Motor Control and Low Back Pain in Dancers

Abstract

Professional dancers suffer a high incidence of injuries, especially to the spine and lower extremities. There is a lack of experimental research addressing low back pain (LBP) in dancers. The aim of this study is to compare lumbopelvic motor control, muscle extensibility and sacroiliac joint pain between dancers with and without a history of LBP. 40 pre-professional dancers (mean age of 20.3 years) underwent a clinical test battery, consisting of an evaluation of lumbopelvic motor control, muscle extensibility, generalized joint hypermobility, and sacroiliac joint pain provocation tests. Also self-reported measurements and standardized questionnaires were used. 41% of the dancers suffered from LBP during at least 2 consecutive days in the previous year. Only one dancer suffered from sacroiliac joint pain. Compared to dancers without a history of LBP, dancers with a history of LBP showed poorer lumbopelvic motor control (p<0.05). No differences in muscle extensibility or joint hypermobility were observed between dancers (p>0.05). Despite their young age, pre-professional dancers suffer from LBP frequently. Sacroiliac joint pain, generalized joint hypermobility or muscle extensibility appears unrelated to LBP in dancers. Motor control is decreased in those with a history of LBP. Further research should examine whether motor control is etiologically involved in LBP in dancers.

Full text

138 Training & Testing
Roussel N et al. Motor Control and Low … Int J Sports Med 2013; 34: 138–143
accepted after revision
June 01 , 2012
Bibliography
DOI http://dx.doi.org/
10.1055/s-0032-1321722
Published online:
September 7, 2012
Int J Sports Med 2013; 34:
138–143 © Georg Thieme
Verlag KG Stuttgart · New York
ISSN 0172-4622
Correspondence
Dr. Nathalie Roussel
Faculty of Medicine
University of Antwerp
Universiteitsplein 1
2610 Wilrijk
Belgium
Tel.: +32/32/652633
Fax: +32/38/202248
Nathalie.Roussel@ua.ac.be
Key words
●
▶
dance
●
▶
injury
●
▶
low back pain
●
▶
health
●
▶
sacroiliac pain
●
▶
joint pain
●
▶
hypermobility
Motor Control and Low Back Pain in Dancers
Despite the high prevalence and incidence of LBP
in dancers compared to non-dancers, there is a
lack of experimental studies evaluating the back
complaints in this population [ 14 ] . Only a few
case reports exist about LBP in dancers [ 9 , 14 ] .
Until further research in this area is undertaken,
it remains unclear whether the increasing
amount of research dealing with the evaluation
and rehabilitation of patients with LBP in the
general population is applicable to dancers [ 14 ] .
Recent developments in LBP research include for
example motor control assessment of the lum-
bopelvic region. The change in feed-forward
mechanisms and postural function of spinal
muscles observed in the patients with acute and
chronic LBP may be very relevant to the dancer’s
ability to control the spine during limb move-
ment [ 33 ] .
Several hypotheses regarding the cause of LBP in
dancers and athletes have been proposed. The
high prevalence of injuries, including LBP, may be
due to repetitive movements in the hypermobile
range of movement, which is typical for dancing.
Another hypothesis states that as a result of
Introduction
▼
Dancers are at increased risk for developing low
back pain (LBP) [ 20 ] , as they regularly perform
repetitive extensions, high velocity twisting and
bending movements. Of all dance injuries,
approximately 60–80 % occur in the lower limbs
and 17–30 % in the spine [ 4 , 11 , 21 ] . Studies
examining the one-year incidence of LBP indicate
that dancers experience spinal complaints very
frequently. For example, in one study performed
in 128 professional adult ballet dancers, 95 % of
the dancers experienced musculoskeletal com-
plaints, and more than 70 % of the dancers indi-
cated that they had suff ered LBP during the
preceding 12 months [ 26 ] . In pre-professional
dancers, values up to 63 % have been reported
[ 32 ] . In studies including children and adoles-
cents, the incidence and magnitude of LBP expe-
rienced during the previous year is signifi cantly
greater in dancers and gymnasts compared to
control subjects, which are defi ned as subjects
devoting less than 6 h per week to physical
activity [ 20 ] .
