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Injury Patterns and Injury Rates in the Circus Arts An Analysis of 5 Years of Data From Cirque du Soleil



Human circus arts are gaining increasing popularity as a physical activity with more than 500 companies and 200 schools. The only injury data that currently exist are a few case reports and 1 survey. To describe injury patterns and injury rates among Cirque du Soleil artists between 2002 and 2006. Descriptive epidemiology study. The authors defined an injury as any work-related condition recorded in an electronic injury database that required a visit to the show therapist. Analyses for treatments, missed performances, and injury rates (per 1000 artist performances) were based on a subset of data that contained appropriate denominator (exposure) information (began in 2004). There were 1376 artists who sustained a total of the 18 336 show- or training-related injuries. The pattern of injuries was generally similar across sex and performance versus training. Most injuries were minor. Of the 6701 injuries with exposure data, 80% required < or =7 treatments and resulted in < or =1 completely missed performance. The overall show injury rate was 9.7 (95% confidence interval, 9.4-10.0; for context, published National Collegiate Athletic Association women's gymnastics rate was 15.2 injuries per 1000 athlete-exposures). The rate for injuries resulting in more than 15 missed performances for acrobats (highest risk group) was 0.74 (95% confidence interval, 0.65-0.83), which is much lower than the corresponding estimated National Collegiate Athletic Association women's gymnastics rate. Most injuries in circus performers are minor, and rates of more serious injuries are lower than for many National Collegiate Athletic Association sports.
*Address correspondence to Ian Shrier, MD, PhD, 3755 Cote
Ste-Catherine Rd, Montreal, Quebec, Canada H3T 1E2 (e-mail: ian.shrier@
One or more authors has declared a potential conflict of interest: Ian
Shrier, MD, PhD, received payment for collaboration on the medical data-
base in 2006. Kristin Wingfield, MD, is a Cirque du Soleil artist. Michael
Montanaro is a choreographer for Cirque du Soleil.
**References 5, 6, 13, 17-20, 22, 24-27.
The American Journal of Sports Medicine, Vol. 37, No. 6
DOI: 10.1177/0363546508331138
© 2009 The Author(s)
Injury Patterns and Injury Rates in the
Circus Arts
An Analysis of 5 Years of Data From Cirque du Soleil
Ian Shrier,* MD, PhD, Willem H. Meeuwisse, MD, PhD, Gordon O. Matheson,§ MD, PhD,
Kristin Wingfield,ll MD, Russell J. Steele, PhD, François Prince, PhD, James Hanley, PhD,
and Michael Montanaro#
From McGill University, Montreal, Quebec, Canada, University of Calgary, Calgary, Alberta,
Canada, §Stanford University, Stanford, California, llCenter for Sports Medicine, Saint Francis
Memorial Hospital, San Francisco, California, Université de Montréal, Montreal, Quebec,
Canada, and #Concordia University, Montreal, Quebec, Canada
Background: Human circus arts are gaining increasing popularity as a physical activity with more than 500 companies and 200
schools. The only injury data that currently exist are a few case reports and 1 survey.
Hypothesis: To describe injury patterns and injury rates among Cirque du Soleil artists between 2002 and 2006.
Study Design: Descriptive epidemiology study.
Methods: The authors defined an injury as any work-related condition recorded in an electronic injury database that required a
visit to the show therapist. Analyses for treatments, missed performances, and injury rates (per 1000 artist performances) were
based on a subset of data that contained appropriate denominator (exposure) information (began in 2004).
Results: There were 1376 artists who sustained a total of the 18 336 show- or training-related injuries. The pattern of injuries
was generally similar across sex and performance versus training. Most injuries were minor. Of the 6701 injuries with exposure
data, 80% required 7 treatments and resulted in 1 completely missed performance. The overall show injury rate was 9.7 (95%
confidence interval, 9.4-10.0; for context, published National Collegiate Athletic Association women’s gymnastics rate was 15.2
injuries per 1000 athlete-exposures). The rate for injuries resulting in more than 15 missed performances for acrobats (highest
risk group) was 0.74 (95% confidence interval, 0.65-0.83), which is much lower than the corresponding estimated National
Collegiate Athletic Association women’s gymnastics rate.
Conclusion: Most injuries in circus performers are minor, and rates of more serious injuries are lower than for many National
Collegiate Athletic Association sports.
Keywords: injury; acrobat; musician; circus
activity being performed, and therefore the development
of prevention programs requires an understanding of the
specific causes of injury that are present within each activ-
ity. The first step in any injury prevention program is to
describe the injury pattern, injury severity, and incidence
associated with the activity.3,28
Historically, clinicians have focused on injury risks for
traditional activities such as baseball, hockey, athletics,
and swimming. Recently, others have noted that activities
within the performing arts also stress the musculoskeletal
system.7,8,12 Of the many performing arts, modern circus
artists (without animals) may be the most closely related
to sport as artists often have training in gymnastics and
acrosport. For example, more than 1000 artists in the
Cirque du Soleil (a company with 17 current shows)
Although there are significant benefits to physical activ-
ity,** there is also an associated increased risk of injury.
