Screening Tools as a Predictor of Injury in Dance: Systematic Literature Review and Meta-analysis

Preseason lower extremity range of motion, flexibility, and strength in relation to in-season injuries in NCAA division I gymnasts

OBJECTIVES

To determine if preseason lower extremity ROM, flexibility, and strength differ in collegiate gymnasts (NCAA Division 1) who do or do not sustain an injury during the competitive season.

METHODS

Over four seasons, a total of 15 female gymnasts (age = 20.5 ± 1.0 years) underwent preseason screening (30 gymnast-season). We tested joint ROM (hip: flexion, internal and external rotation; ankle: weightbearing dorsiflexion), muscle flexibility (passive straight leg raise, Thomas,' Ober's, Ely's tests) and strength (hip extensors, abductors, and flexors isometric strength via a handheld dynamometer; knee: quadriceps and hamstring isokinetic strength at 60°/sec). The team athletic trainer tracked overuse lower extremity injuries (restricted gymnasts from full participation, occurred as from participation in organized practice or competition, and required medical attention) during each season. For athletes that tested multiple seasons, each encounter was considered independent, and each preseason assessment was linked to overuse injuries sustained during the same competitive season. Gymnasts were dichotomized into injured and non-injured groups. An independent t-test was used to measure differences in preseason outcomes between injured and non-injured groups.

RESULTS

During four years, we recorded 23 overuse lower extremity injuries. Gymnasts that sustained an in-season overuse injury demonstrated significantly lower hip flexion ROM (mean difference: -10.6°; 95% confidence interval: -16.5, -4.6; p < 0.01) and lower hip abduction strength (mean difference: -4.7% of body weight; 95% confidence interval: -9.2, -0.3; p = 0.04).

CONCLUSION

Gymnasts who sustain an in-season overuse lower extremity injury have significant preseason deficit of hip flexion ROM and weakness in the hip abductors. These findings indicate potential impairments in the kinematic & kinetic chains responsible for skill performance and energy absorption during landing.

Development and Feasibility of an Adolescent Dancer Screen

Background

Adolescent dancers are at high risk for injuries due to the physical demands of dance training and the physiological changes that occur during adolescence. Though studies report high injury rates, there are few standardized screening tools available for adolescent dancers.

Hypothesis/Purpose

To develop and describe a standardized, feasible, evidence-based, and clinically relevant screen for adolescent dancers.

Study Design

Descriptive Epidemiology Study.

Methods

Dancers at two suburban pre-professional dance studios, in two cohorts, participated in the Columbia Adolescent Dancer Screen (CADS) that includes dance injury history, health questionnaires (EAT-26, SF-36, DFOS), aerobic capacity, range of motion, strength, balance/orthopedic special tests, and dance technique. Participants were asked to complete a weekly injury surveillance questionnaire derived from the Dance-Specific Oslo Sports Trauma Research Centre Questionnaire on Health Problems for 14 weeks following the screening. Feasibility was assessed using process and content analysis in four areas: practicality, demand, implementation, and adaptation.

Results

Descriptive data were collected from 32 female dancers aged 11-17 with cohort one averaging 18.57 dance hours per week and cohort two averaging 10.6 dance hours per week. The screen was practical, able to screen seven to eight dancers per hour utilizing nine assessors and requiring a one-hour commitment from dancers. Cost and space requirements were considered and kept to a minimum while utilizing portable equipment. All screening slots were filled with all dancers agreeing to follow-up injury surveillance, indicating high demand. The screen was implemented with two cohorts with revisions to improve efficiency applied for the second cohort.

Conclusion

The CADS is a feasible screening tool for adolescent dancers that overcomes barriers by being pragmatic, evidence-based, and efficient. Screening can be implemented to obtain baseline values, inform wellness recommendations, and establish relationships with medical professionals.

Level of Evidence

Level 3b.

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.