Authors N. Roussel
1
,
2
,
5 , M. De Kooning
2 , A. Schutt
3 , S. Mottram
4 , S. Truijen
5 , J. Nijs
2 , L. Daenen
1
,
2
Affi liations
1 Faculty of Medicine, University of Antwerp, Belgium
2 Human Physiology, Vrije Universiteit Brussel, Brussels, Belgium
3 Royal Conservatoire, Artesis University College, Antwerp, Belgium
4 Movement Performance Solutions, Physiotherapy, Chichester, United Kingdom
5 Health Care Sciences, Artesis University College, Antwerp, Belgium
Abstract
▼
Professional dancers suff er a high incidence
of injuries, especially to the spine and lower
extremities. There is a lack of experimental
research addressing low back pain (LBP) in danc-
ers. The aim of this study is to compare lum-
bopelvic motor control, muscle extensibility and
sacroiliac joint pain between dancers with and
without a history of LBP. 40 pre-professional
dancers (mean age of 20.3 years) underwent a
clinical test battery, consisting of an evaluation of
lumbopelvic motor control, muscle extensibility,
generalized joint hypermobility, and sacroiliac
joint pain provocation tests. Also self-reported
measurements and standardized questionnaires
were used. 41 % of the dancers suff ered from LBP
during at least 2 consecutive days in the previous
year. Only one dancer suff ered from sacroiliac
joint pain. Compared to dancers without a his-
tory of LBP, dancers with a history of LBP showed
poorer lumbopelvic motor control (p < 0.05).
No diff erences in muscle extensibility or joint
hypermobility were observed between dancers
(p > 0.05). Despite their young age, pre-profes-
sional dancers suff er from LBP frequently. Sacro-
iliac joint pain, generalized joint hypermobility
or muscle extensibility appears unrelated to LBP
in dancers. Motor control is decreased in those
with a history of LBP. Further research should
examine whether motor control is etiologically
involved in LBP in dancers.

139Training & Testing
Roussel N et al. Motor Control and Low … Int J Sports Med 2013; 34: 138–143
injury, degenerative change or repetitive motion, dancers may
develop a spinal motor control dysfunction [ 37 ] . Impaired motor
control of the lumbopelvic region leads to compensatory move-
ments of the spine and lower limbs, which may result in LBP
[ 37 ] .
Surprisingly, there are no data on the incidence of motor control
disorders in dancers with LBP. However, it has been suggested
more than 20 years ago that dance injuries involving lower
extremities are related to dysfunction or derangement of the
lower back and pelvis [ 2 ] . We previously undertook a study to
examine the relationship between motor control, hypermobility
and injuries in dancers and found that dancers with altered lum-
bopelvic motor control at baseline were at risk for developing
injuries to the spine and lower extremities [ 32 ] . Neither a his-
tory of LBP nor generalized joint hypermobility were able to pre-
dict the occurrence of new injuries to spine or lower extremities
[ 32 ] . However, this study evaluated motor control and general-
ized joint hypermobility in relation to new injuries and not spe-
cifi c in relation to LBP.
Dance injuries in general, and LBP in particular, are seldom
caused by one single factor, but are usually the result of repeated
overload, superimposed on multiple factors [ 2 ] . It is for example
known that dancers may compensate a lack of hip external rota-
tion or hip extension by hyperextending the lumbar spine, in
order to achieve Arabesque positions (i. e., 90 ° of hip extension/
external rotation with an extended leg during stance) [ 2 ] . Ante-
rior pelvic tilt and hyperlordosis of the spine are indeed very
common in dancers. Unsurprisingly, spinal pathologies such as
spondylosis and spondylolisthesis are much more common in
dancers and gymnasts than in the general population [ 13 ] .
Uncontrolled movement of the pelvis and the lumbar spine may
contribute to the complaints. Therefore it is essential to evaluate
lumbopelvic motor control in dancers. It is hypothesized that
dysfunctional lumbopelvic motor control, muscle extensibility
and generalized joint hypermobility are related to (a history of)
LBP in dancers.