Injury patterns and injury rates are specific to the type of
1144 Shrier et al The American Journal of Sports Medicine
perform a wide variety of athletic acts that include
tethered and untethered aerial maneuvers, diving and
swimming maneuvers, martial arts, dance, and Chinese
acrobatic arts. A worldwide registry16 reports that there
are more than 500 companies dedicated to circus arts, and
they are practiced in at least 19 countries. In addition to
their regular show schedules, these companies regularly
perform more than 200 festivals or events per year. The
infrastructure includes at least 216 circus schools and 19
federations dedicated to circus arts. These numbers reflect
only official circus arts, and the numbers are greater if one
also includes street artists.
Despite the large numbers of circus artists and trainees,
the only reference related to training or performance-
related injuries in circus artists that we could find in
PubMed or Embase using a broad-based search strategy
(“circus” AND “injury”) was 1 case report of a proximal
fibular stress fracture2; we are also aware of references
related to the specific act of sword swallowing.29 Given the
importance of physical activity, the increasing popularity
of circus arts and circus shows, the unique environment in
which the artists work, and the unknown patterns/risk of
injury, a better understanding of the injury patterns and
rates is required to develop appropriate and effective
injury prevention programs. We therefore approached
Cirque du Soleil (Cirque) who provided us with access to
all the injury data and work records required. We hope the
results of this descriptive historical cohort study will help
other investigators/clinicians study and prevent injuries of
circus artists around the world.
We obtained data from the Cirque injury database. Cirque
is 25 years old, currently has 17 shows, and has performed
at the Academy Awards and the World Aquatic
Championships. According to our research ethics commit-
tee, because this project uses historical data in the records
of a private company, and those data were not gathered for
research purposes, it therefore falls under a category of
quality assurance that is exempt from a requirement for
formal research ethics approval.
Each show in Cirque has 2 or 3 certified rehabilitation
therapists (athletic trainer/therapist or physiotherapist/
physical therapist) who have recorded injury-related
information in an electronic database since 2002. We
defined an injury as any visit to the therapist for a new
work-related complaint (eg, sprained ankle while skiing
would be excluded). This is equivalent to the “medical
attention injury” definition suggested by others.9-11
We extracted the de-identified data from the database.
We categorized injuries according to anatomical location
and injury type similar to that recommended by published
consensus statements.9-11 Duplicate injuries were deleted
(eg, 2 injuries to the same artist on the same date with the
same location and injury type), and exacerbations were
considered as part of the initial injury. If an event resulted
in multiple injuries (eg, knee injury and ankle injury), each
injury was considered a separate injury in the analysis.
Because the Cirque database was originally designed as a
management tool, some of the data did not immediately
lend themselves for a complete analysis. For example, if an
injury category was ambiguous (eg, “irritation”), we searched
the electronic medical record manually, and the injury/
treatment was recategorized appropriately or marked as
“other.” For anatomical locations, trunk refers to nonspine
injuries, spine refers to thoracolumbar and sacroiliac joint
injuries, and spinal neck injuries are considered under
head and neck injuries. If specific information about an
artist was lacking in the database, the performance medicine
department or human resources department provided the
missing information using other sources. Finally, we
categorized artists as acrobatic, nonacrobatic, or musician.
Artists perform many roles within a performance. Any
artist who participated in an act that required an acrobatic
coach was defined as acrobatic (eg, acts requiring gymnastics,
diving, martial arts, aerial movements); any artist who
participated as a musician was considered a musician
(Cirque performances all use live music with the exception
of the tribute show to the Beatles called “LOVE,” and these
artists do not generally perform any form of acrobatic
maneuver); all other artists were considered nonacrobats
(eg, dancers, jugglers, swimmers, clowns, and characters in
a show that do not perform gymnastic or martial arts or
aerial movements).
Injury Rates
Exposure data (number of performances) necessary to
calculate injury rates (number of injuries/number of
exposures) and treatments were not available for the
entire data set of injuries. In August 2004, Cirque began
to electronically record which artists participated in which
performances and whether they were able to perform as
expected or only partially. The start date for the imple-
mentation of the software varied for each show (range,
August 2004 to May 2006) and is not collected for artists
with certain types of contracts. Therefore, analyses
related to the injury rates as well as the consequences of
injury (number of treatments per injury and number of
missed performances) were calculated on a subset of the
full data set that contained information on the number of
performances for each artist (ie, exposure data). These
analyses are limited to show-related injuries because
training sessions are not documented within the elec-
tronic database, and therefore training injury rates could
not be calculated.