Prevalence of dance-related injuries and associated risk factors among children and young Chinese dance practitioners

While Chinese dance is a popular dance genre among Chinese teenagers and adults, little is known regarding the prevalence of dance-related injuries or factors associated with such injuries among Chinese dance practitioners. The current cross-sectional study aimed to determine the prevalence of dance-related injuries and their associated risk factors among young Chinese dance practitioners in Hong Kong. Online surveys were distributed to dancers through local dance associations, while paper-based surveys were distributed to young Chinese dance performers during the 54th School Dance Festival in Hong Kong. Self-reported hours of dancing, injuries in the last 12 months, injury sites, and related factors were collected. The injury rate, 12-month prevalence of dance-related injuries were determined. Risk factors for common dance injuries were analyzed using separate multivariate regression models. A total of 175 children (aged 10-14 years) and 118 young (aged 15-24 years) Chinese dance practitioners provided their dance injury information. Young dancers had a significantly higher injury rate (6.5 injuries vs 4.6 injuries/1000 dance hours) and 12-month prevalence (52.5% vs 19.4%) than their child counterparts. The most commonly injured sites were the knee (children:7.4%; young:15.3%), lower back (children: 4.6%; young: 9.5%), and ankles (children: 5.1%; young: 16.9%). Age was a significant independent risk factor for dance-related injuries to the upper back, lower back, and pelvis/buttock (odds ratios ranging from 1.2 to 1.3/additional years). Additionally, height was a significant independent risk factor for lower limb injury (odds ratios ranging from 1.0-1.1/additional centimeter). Collectively, young Chinese dance practitioners are more vulnerable to dance-related injuries than are child dancers. Older age increases the risk of trunk injuries, whereas taller dancers are more likely to sustain lower-limb injuries. Future research should determine the mechanisms underlying dance-related injuries among these dancers.

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.

Posturography measures in specific ballet stance position discriminate ballet dancers with different occurrences of musculoskeletal injuries

BACKGROUND

This study aimed to identify the postural sway variables that can distinguish between ballet dancers with high and low occurrences of musculoskeletal injuries.

METHODS

Fourteen professional ballet dancers were assigned to a high-occurrence group (N = 5, reports >2 injuries in the previous 6-months) or a low-occurrence group (N = 9, reports ≤1 injury). Center-of-pressure (COP) data were acquired using a force platform during the following tasks: single-leg stance with eyes open, single-leg stance with eyes closed, and demi-pointe stance with eyes open. The COP standard deviation (SD) and range (RA) in both the medial-lateral (ML) and anterior-posterior (AP) directions were estimated. Between-group comparisons were made through Welch's t-tests for unequal sample size along the effect size measure (Cohen's d). Spearman's rho was used to estimate the association between the number of injuries and the COP variables. The statistical threshold was set at 1%.

RESULTS

A between-group effect was found only for the demi-pointe stance, with large effects for SDML (P = 0.006, d = 1.7), RAAP (P = 0.006, d = 1.7), and RAML (P = 0.005, d = 1.7). An inverse relationship was found between the number of injuries and the demi-pointe's COP range in both directions (Spearman's rho from -0.681 to -0.726, P = 0.007).

CONCLUSIONS

COP measures taken in ballet-specific positions can distinguish between dancers with a high and low occurrence of musculoskeletal injuries. Suggestions are made to include ballet-specific tasks in the functional assessments of professional dancers.

Body asymmetries as risk factors for musculoskeletal injuries in dancesport, hip-hop and ballet dancers?

OBJECTIVES

The study aimed to determine the incidence and expression of body asymmetries in dancers of three different dance styles: dancesport (n = 14), hip-hop (n = 21) and ballet (n = 20) and to examine how body asymmetries (muscle strength and power, stability and range of motion) are associated with musculoskeletal injuries occurring over the past 12 months.

DESIGN

Cross-sectional and retrospective study.

METHODS

Maximal isometric voluntary contraction was measured for trunk, hip, knee and ankle movements. Participants performed a single leg stance, unilateral landing, weight bearing symmetry, squat and countermovement jump on force platforms. Passive range of motion was measured for hip, knee and ankle with two-arm goniometer or digital inclinometer (hip flexion, extension and rotations). A retrospective questionnaire was used to collect data on musculoskeletal injuries occurring in the last 12 months.

RESULTS

Different dance styles were associated with different body asymmetries, including strength asymmetries (hip flexion and external rotation), agonist/antagonist asymmetries (trunk flexion/extension, hip abduction/adduction, ankle dorsi/plantar flexion) and hip adduction and internal rotation range of motion asymmetries. Moreover, strength asymmetries of hip flexion, adduction and abduction/adduction as well as stability asymmetries were associated with the total number of musculoskeletal injuries.