Finally, also sacroiliac joint pain has been suggested as cause for
LBP in dancers [ 8 ] . The sacroiliac joint plays an important role in
dancing, as dance choreographies lean on correct biomechanics
of spine and pelvis [ 8 ] . Indeed, dance movements – in which the
esthetic aspect is crucial – are only made possible by optimal
functioning of muscles, joints and ligaments of spine and
extremities. Pelvic motion provides for example a large propor-
tion of the battement movement [ 5 ] . Loss of pelvic motion may
therefore alter the biomechanics of dance movements, and may
be associated with pain and dysfunction. Again, no experimental
studies regarding sacroiliac joint pain are available in dancers.
Study aims
▼
The aim of this study is to compare lumbopelvic motor control,
muscle extensibility and sacroiliac joint pain between dancers
with and without a history of LBP.
Materials and Methods
▼
Design
A cross-sectional design was used to evaluate diff erences in test
results between dancers with and without a history of LBP. All
participants were subjected to a clinical test battery, consisting
of the assessment of lumbopelvic motor control, muscle length,
generalized joint hypermobility and explosive muscle strength.
Pain provocation tests were used to evaluate the sacroiliac joint.
In addition, an anthropometric evaluation was performed in all
subjects. Finally, participants were asked to fi ll in several ques-
tionnaires. The Human Research Ethics Committee of the local
University Hospital approved the study. The study was con-
ducted in accordance with the ethical standards of the Interna-
tional Journal of Sports Medicine and was approved by the
University Institutional Review Board [ 15 ] , all participants com-
pleted and signed an informed consent document.
Study participants
Participants were recruited among dancers (n = 41) enrolled at
the Department of Dance of a Conservatoire, the only profes-
sional bachelor education for dance in Belgium. At the start of
the academic year, all subjects received verbal information
addressing the study. Next, an information leafl et was handed
out to the participants. Participants were instructed to read it
vigilantly and to ask for additional explanation if necessary.
Inclusion criteria were full-time enrolment, availability for
study participation, willingness to participate and hence to sign
the informed consent form. 40 dancers (2 men, 38 women)
agreed to participate in the study and signed the informed con-
sent form. One student performed a stay abroad in a foreign
country during the whole academic year and was excluded from
the study. The age of the participants varied between 17 and 26
years, with a mean age of 20.3 (2.4) years (see
●
▶
Table 1 ). Danc-
ers suff ering from LBP during at least 2 consecutive days were
defi ned as dancers with a history of LBP [ 20 ] .
Outcome measures
Questionnaires
Participants were asked to fi ll in several questionnaires such as
the Short Form 36-questionnaire (SF-36), the Tampa Scale for
Kinesiophobia (TSK) and a self-established medical question-
naire. The psychometric properties of the SF-36 [ 37 ] and the TSK
[ 30 ] have been described elsewhere. The visual analogue scale
(VAS – 100 mm) was used for the assessment of pain severity
[ 25 ] . A standardized questionnaire was used to collect demo-
graphic information at baseline, in addition to questionnaire
previously used to register LBP in dancers [ 20 ] . To gather infor-
mation about complaints in other regions, the following ques-
tion was asked in the self-reported questionnaire: Have you at
any time during the last 12 months had some trouble (ache pain,
discomfort) in: neck, upper back, low back, hips/thighs, knees,
ankle/feet [ 26 ] . No time frame for the complaints was provided
in this questionnaire.
Table 1 Descriptive statistics of 40 dancers.