Consequences of Injury
With respect to the number of treatments per injury, we
considered an injury to be fully resolved as of the date of
the last encounter with a therapist for that injury. Although
some consensus statements suggest that an injury is
healed once the subject returns to unrestricted activity,10,11
we preferred our definition because athletes often “play
hurt,” and therefore the consensus definition may grossly
underestimate the consequences of injury. We excluded all
Vol. 37, No. 6, 2009 Circus Injuries 1145
“treatments” that were entered to document a “no-show” or
to add a comment about a consultation with a physician.
We considered the first visit to the therapist as a treat-
ment, even if it consisted only of an evaluation (ie, every
injury had at least 1 treatment). Finally, some injuries had
long periods without treatment. We considered the original
injury healed when there was no treatment for a period of
3 months and considered subsequent treatments as part of
a new injury.
With respect to the number of performances missed or
altered due to injury, the data were entered as part of the
process to determine an artist’s pay or injury compensation.
The pattern of injuries in the entire data set and the
subset of data used to calculate rates were compared to
ensure comparability and found to be very similar.
Patterns of Injury: Full Data Set of Injuries
We describe the patterns of injuries separately by ana-
tomical location and type of injury11 for (1) male and
female performers, (2) training and performances, and (3)
acrobatic, nonacrobatic, and musician-related injuries. We
report the proportion of injuries within each category
along with the 95% confidence intervals (95% CIs) calcu-
lated using bootstrapping techniques30 to account for
repeated injuries within the same artist but did not con-
duct any formal statistical significance testing.
Consequences of Injury and Injury Rates:
Subset of Data With Exposures
Within the subset of show-related data that documented
the consequences of injury and exposure information, we
summarized the number of treatments and missed perfor-
mances associated with injuries using the median (50th
percentile) and 80th percentile. We then described injury
rates per 1000 artist-performances using standard meth-
ods.21 Because our exploration of the data distribution
showed that the overall mean rate was very unstable if we
included artists with fewer than 3 performances, these 16
artists were excluded from this part of the analysis in
accordance with accepted statistical principles. We describe
the heterogeneity of individual injury rates by plotting the
injury rate against the number of exposures. Individuals
with very few exposures will have only a few injuries, and
a difference between 2 injuries and 4 injuries (doubling of
the injury rate) can easily occur by chance. Therefore, one
expects a very high variability in injury rates among indi-
viduals with few exposures, and this must be accounted for
when interpreting the results.
We compared injury rates per 1000 artist-performances
for male and female performers and for acrobatic artists
versus nonacrobatic artists versus musician artists using
rate ratios and 95% CI in a quasi-Poisson regression
analysis because the data were overdispersed. We also
analyzed sex- and role-specific rates (in a quasi-Poisson
regression analysis) to determine the independent effects
of each on injury rates. All analyses were done in R
Statistical Package 2.4.1.
Patterns of Injury: Full Data Set
Patterns of injury were derived from the entire database of
injuries. There were 18 336 show- or training-related
events that resulted in injuries to 1376 Cirque artists (534
[38.8%] female artists and 842 [61.2%] male artists; 1107
acrobats, 107 musicians, and 162 nonacrobats) between
January 1, 2002, and December 31, 2006. Of these, 40.2%
occurred in female artists and 59.8% in male artists. Of
the 18 336 events causing injury, most were minor, 17 740
caused a single injury, 279 caused 2 injuries, and 10 events
caused 3 or 4 injuries.
There were no clinically relevant differences in the gross
anatomical pattern of injuries between the sexes or perfor-
mance versus training (see online Appendix 1, Figure 1,
for this article at
Differences between acrobatic and nonacrobatic acts were
minimal. The locations for musician-related injuries were
quite different, with more head and neck injuries and
fewer lower extremity injuries.
When we examined the distribution of upper extremity
injuries in more detail (see online Appendix 1, Figure 2,
top, for this article at,
the shoulder was the most commonly injured area, and
there were only slight differences by sex and training/
performance. Musicians’ injuries were distributed more
distally compared with those of acrobats and nonacrobats,
and musicians were the only group to have a significant
number of forearm injuries. In the lower extremity (see
online Appendix 1, Figure 2, bottom, for this article at, injuries were more
evenly distributed, with the knee and ankle having the
highest proportions. Female artists had more hip/groin
injuries, but other categories had only minor differences.
Although musicians had a significantly higher proportion
of their lower extremity injuries to the ankle (presumably
from running on stage as part of an act or backstage
during the show), lower extremity injuries were only a
small proportion of total injuries in this group (see online
Appendix 1, Figure 1, for this article at http://ajs.sagepub
Similarly, there were minimal differences in the patterns
of types of injury between the sexes or performance versus
training (see online Appendix 1, Figure 3, for this article at Injuries to the
joints and ligaments, contusions, and lacerations were less
common among musician-related injuries. An overview of
the types of injuries according to anatomical location is
provided in Table 1. The most common injuries were
strains and sprains to the upper and lower extremities. Of
the 10 events that caused 3 or 4 injuries, 4 resulted in a
fracture and/or a concussion.