CONCLUSIONS

The incidence of body asymmetries (> 10%) in dancesport, hip-hop and ballet dancers was confirmed, as well as the association of some asymmetries with self-reported injuries occurring over the last 12 months. The cause-effect relationship should be clarified by further studies.

Comparison of Dance-Related Foot and Ankle Injuries Among Pre-Professional Ballet, Contemporary, and Chinese Dancers

BACKGROUND

Foot and ankle injuries have been noted as the most common in dancers. However, the variability of injury epidemiology across different dance genres has not been clearly evaluated. Herein, this study aimed to evaluate the prevalence and incidence of foot and ankle problems in pre-professional ballet, contemporary, and Chinese dancers.<br/> Methods: Participants (N = 54) were recruited from a local dance institution that offered a formal undergraduate dance program. Demographic characteristics and specifics of foot and ankle pain during dancing were collected through an online self-reporting survey from September 2018 to June 2019. Descriptive statistical analyses, including injury incidence and risk rates, were conducted.<br/> Results: The overall response rate was 69.3%, with a total of 88 subjects eligible for analysis of which the results from 54 subjects were ultimately analyzed. The incidence of foot and ankle pain during the academic year of 2018 to 2019 was highest in contemporary dancers (0.38 per 1,000 dance hours) when compared to that of ballet (0.32 per 1,000 dance hours) and Chinese dancers (0.22 per 1,000 dance hours). Prevalence of foot and ankle pain within the same year was 84% in ballet dancers, 79% in Chinese dancers, and 70% in contemporary dancers. Ballet dancers were six times more likely to suffer from pain in the Achilles region than Chinese and contemporary dancers (p < 0.01). Chinese dancers were found to experience more forefoot and midfoot problems compared to ballet and contemporary dancers (p < 0.05).<br/> Conclusion: This study illustrated that foot and ankle pain is highly prevalent among pre-profes- sional dancers. Ballet was associated with the highest prevalence of foot-ankle pain while contemporary dance was associated with the highest incidence. There were significant differences of foot and ankle pain among dance genres and anatomical subregions, which suggests a need for targeted genre-specific injury prevention programs in hopes of preventing potentially career-ending injuries in dancers.

Screening Tools as a Predictor of Injury in Gymnastics: Systematic Literature Review

Background

Gymnastics requires a high level of physical ability and technical skill which utilises short sets of athleticism and artistry to perform complex and intense movements which can overload musculoskeletal tissues and result in acute injuries which can develop into chronic injuries. The aim of this systematic literature review was to investigate which screening tools predict injury in gymnasts and encompasses all genres, levels and ages.

Methods

An electronic search of seven databases from their inception until March 2021 was conducted. The databases were the Allied and Complementary Medicine Database, CINAHL, eBook Collection (EBSCOhost), MEDLINE, Cochrane Database of Systematic Reviews, SPORTDiscus and PEDro (the Physiotherapy Evidence Base). A combination of the following search terms was used: (1) Gymnastics AND injury AND Screening, (2) Screening AND Gymnastics and (3) Musculoskeletal AND Screening AND Gymnastics. These terms were searched in all text, abstract, title and subject terms. Studies were assessed using a 20-point scoring tool.

Results

The mean methodological quality score was 13.1 points (range 10–17 points). Range of motion, anthropometric and postural measurements, hypermobility, clinical diagnostic tests, movement screening tools, muscle strength, power and endurance were reported in the included studies. Some evidence existed for screening measurement of height and mass as taller and heavier gymnasts might be more susceptible to injury; however, the different methodologies utilised and lack of acknowledgment of confounding variables limit the clinical relevance of these findings.

Conclusions

Height and mass should be recorded during the screening process. A lack of heterogeneity in study methodology prevented a meta-analysis. Studies were limited by a lack of prospective injury design, poor injury definition, self-reporting of injury and only 2 studies reported reliability of screening tools. Further research is required to determine the role of injury screening in gymnastics.

Registration: The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42020218339.

On-site Clinical Care for Professional Dance Companies

Thirty years ago the introduction of on-site health care for professional dance companies was a novel concept and dance medicine clinicians often had limited on-site hours, restricted treatment space, and small budgets. Companies are now developing fully staffed on-site clinics and backstage care that provide a multidisciplinary approach to dancer health and wellness. On-site dance medicine programs focus on holistic dancer health and preventive care rather than just triage and rehabilitation. Best practice recommendations for care of professional dancer patients allow for streamlined patient care within a network of medical professionals who understand the demands of a professional dance career.