Mean SD Range [min;max]
age (y) 20.30 2.40 [17;26]
height (m) 1.66 0.06 [1.6;1.8]
weight (kg) 56.43 5.71 [48.8;74.8]
BMI (kg/m2) 20.45 1.65 [16.7;28.9]
waist hip-ratio 0.73 0.04 [0.7;0.8]
sum skinfolds (mm) 41.70 8.05 [25.1;93.0]
physical activity during
classes (h/week)
21.5 2.1 [6.9;29.7]
physical activity outside
classes (h/week)
4.6 1.3 [0;23.3]
SD = standard deviation; [min;max] = minimal and maximal value; BMI = Body Mass Index

140 Training & Testing
Roussel N et al. Motor Control and Low … Int J Sports Med 2013; 34: 138–143
Lumbopelvic motor control
Lumbopelvic motor control was assessed by evaluating the sub-
jects’ ability to control movement of lumbopelvic region while
performing simple movements in the hips. The Knee Lift
Abdominal Test (KLAT, see
●
▶
Fig. 1 ) and Bent Knee Fall Out
(BKFO, see
●
▶
Fig. 2 ) were used for the evaluation of lumbopelvic
motor control. The tests were performed in supine position and
monitored with a pressure biofeedback unit (PBU), as previously
described [ 32 ] . In brief, the pressure of the PBU was infl ated to
40 mmHg (baseline pressure) [ 28 ] . Participants were instructed
to maintain neutral spine position (i. e., preventing spinal move-
ment) during lower extremity movement. The other leg was
extended (BKFO) or fl exed (KLAT) and rested on the table, except
for the bilateral KLAT. A pre-testing trial was organized to famil-
iarize the subjects with the PBU and the clinical tests. Maximal
pressure deviation from baseline was recorded during each test
and these scores were used for further analyses. The aim of the
test was to have as little deviation from the baseline pressure as
possible. Although it is unnatural to keep the spine still during
movements, previous research demonstrated that healthy sub-
jects with good trunk stabilization are able to maintain neutral
spine position while moving the legs [ 17 ] and that signifi cant
diff erences are observed between patients with LBP and healthy
subjects [ 32 ] . The reliability of these tests is acceptable [ 32 ] .
In addition, contraction of the M. transversus abdominis was
assessed in the dancers by the abdominal ‘drawing in’ action in
crook lying [ 7 ] . For a correct test performance (negative test),
participants should be able to tension the M. transversus
abdominis (hollowing of the lower abdominal wall) without
excessive overfl ow to the upper abdominal wall, expansion of
the Mm. internal obliques, spinal or rib cage movement, as pre-
viously described [ 7 , 27 ] . Observation and manual palpation
were used to evaluate the correct contraction of M. transversus
abdominis. In case of compensations as mentioned above, the
test was considered positive. In addition, the breathing pattern
during the test was observed, as breath holding occur in patients
with LBP, which is also considered as compensatory strategy
[ 31 ] . Movements of the thorax and the abdomen during respira-
tion were inspected and palpated during motor control tests. A
normal breathing pattern (costo-diaphragmatic breathing) was
defi ned as a displacement of the ribcage in cranial, lateral out-
ward and ventral direction and an outward movement of the
abdomen during inspiration and the reverse pattern during
expiration. All other breathing patterns were defi ned as asyn-
chronous breathing patterns [ 31 ].
Muscle extensibility
Muscle extensibility was evaluated by assessing the range of
motion of several joints. The length of the hip adductors was
examined in supine position, with the contralateral leg hanging
over the table to stabilize the pelvis. The leg to be measured was
then abducted passively with the leg maintained in neutral posi-
tion (foot pointing towards the ceiling). Range of motion of hip
abduction was evaluated with the stationary arm of the goniom-
eter on a line between the umbilicus and the symphysis pubis
and the moving arm along the long axis of the abducted thigh,
between the umbilicus and the patella [ 34 ] . Both the mono-
articular adductors (knee fl exion of the testing leg) as the bi-
articular adductors (extended leg) were assessed.
The length of the hamstrings muscles was evaluated in supine
position with the contralateral leg resting on the table. The leg to
be measured was fl exed passively in the hip, with an extended
knee, while fi xating the pelvis to avoid pelvic movement (straight
leg raise maneuver). The moving arm of the goniometer was
positioned parallel with the lateral knee epicondyle and the
greater trochanter, while the stationary arm was positioned
horizontally (parallel with the table) [ 24 ] .
The length of the M. tensor fascia latae was evaluated in side
lying (Ober’s test) [ 38 ] .
Generalized joint hypermobility was assessed according to the
description provided by Beigthon et al. [ 3 ] . The clinimetric prop-
erties of the Beigthon score have been summarized elsewhere
[ 22 ] . 3 subgroups were defi ned based on the individual Beigthon
scores: tight (0–3); hypermobile (4–6); extremely hypermobile
(7–9) [ 35 ] .
5 pain provocation tests for the assessment of sacroiliac joint
pain were used in the present study: Posterior Pelvic Pain provo-
cation test (P4), Patrick or Faber Test, Gaenslen Test, Compres-
sion Test and distraction or gapping test [ 29 ] . The reliability and
validity of these tests is moderate to good, especially when used
in clusters [ 18 , 29 ] . Dancers were therefore classifi ed as having a
sacroiliac joint pain disorder when three or more tests were
positive [ 18 , 29 ] .