1146 Shrier et al The American Journal of Sports Medicine
Consequences of Injury and Injury Rates:
Subset of Data With Exposures
Data analyses related to the number of treatments, missed
performances, and injury rates were carried out on the
subset of the show-related data that included exposure
information as described in the “Methods” section (there is
no training-related exposure information to calculate
training-related injury rates). There were 966 artists (348
female and 618 male artists) with 6701 show-related inju-
ries and 38 224 treatments included in this analysis. Most
of the injuries incurred by Cirque artists require relatively
few treatments and result in few missed or altered perfor-
mances (see online Appendix 2 for this article at http://ajs For example, 50% of injuries
required 2 treatments and did not result in any missed or
altered performances. In addition, 80% of injuries required
7 treatments and resulted in 1 completely missed perfor-
mance and 2 altered performances. These numbers were
relatively stable over all anatomical locations (data not
shown) and whether the injury occurred during an acro-
batic act or nonacrobatic act; musician-related injuries had
a similar number of treatments but fewer missed or
altered performances.
The overall and anatomical location-specific injury rates
are shown in Table 2 for all artists combined and for male
and female artists separately. Overall, female artists had a
slightly higher injury rate than did male artists for all
injuries, but the magnitude of the difference was small.
There was considerable heterogeneity in injury rates.
There were 14 of 348 (4.0%) female and 32 of 618 (5.2%)
male artists with rates greater than 30 injuries per 1000
artist-performances. A plot of the injury rate against the
number of exposures for each artist is shown in Appendix
1, Figure 4 (inset is an enlargement for low injury rates,
see online Appendix for this article at http://ajs.sagepub
.com/supplemental/). As expected, the injury rates are
unstable (very heterogeneous) when there are few
exposures and then stabilize as the number of exposures
increases. The solid line represents the overall injury rate
shown in Table 2.
The injury rate for acrobatic artists was 11.2 (95% CI,
10.9-11.6) injuries per 1000 artist performances. Compared
with acrobats, nonacrobatic artists had a lower injury rate
Frequency of Injuries, Cross-classified by Anatomical Location and Typea
Head and Neck Trunk Spine Upper Extremity Lower Extremity Other
Type (n = 2611) (n = 901) (n = 3885) (n = 4214) (n = 6347) (n = 378)
Central/peripheral 121 1 2 10 6 2
nervous system (n = 142)
Contusions/lacerations 254 143 81 369 771 4
(n = 1622)
Fractures and bone 17 10 7 51 74 1
stress (n = 160)
Joint (nonbone) and 557 89 1026 822 1373 1
ligament (n = 3868)
Muscle and tendon 880 246 1431 2059 2603 340
(n = 7559)
Other (n = 4985) 782 412 1338 903 1520 30
aThe total number of injuries was 18 336.
Injury Rates for All Artists, Female Artists and Male Artists for All Injuries Combined, and by Anatomical Locationa
All Female Male Referenceb
Rate 95% CI Rate 95% CI Rate 95% CI Injury Rate Ratio 95% CI
All combined 9.7 9.4-10.0 10.2 9.7-10.6 9.4 9.1-9.8 0.93 0.82-1.04
Head and neck 1.4 1.3-1.5 1.4 1.2-1.6 1.3 1.2-1.5 0.95 0.79-1.15
Trunk 0.5 0.4-0.6 0.6 0.5-0.8 0.4 0.3-0.5 0.64 0.49-0.86
Spine 1.9 1.8-2.0 2.3 2.1-2.5 1.7 1.5-1.8 0.73 0.62-0.87
Upper extremity 2.2 2.1-2.4 2.1 1.9-2.3 2.3 2.1-2.5 1.08 0.90-1.28
Lower extremity 3.5 3.4-3.7 3.5 3.3-3.8 3.5 3.3-3.8 1.00 0.85-1.18
Other 0.2 0.1-0.2 0.2 0.1-0.2 0.2 0.1-0.2 1.00 0.44-2.23
aInjury rates are injuries per 1000 artist-performances. CI, confidence interval.
bReference female artists = 1.0.
Vol. 37, No. 6, 2009 Circus Injuries 1147
(6.8 [95% CI, 6.1-7.4]; rate ratio, 0.60 [95% CI, 0.49-0.73]),
than did musicians (4.3 [95% CI, 3.7-4.8]; rate ratio, 0.38
[95% CI, 0.30-0.49]). The rate ratios from the quasi-
Poisson regression model that included both sex and role
were almost identical to the univariate analyses: male to
female, 0.92 (95% CI, 0.82-1.03); nonacrobat to acrobat,
0.60 (95% CI, 0.49-0.73); musician to acrobat, 0.38 (95%
CI, 0.30-0.49).
