk.

Conclusion

The user experience of the monitor contributes to the willingness of dancers to keep using the PAHM. Dancers recommended adjusting the content in the PAHM to match their dance activities and health problems. The conditions for using the PAHM effectively within a company are a safe and trusting culture. Even though the PAHM alone cannot change the culture in a ballet company, it can play a role in the communication between staff and dancers.

Characteristics of Contact Force and Muscle Activation During Choreographed Falls With 2 Common Landing Techniques in Contemporary Dance

This study investigated the contact forces and muscle activation during 2 choreographed fall techniques in contemporary dancers and how these were affected by the fall technique. Ten collegiate-level dancers were instructed in 2 choreographed falls: (1) an anteriorly focused fall involving ankle plantar flexion, knee flexion, and hip flexion with dispersion of forces up the anterior surface of the shank (technique 1) and (2) a laterally focused fall involving inversion at the ankle with dispersion of forces up the lateral aspect of the shank (technique 2). The knee and hip contact forces were 26.3% smaller (technique 1: 1743 N vs technique 2: 1284 N) and 24.1% greater (technique 1: 1334 N vs technique 2: 1656 N), respectively, in technique 2 (P < .03). At the time of knee contact, percentage of maximal voluntary isometric contraction (%MVIC) was 45.8% greater for rectus femoris muscle (technique 1: 7.2% vs technique 2: 10.5%) and 96.9% greater for gluteus medius muscle (technique 1: 3.2% vs technique 2: 6.3%) (P < .01) in technique 2. The results provide insight into determining safer landing strategies to avoid knee injuries in individuals who experience a fall (ie, dancers, athletes, and older adults).

Dance Functional Outcome Survey: Development and Preliminary Analyses

The Dance Functional Outcome Survey (DFOS) was developed as a self-report questionnaire for healthy and injured ballet and modern dancers, focusing on the low back and lower extremities. Our aim was to determine factor analysis and internal consistency of the 16 items and to investigate test-retest and equivalence reliability and validity of the DFOS compared to three orthopedic outcomes instruments. Data were collected from 80 healthy and injured adult ballet and modern pre-professional and professional dancers. DFOS Likert-type and visual analog scales were completed twice within 4-9 days to study test-retest reliability. The Cincinnati Knee Rating System, Olerud and Molander Foot-Ankle Questionnaire, and Oswestry Disability Index were used to assess concurrent validity using intraclass correlation coefficients in SPSS, p<0.05. To determine instrument dimensions and internal consistency of the items, we conducted exploratory factor analysis and calculated Cronbach's α in JASP. DFOS demonstrated single factor loading and high Cronbach's α; high test-retest repeatability and equivalence reliability ( r =0.74-0.99) and acceptable criterion validity compared to the orthopedic outcomes instruments (r≥0.67). These results support further study of a revised 14 item Likert-version DFOS for repeatability, validity and responsiveness.

The Influence of Injury Definition on Injury Burden in Preprofessional Ballet and Contemporary Dancers

Study Design Cohort study. Background Multiple operational definitions of injury exist in dance research. The influence that these different injury definitions have on epidemiological estimations of injury burden among dancers warrants investigation. Objective To describe the influence of injury definition on injury prevalence, incidence, and severity in preprofessional ballet and contemporary dancers. Methods Dancers registered in full-time preprofessional ballet (n = 85; 77 female; median age, 15 years; range, 11-19 years) and contemporary (n = 60; 58 female; median age, 19 years; range, 17-30 years) training completed weekly online questionnaires (modified Oslo Sports Trauma Research Centre questionnaire on health problems) using 3 injury definitions: (1) time loss (unable to complete 1 or more classes/rehearsals/performances for 1 or more days beyond onset), (2) medical attention, and (3) any complaint. Physical therapists completed injury report forms to capture dance-related medical attention and time-loss injuries. Percent agreement between injury registration methods was estimated. Injury prevalence (seasonal proportion of dancers injured), incidence rates (count of new injuries per 1000 dance-exposure hours), and severity (total days lost) were examined across each definition, registration method, and dance style. Results Questionnaire response rate was 99%. Agreement between registration methods ranged between 59% (time loss) and 74% (injury location). Depending on definition, registration, and dance style, injury prevalence ranged between 9.4% (95% confidence interval [CI]: 4.1%, 17.7%; time loss) and 82.4% (95% CI: 72.5%, 89.8%; any complaint), incidence rates between 0.1 (95% CI: 0.03, 0.2; time loss) and 4.9 (95% CI: 4.1, 5.8; any complaint) injuries per 1000 dance-hours, and days lost between 111 and 588 days. Conclusion Time-loss and medical-attention injury definitions underestimate the injury burden in preprofessional dancers. Accordingly, injury surveillance methodologies should consider more inclusive injury definitions. J Orthop Sports Phys Ther 2018;48(3):185-193. Epub 13 Dec 2017. doi:10.2519/jospt.2018.7542 Level of Evidence Symptom prevalence study, level 1b.