Fig. 1 Knee lift abdominal test. The subject is instructed to lift one foot
off the table to 90 ° of hip fl exion with knee fl exion, keeping the lumbar
spine stable.
Fig. 2 Bent knee
fall out. The subject
is instructed to lower
out the bent leg to
approximately 45 ° of
abduction/lateral rota-
tion, while keeping the
foot supported beside
the straight leg, and
then to return to the
starting position.

141Training & Testing
Roussel N et al. Motor Control and Low … Int J Sports Med 2013; 34: 138–143
An anthropometric evaluation was performed in all subjects.
The subjects wore light clothes (T-shirts and tights) and no
shoes. Height was measured to the nearest centimeter (cm)
using a stadiometer
a . Weight was measured using a CE approved
medical digital column scale
b . Hip and waist circumference as
well as subcutaneous thickness (middle of the triceps and of the
biceps, 5 cm above the superior and anterior iliac spine and 2 cm
below and lateral below the inferior angle of the scapula) were
measured with a calliper [ 10 ] . Body Mass Index (BMI) and waist
to hip ratio were calculated.
Statistical analysis
Statistical analysis was performed with Statistical Package for
Social Sciences (SPSS)
f version 18.0. We used a one-sample Kol-
mogorov-Smirnov (K-S) goodness-of-fi t test to examine whether
the variables were normally distributed. In cases of normally
distributed variables, we used the independent samples Stu-
dent’s t -test to compare the dancers with a history of LBP with
the dancers without LBP. If the K-S revealed that a variable was
not normally distributed, then the nonparametric Mann-Whit-
ney test was used. The Fisher’s exact test was used to compare
categorical data between the participants with and without LBP.
A Spearman correlation coeffi cient was used to analyze correla-
tions between several parameters. The signifi cance level was set
at 0.05, except for the correlation analysis which was set at 0.01
to help protect against potential type I errors.
Sample size calculations indicated that we need to study 17 sub-
jects for each group. These calculations were based on a power
analysis (power of 0.80 and α of 0.05), based on a previous study
assessing lumbopelvic motor control in healthy subjects and
patients with LBP [ 31 ] and on a study evaluating LBP in dancers
[ 32 ] . We anticipated that approximately half of the dancers
would have experienced LBP in the year before the study and
that diff erences in pressure between healthy subjects and
patients would be 2.5 mm Hg (2.3). In order to account for pos-
sible drop out, 44 dancers were recruited.
Results
▼
40 dancers completed the study. Descriptive statistics of the
study participants are presented in
●
▶
Table 1 . 24 dancers (60 %)
demonstrated generalized joint hypermobility. 9 of these danc-
ers (22 %) obtained a Beigthon score ≥ 7, which can be consid-
ered as extreme hypermobility. 23 dancers (58 %) experienced at
least once LBP during the previous year. Fifteen dancers (38 %)
experienced at least once upper back pain during the previous
year. The percentage of dancers experiencing complaints at hips,
thighs, knees or ankle and feet during the previous year was
54 %, 48 % and 45 %, respectively.
Comparison of data between dancers with and without
a history of LBP
16 dancers (41 %) reported at least one experience of LBP lasting
more than 2 consecutive days in the last year. This group is fur-
ther classifi ed as dancers with a history of LBP.
Evaluation of range of motion and generalized joint
hypermobility
There was no diff erence in Beigthon score for the assessment of
generalized joint hypermobility or in range of motion between
dancers with or without a history of LBP (see
●
▶
Table 2 ) .
Lumbopelvic motor control assessment
Signifi cant diff erences were observed between dancers with and
without a history of LBP for 2 lumbopelvic motor control tests
(see
●
▶
Table 3 ) .
A signifi cant diff erence was also found for the proportion of
dancers with a correct contraction of the transversus abdominis
muscle. 30 % (7/23) of the dancers without a history of LBP were
not able to perform a correct contraction of the transverse
abdominis muscle, compared to 63 % (10/16) of the dancers with
a history of LBP (p = 0.048).
Sacroiliac joint pain provocation tests
Only one dancer had more than 3 positive sacro-iliac joint pain
provocation tests. This dancer did not experience LBP during the
previous year.