There was a total of 294 of 6701 (4.4%) injuries that
resulted in more than 15 missed performances (this
represents approximately 10 days and was chosen for
comparison with other sports) and occurred in 194 artists
(149 acrobats, 41 nonacrobats, and 4 musicians). The
injury rates by role were 0.74 (95% CI, 0.65-0.83) for
acrobats, 0.35 (95% CI, 0.20-0.50) for nonacrobats, and 0.05
(95% CI, 0.00-0.12) for musicians. Compared with acrobats,
the rate ratio for sustaining an injury resulting in more
than 15 missed shows was 0.47 (95% CI, 0.26-0.87) for
nonacrobats and 0.07 (95% CI, 0.01-0.44) for musicians.
The actual 294 injuries were 3 burns/lacerations/abrasions,
10 contusions/acute bursitis/acute tendinopathies, 78 muscles
strains/cramps/stiffness, 7 concussions, 21 fractures, 134
joint (nonbone)/ligament injuries, 28 overuse tendinopathies/
bursitis, 2 peripheral nerve injuries, and 11 other injuries
that could not be unambiguously classified. Table 3 shows
the frequencies of fractures/bone stress, joint (nonbone)/
ligament injuries, muscle and tendon injuries, and other
injuries for the anatomical locations with at least 25
injuries. Of the 16 “other” fractures, there were 8 in the
foot, 2 in the hand, 2 in the head and face, and 1 each in
the elbow, hip, lower leg, and ribs.
Professional circus artists have similar injury patterns
across male versus female performers, training versus per-
formance-related injuries, and acrobats versus nonacrobats,
although musicians have more head and neck and fewer
lower extremity injuries. Most injuries to professional circus
artists require few treatments and do not result in missed
or altered performances. The overall injury rate for male
artists is slightly lower than that of female artists, and
acrobats have higher injury rates than do nonacrobats and
The overall anatomical and injury patterns suggest
little difference across sex and training/performance (see
online Appendix 1, Figure 1, for this article at http://ajs When we examined the
distribution of upper and lower extremity injuries in more
detail (see online Appendix 1, Figure 2, for this article at, we found that
approximately 50% of the upper extremity injuries were
to the shoulder. Therefore, injury prevention programs
targeting this area would likely have the greatest effect in
reducing upper extremity injuries. Although lower extre-
mity injuries were more evenly distributed, prevention
programs targeting the knee and ankle would likely
produce the most overall benefit.
The differences in upper and lower extremity injuries
across sex and training/performance were not great enough
to warrant targeting a prevention program, with 2 possible
exceptions. Female artists had many more hip/groin injuries
than did male artists (presumably because of differences in
the acts female acrobats perform compared with those of
male acrobats), and musicians’ upper extremity injuries
were distributed more distally. Future analyses and studies
examining the specific causes of these injuries could help
strengthen the prevention programs already in place
(which include meeting standards for usual equipment
design, engineering and industrial design analyses of new
equipment designs, artist rotations and management of
workload, strength and conditioning prevention programs,
rapid and appropriate rehabilitation after an injury).
Although musicians had a significantly higher proportion
of their lower extremity injuries to the ankle (presumably
from running on stage as part of an act or backstage during
the show), lower extremity injuries were only a small
proportion of total injuries in this group (see online
Appendix 1, Figure 1, for this article at http://ajs.sagepub.
com/supplemental/), and targeting this area for prevention
would not be expected to substantially reduce overall
injury rates.
This is the first study to describe injury patterns and
rates in modern circus artists. The National Collegiate
Athletic Association (NCAA) recently published injury
rates calculated from 25 years of data.15 Of the many sports
listed, women’s gymnastics is the most closely associated
with circus arts (figures for men’s gymnastics were not
published). The competition injury rate for women’s
gymnastics was 15.2 injuries per 1000 athlete-exposures,
which is much higher than the overall injury rate of Cirque
artists. The NCAA did not publish injury rates for high-risk
positions within each sport (some gymnastics events are
Frequency of Injuries With 10 or More Missed Performances, Cross-classified by Anatomical Location and Typea
Neck Low Back Shoulder Knee Ankle Other
Type (n = 25) (n = 33) (n = 50) (n = 38) (n = 44) (n = 104)
Fractures/bone stress (n = 18) 0 0 0 1 1 16
Joint (nonbone) and ligament (n = 125) 8 18 24 19 28 28
Muscle and tendon (n = 97) 11 9 22 5 12 38
Other (n = 54) 6 6 4 13 3 22
aThe total number of injuries was 294.