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.

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.

Clinical Evaluation Techniques for Injury Risk Assessment in Elite Swimmers: A Systematic Review

CONTEXT

Evidence concerning a systematic, comprehensive injury risk assessment in the elite swimming population is scarce.

OBJECTIVE

To evaluate the quality of current literature regarding clinical assessment techniques used to evaluate the presence and/or development of pain/injury in elite swimmers and to categorize objective clinical assessment tools into relevant predictors (constructs) that should consistently be evaluated in injury risk screens of elite swimmers.

DATA SOURCES

PubMed, Embase, Scopus, CINAHL, SPORTDiscus, PEDro, and the Cochrane Library Reviews were searched through September 2018.

STUDY SELECTION

Studies were included for review if they assessed a correlation between clinic-based objective measures and the presence and/or development of acute or chronic pain/injury in elite swimmers. All body regions were included. Elite swimmers were defined as National Collegiate Athletic Association, collegiate, and junior-, senior-, or national-level swimmers. Only cohort and cross-sectional studies were included (both prospective and retrospective); randomized controlled trials, expert opinion, and case reports were excluded, along with studies that focused on interventions, performance, or specific swim-stroke equipment or technology.

STUDY DESIGN

Systematic review and qualitative analysis.

LEVEL OF EVIDENCE

Level 3.

DATA EXTRACTION

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were utilized at each phase of review by 2 reviewers; a third reviewer was utilized for tie breaking purposes. Qualitative analysis was performed using the Methodological Items for Non-Randomized Studies (MINORS) assessment tool.

RESULTS

A total of 21 studies assessed the presence and/or development of injury/pain in 3 different body regions: upper extremity, lower extremity, and spine. Calculated average MINORS scores for comparative (n = 17) and noncomparative (n = 4) studies were 18.1 of 24 and 10.5 of 16, respectively. Modifiable, objectively measurable injury risk factors in elite swimmers were categorized into 4 constructs: (1) strength/endurance, (2) mobility, (3) static/dynamic posture, and (4) patient-report regardless of body region.

CONCLUSION

Limited evidence exists to draw specific correlations between identified clinical objective measures and the development of pain and/or injury in elite swimmers.

The Relationship Between the Golf-Specific Movement Screen and Golf Performance

CONTEXT

Golf requires effective movement patterns to produce an effective swing and performance.

OBJECTIVE

To determine the relationship between the Titleist Performance Institute golf-specific functional movement screening (GSFMS) composite and individual element scores and golf performance by assessing a player's handicap, clubhead speed, side accuracy, ball speed, peak pelvis rotation speed, swing sequence, and common swing faults.

DESIGN

Cohort study, clinical measurement.

SETTING

English golf club.

PARTICIPANTS

A total of 11 amateur golfers: 5 males (age: 37.2 [18.7] y, height: 184.4 [9.6] cm, body mass: 89.5 [13.4] kg, and handicap: 9 [6.6]) and 6 females (age: 53.7 [15.0] y, height: 166.8 [5.5] cm, body mass: 67.9 [16.6] kg, and handicap: 13 [6.1]).

MAIN OUTCOME MEASURES

GSFMS composite and individual element scores and golf performance variables.

RESULTS

Significant relationships existed between GSFMS composite scores and handicap (r = -.779, P = .01); clubhead speed (r = .701, P = .02); ball speed (r = .674, P = .02); and peak pelvis rotation speed (r = .687, P = .02). Significant relationships existed between 90°/90° golf position and clubhead speed (r = .716, P = .01); ball speed (r = .777, P = .01); seated trunk rotation and peak pelvis rotation speed (r = .606, P = .048); single-leg balance and handicap (r = -.722, P = .01); torso rotation and handicap (r = -.637,P = .04); and torso rotation and peak pelvis rotation speed (r = .741, P = .01). Single-leg balance, overhead deep squat, and pelvic tilt were the GSFMS tests which participants had most difficulty in performing. The most common swing faults identified included loss of posture, slide, chicken winging, and early hip extension.

CONCLUSIONS

The GSFMS may be used to identify movement limitations that relate to golfing performance. These findings may potentially allow intervention to correct movement patterns and potentially improve golf performance.

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.