No correlations were observed between muscle extensibility,
generalized joint hypermobility, and sacroiliac joint pain on the
one hand, and LBP on the other hand.
Table 2 Assessment of joint hypermobility and joint ROM in dancers with and without a history of low back pain.
No LBP (n = 23) LBP (n = 16)
Mean SD Mean SD t df p 95 % CI
Beigthon score (0–9) 4.30 2.265 4.69 2.798 − 0.472 37 0.640 − 2.029 1.263
hip fl exion left ( °ROM) 119.48 12.724 116.50 13.337 0.705 37 0.485 − 5.581 11.537
hip fl exion right ( °ROM) 121.65 13.435 119.69 10.209 0.493 37 0.625 − 6.103 10.032
hip adduction left ( °ROM) 61.70 7.468 60.06 8.330 0.641 37 0.526 − 4.162 5.700
hip adduction right ( °ROM) 61.26 8.433 60.00 8.907 0.449 37 0.656 − 0.301 0.187
SD = standard deviation, CI = confi dence interval. Values are expressed as total score (Beigthon Score) or degrees in range of motion (ROM)
Table 3 Motor control assessment in dancers with and without a history of low back pain.
No LBP (n = 23) LBP (n = 16)
Mean SD Mean SD t df p 95 %CI
knee lift abdominal test bilateral (mm Hg) 53 8.2 59 8.9 − 2.041 37 0.048* − 11.3 − 0.041
bent knee fall out left (mm Hg) 36.1 5.7 32.9 3.1 2.037 37 0.049* 0.017 6.39
bent knee fall out right (mm Hg) 35.1 5.8 33.5 2.8 1.042 37 0.304 − 1.55 4.82
SD = standard deviation, CI = confi dence interval. Values are expressed in mm Hg

142 Training & Testing
Roussel N et al. Motor Control and Low … Int J Sports Med 2013; 34: 138–143
Questionnaires
N o d i ff erences were observed for the results of the SF-36
between dancers with and without a history of LBP. Also the
results of the Tampa Scale for Kinesiophobia did not diff er
between the 2 groups (for the dancers without and with a his-
tory of LBP mean value of 34.2 and 36.2, respectively, p = 0.293).
Discussion
▼
The results of the present study demonstrate that LBP is very
common in dancers and that dancers with a history of LBP do
not demonstrate increased muscle extensibility or joint hyper-
mobility, but show altered motor control of the lumbopelvic
region (2 out of 3 tests), when compared to dancers without a
history of LBP. Sacroiliac joint pain, generalized joint hyper-
mobility or muscle extensibility appears unrelated to LBP in
dancers.
The incidence of musculoskeletal complaints to the spine and
the lower extremities during the last year was in line with other
studies on professional and pre-professional dancers [ 4 , 11 , 21 ] .
The spine is the second most injured area of the body in dancers
[ 4 , 11 , 13 ] . Literature reports indicate that 10–29 % of the dance
injuries involve the lower back [ 4 , 21 ] . 58 % of the dancers in the
present study reported that they had at least one episode of LBP
in the previous year, and 41 % of the dancers suff ered from LBP
lasting at least 2 consecutive days. This is comparable to the val-
ues observed in young dancers and gymnasts, ranging from
32–50 % [ 20 ] . In children and adolescents, it has been suggested
that more than 30 h of physical activity per week increases the
likelihood of developing LBP [ 20 ] . Our population has a schedule
with nearly 30 h of weekly physical activity, which may explain
the high proportion of dancers with LBP observed in the present
study.
The exact cause of the spinal complaints remains unknown.
Using magnetic resonance imaging, Capel observed a similar
rate of degenerative disc diseases between dancers and non-
dancers [ 6 ] . Medical imaging is, however, not recommended in
the general population to examine patients with non-specifi c
LBP [ 1 ] . An exception may be the use of medical imaging in danc-
ers in which spondylolisthesis is suspected. Recent developments
regarding LBP in the general population focus on the bio-psycho-
social aspect. In addition to psychosocial factors, spinal motor
control appears to be an important issue in patients with recur-
rent LBP [ 36 ] . It has been demonstrated that the observed altera-
tions of motor control are associated with a reorganization of
trunk muscle representation at the motor cortex [ 36 ] .