1148 Shrier et al The American Journal of Sports Medicine
expected to have higher injury rates than do others). Even
so, the injury rate of acrobats (the circus artists most at risk
of injury) was only 11.2 (95% CI, 10.9-11.6), which is still
considerably lower than the overall rate for women’s
To further put the Cirque injury rates in context, game
injury rates for women’s softball, volleyball, and lacrosse
ranged from 4.3 to 7.2 injuries per 1000 athlete-exposures;
women’s basketball and field hockey were 7.7 and 7.9
injuries per 1000 athlete-exposures, respectively; and
women’s ice hockey and soccer were 12.6 and 16.4 injuries
per 1000 athlete-exposures, respectively. Men’s baseball and
basketball had injury rates of 5.8 and 9.9 injuries per 1000
athlete-exposures, respectively, and the injury rates for
men’s lacrosse, hockey, soccer, wrestling, and football ranged
from 12.6 to 35.9 injuries per 1000 athlete-exposures.
We are not aware of any similar reviews or large-scale
cohort studies for musician-related injuries. With respect to
comparisons with the dance literature, different studies
report injury rates using different methods. A recent
systematic review of cohort studies reported an injury rate
of 4.7 injuries per 1000 dance hours in the 1 study that used
an injury definition similar to ours (ie, any event in which
the subject sought medical attention).14 This is lower than
the injury rate for circus nonacrobats (6.8 injuries per 1000
artist-performances), but our nonacrobatic category is not
limited to dancers; it also includes jugglers, swimmers,
and when artists work on the set during a performance
(removing equipment from stage, tightening of nets, etc).
We also calculated the injury rate for injuries that
required an artist to miss more than 15 performances
(approximately 10 days). The acrobats represented the
highest risk group at Cirque with a rate of 0.74 (95% CI,
0.65-0.83) injuries per 1000 artist performances. The
NCAA also published estimates for injuries resulting in
more than 10 days missed but only as proportions (overall
Cirque proportion, 4.4%); this occurred in 39% of women’s
gymnastics competition injuries,23 18% of men’s basketball
game injuries,4 and 27% of women’s hockey game injuries.1
Simply multiplying the estimated proportion of injuries by
the game injury rate from the preceding paragraph
provides the estimated injury rate per 1000 athlete-
exposures in these sports; women’s gymnastics is 5.9,
men’s basketball is 1.8, and women’s hockey is 3.4.
Therefore, the estimated rate of injuries resulting in more
than 10 days missed is considerably less in Cirque
compared with many NCAA varsity sports.
Although this is the first report on the epidemiological
injury patterns and injury rates among a group of
professional artists who are extremely physically active,
there are limitations to this study. This study is subject to
the limitations of any historical cohort study. However, our
data were obtained from electronic records completed by
health care professionals as part of their official
documentation of a patient visit, as opposed to databases
based on billing or the requirement to fill out additional
paperwork of little use to the individual clinician. All
ambiguous entries were individually searched and
recategorized. There were data that were not obtained
such as mechanism of injury, and Cirque has since
introduced changes to record this information. Some
artists without exposure information could not be included
in the injury rate analysis. Although the data were
obtained from only 1 circus “company”, the injury patterns
and injury rates represent an overall view from 17 distinct
shows. In addition, there are particular challenges to
categorizations. Artists perform multiple roles in a show;
the corresponding situation in sports is rare (eg, offensive
football players rarely play defense). We categorized artists
according to their primary role within a show because this
seemed the most logical choice.
In conclusion, although Cirque shows are highly athletic
and acrobatic, with jumps and tethered and untethered
aerial maneuvers, the injury rates are less than those for
NCAA women’s gymnastics and similar to those of NCAA
men’s basketball. In addition, the estimated rate of injuries
that result in more than 10 missed days is much less.
We acknowledge Cirque du Soleil for their help in con-
ducting the study. This study could not have been com-
pleted without major contributions from their human
resources department (Stéphanie Tremblay), performance
medicine department (Janet Pundick, Eric Lamme, Jay
Mellette), coaching staff (Marie-Hélène Martineau, Boris
Verkhovsky), and vice presidency of casting and perfor-
mance (Sylvie Geneau, Bernard Petiot). Dr Shrier is
funded by the Senior Clinician Scientist award from the
Fonds de la Recherche en Santé du Quebec.
1. Agel J, Dick R, Nelson B, Marshall SW, Dompier TP. Descriptive epi-
demiology of collegiate women’s ice hockey injuries: National
Collegiate Athletic Association Injury Surveillance System, 2000-2001
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... Circus performance encompasses a wide variety of disciplines, ranging from acrobats, artistic characters, former Olympic-level and professional athletes, and musicians, where unique skill sets are creatively integrated with artistic components and athletic ability to create show performance. [1][2][3] Further, within performance acrobats, the individual performers are highly specialized with backgrounds which include ballet, dance, gymnastics, and acrobatic sport. As a result of these specializations and performance demands, the medical management of these performers requires an understanding of the complex interaction of both discipline specific considerations and performance act requirements. ...
... Further, these disciplines have been previously characterized as either acro-bats, non-acrobats or musicians. 1 In order to further distinguish between types of performers, a classification system of either sudden load performers, non-sudden load performers and musicians has also been used. 4 Sudden load performers would be those who incur a sudden, substantial increase in physical compression or distraction loads as previously defined by Orlando et al. 4 Skill sets such as diving, gymnastics, trampoline, partner lifting or catching, hand balancing, contortion (Figure 2), ballistic style dancing and aerial movements would be categorized as sudden load. ...
... 4 Sudden load performers would be those who incur a sudden, substantial increase in physical compression or distraction loads as previously defined by Orlando et al. 4 Skill sets such as diving, gymnastics, trampoline, partner lifting or catching, hand balancing, contortion (Figure 2), ballistic style dancing and aerial movements would be categorized as sudden load. 1,4 Non-sudden load performers may include jugglers (Figure 3), artistic image dancers and clowns, however features within the skill sets of these performers may also be dynamic and sudden load in nature, indicating a diversity in skill sets across all performer disciplines. 1 Beyond the primary act requirements specific to a performer's discipline, a show performance also includes cue tracks, or minor performances such as brief dancing, character or image expression sequences specific to creating an artistic effect on stage for a particular act. While the cues required for each show may vary and generally have performer rotations, they do require specific movement demands which may or may not be similar to those of the performer's specific act while contributing to overall performance workload. ...
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Medical management of the circus performer encompasses a wide variety of multicultural, transdisciplinary and multifaceted decision-making considerations. There is a paucity of research evidence investigating both the unique diversity of skill sets and cultural considerations in addition to injury patterns of performers within the circus environment. Since a previously established framework for supporting the health and well-being of the circus performer across various aspects of medical management does not exist in the literature, most recommendations in this regard must come from practical experience working with this highly specialized performance athlete population. The purpose of this clinical commentary is to provide the reader with a greater understanding of the unique challenges associated with the medical management of performance artists and acrobats as well as recommendations for developing an integrated approach for mitigating injury risk within a highly specialized, diverse athlete population. Level of evidence: 5.
... A large proportion of injuries reported in professional and amateur circus performers are to the lower limb, specifically the knee and ankle. (2)(3)(4)(5) At Cirque du Soleil, lower limb injuries accounted for 34.6% of all injuries reported in the 5-year period from 2002 to 2006. (3) Other studies have also reported lower limb injuries as a cause of medical attention and time loss in the circus population. ...
... (2)(3)(4)(5) At Cirque du Soleil, lower limb injuries accounted for 34.6% of all injuries reported in the 5-year period from 2002 to 2006. (3) Other studies have also reported lower limb injuries as a cause of medical attention and time loss in the circus population. (1) The rate of injuries amongst acrobats in Cirque du Soleil has been recorded as 11.2/1,000 exposures. ...
... (1) The rate of injuries amongst acrobats in Cirque du Soleil has been recorded as 11.2/1,000 exposures. (3) However, this includes only those injuries recorded formally, so it is possible these injury rates may underrepresent the actual prevalence and severity of all health problems in these performers, similar to that shown in the sporting environment where using self-reported symptoms can lead to a more complete representation of the burden of injury. (6) In professional circus arts performers, there has been no data published on self-reported acute and overuse health problems, nor has the feasibility of implementing a routine intervention in an operating show been explored. ...
Background: Demanding performance schedules in modern professional circus can result in less time for injury rehabilitation and strength and conditioning for injury prevention. Lower limb injuries are a common injury presentation in Cirque du Soleil touring show performers. Objective: To examine the feasibility of introducing a calf raise exercise program in an established professional touring circus show over a 9-week period. Methods: Twenty-nine professional Cirque du Soleil circus performers were recruited (mean age 31.28 [SD 4.99] yrs). Performers completed the Oslo Sports Trauma Research Centre Overuse (OSTRC) questionnaire each week for 18 weeks. In the second 9-week period, performers completed one set of single-leg calf raises to fatigue on each limb, once per day, every workday. Health problems between each 9-week period were compared. Feasibility was measured via program adherence and an end-of-study survey. Calf endurance was assessed by measuring the number of single leg calf raises to fatigue. Results: Adherence was high throughout the program, with 93.5% of all exercise sessions completed. Endurance increased by a mean of 22.62 (SD 27.99) calf raises. No significant changes in the prevalence of self-reported soreness and injury were found: 51.9 (95%CI 44.4, 57.5) of the population reported lower limb injuries during the pre-intervention period and 52.5 (95%CI 49.2, 55.8) during the intervention. Similarly, no significant changes were found in severity scores: 20.7 (95%CI 17.7, 23.7) pre-intervention and 20.9 (95%CI 19.4, 22.4) during intervention. Conclusion: A single-leg calf raise exercise program can be feasibly introduced into a touring, performing professional circus show without increasing injury numbers or self-reported soreness. Furthermore, gains in calf raise endurance can be obtained during a 9-week intervention period.