Motor control of the lumbopelvic region seems essential in
dancers as well, to control the spine during limb movement.
Most dance movements involve lower extremities or the trunk
while keeping the esthetic aspect in mind, and are made possi-
ble by dynamic stabilization of the lumbopelvic region. The
rapid and extreme movements of the legs in all directions, the
jumps, twisting and bending movements impose tremendous
forces on the spine and the pelvis [ 8 ] . It is known from the gen-
eral population and athletes that patients with LBP demonstrate
altered motor control of the lumbopelvic region [ 16 , 31 ] . Poor
technique, muscle imbalance and altered motor control have
been suggested as contributing factors to LBP in dancers [ 12 , 13 ,
14 , 33 ] . Nevertheless, this is the fi rst study reporting altered
motor control in dancers with LBP. A large proportion of dancers
with a history of LBP are not able to contract their M. transversus
abdominis, and these dancers demonstrate higher pressure
deviations on the pressure biofeedback unit during 2 out of 3
motor control tests.
Altered motor control was the only factor which was signifi -
cantly diff erent between dancers with and without a history of
LBP, implying that neither generalized joint hypermobility, nor
sacroiliac joint pain are more prevalent in dancers with a history
of LBP. The role of altered motor control in the etiology of LBP
should be further explored. In the present study, the observed
diff erences between the groups are consistent, but relatively
small. In addition, the present study has a cross sectional design
and causative interpretations should not be made.
In a prospective study, performed in a similar population, altered
motor control was the only test associated with an increased
injury risk to the lower extremities and the spine [ 32 ] . Again,
generalized joint hypermobility appeared to be unrelated to
dance injuries [ 32 ] . Taking the multifactorial etiology of LBP into
consideration, it is important to analyze other factors that may
be related to LBP. In the general population, psychosocial factors
appear to play an important role in the recurrence of LBP as well.
In the present study, fear avoidance was similar in dancers with
and without a history of LBP. Also the results of the SF-36 did not
diff er between the 2 groups. Only limited attention has been
paid to psychological factors in dancers until now. Anxiety,
stress and self-critique are common in dancers [ 8 ] . Noh et al.
identifi ed major sources of stress in Korean dancers (i. e., physi-
cal, psychological, interpersonal and situational) [ 23 ] . Mainwar-
ing et al. observed a strong correlation between stress and
injuries [ 19 ] . These studies evaluated stress and psychosocial
factors in relation to injuries in general and not in relation to LBP.
Further research should evaluate to what extent stress, emotional
and psychological factors may play a role in LBP in dancers.
Limitations of the Present Study
▼
The results of this study should nevertheless be seen in the light
of some methodological concerns. Firstly, these results apply to
pre-professional dancers following a Bachelor in Dance. Univer-
sity dance programs may not refl ect general dance populations
and the evaluation of lumbo-pelvic motor control in relation to
LBP should certainly be performed in professional dance compa-
nies as well, thereby diff erentiating the diff erent dance styles
(ballet vs. contemporary dancing). Secondly, we performed fi eld
tests using a goniometer for the evaluation of joint range of
motion, as we had no possibility to evaluate dancers in a control-
led laboratory setting.
Conclusion
▼
Dance is a physically demanding activity. Strength, extensibility,
endurance and motor control are required to perform dance
choreographies. The repetition of movements to extreme posi-
tions can contribute to pain. Dancers with a history of LBP do not
demonstrate increased muscle extensibility or joint hypermo-
bility, but show altered motor control of the lumbopelvic region,
when compared to dancers without a history of LBP. Sacroiliac
joint pain appears to be unrelated to the LBP in dancers. Further
research should evaluate the psychosocial aspect in dancers
with LBP and should develop strategies to prevent and manage
LBP in dancers.

143Training & Testing
Roussel N et al. Motor Control and Low … Int J Sports Med 2013; 34: 138–143
Acknowledgements
▼
Funding sources Nathalie Roussel, Liesbeth Daenen en Anne
Schütt were fi nancially supported by a research grant supplied
by the Royal Conservatoire, Artesis University College Antwerp,
Antwerp, Belgium. The funders had no role in study design, data
collection and analysis, decision to publish, or preparation of the
manuscript. The authors thank all dancers and dance teachers
for their participation.
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