... In 2009, over 500 circus companies and 200 circus schools existed worldwide. 1 Since then, many new circus schools and studios have opened, and the numbers have been steadily growing. According to the American Circus Educators, 2 in July 2019, there were 256 circus schools alone registered in the United States, where the number of students per school ranges anywhere between 50 and 500. ...
... 3 Sustained periods in an upper extremity weight-bearing position create different strength and range of motion needs in the circus shoulder, making the research available at this time on artistic gymnasts less directly applicable to circus artists. 1 The impairments specific to the circus shoulder might not show up as problematic using data from the general or gymnast populations. ...
Objectives: To begin to establish normative data for shoulder range of motion (ROM) and strength in the circus acrobats and to compare these values based on age, sex, hand dominance, and acrobatic subgroup. Methods: Active (AROM) and passive (PROM) of the full shoulder complex and PROM of the isolated glenohumeral joint were measured in 193 circus acrobats using standardized techniques for anterior elevation (flexion), posterior elevation (extension), lateral elevation (abduction), and external and internal rotation. Shoulder strength was measured using a hand-held dynamometer in all planes of motion. Measurements were taken twice and averaged. Mixed ANOVA were performed. One-sample t-tests were used to compare with general population. Results: Several significant differences were noted between dominant and non-dominant sides, but not between the sex or age groups tested. Acrobats who did both aerial and ground acrobatics had significantly greater full shoulder complex flexion AROM than the aerial group, and AROM extension than the ground group. Circus acrobats had significantly greater AROM full shoulder complex extension, abduction, internal and external rotation, and shoulder strength than the general population. Conclusion: Overall, results from this cross-sectional study revealed that circus acrobats had greater shoulder strength and ROM than the general population, which could affect the way these patients should be treated in a clinical setting. Age and sex seemed to have minimal effects, but there was clearly an effect of hand dominance. Acrobats who train both aerial and ground acrobatics may have greater ROM in certain planes than those who train in only one type of discipline.
... performances for reported Cirque Du Soleil acrobats, slightly lower than upper extremity injuries occurring 2.2/1.000. [7] Wanke et al., in 2012, evaluated 169 circus school students and reported that 15.1% developed cervical spine injuries due to accidents while practicing [8] [Table1]. ...
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Background Pole dancing is a sport that has become very popular. However, there is scarce literature on injuries associated with this sport. Here, we present a 23-year-old female who sustained a traumatic C4-C5 vertex cervical spine injury caused by a fall of 1 m while practicing pole dancing in an inverted position, requiring a 360 decompression/fusion. Case Description A 23-year-old female sustained a 1 m fall in an inverted position while pole dancing resulting in a direct axial impact to the head. She developed the rapid onset of quadriparesis that was attributed to the emergent CT/MR-documented cervical flexodisruptive luxofracture (AOSpine C4-C5 fracture: C, F4 unilateral, N3, M2). Four hours post injury, she underwent a C4-C5 anterior cervical discectomy and fusion. Four days later, a posterior fusion was performed to add to the stabilization. Six years later, the patient remains neurologically intact. Conclusion Pole dance is an emerging sport which carries a risk of cervical spine injury.
... As with any population, treatment strategies must be supported by evidencebased medicine. Analysis of dancer WMSI severity and diagnostic patterns allows comparison to other professional athletes (e.g., soccer, rugby, circus, gymnastics) (Fuller, 2007;Hagglund et al., 2005;Shrier et al., 2009;Westermann et al., 2015) and helps identify best-practices for risk reduction, preventive care, and rehabilitation of dancers (Bronner & Bauer, 2018;Bronner et al., 2006;Jacobs et al., 2017). ...
We investigated work-related-musculoskeletal-injuries (WMSI) over 15-years in professional modern dancers to determine injury rate and pattern differences due to sex and professional-experience. Injuries were coded to allow analyses by tissue-type, body-region, severity, setting, mechanism, action-causation, and repertory-style. Injury prevalence (IP) was defined as average risk of injury/dancer. Injury incidence rate (IIR) was calculated per 1000-hrs exposure/block. Negative binomial logistic regression analyses were conducted with exposure-hrs to determine IIR, p < 0.05. Multinomial logistic regressions determined differences in tissue-type, body-region, action-causation and repertory-style; Poisson loglinear regressions determined differences in severity and mechanism, p < 0.05. Females were 15-times more likely to sustain bone-injuries, p = 0.016; males 8- and 15-times more likely to sustain muscle/tendon-injuries or lacerations/ contusions, p ≤ 0.016. Females were more likely to sustain severe injury resulting in more lost-workdays and missed-performances, p < 0.001. In both sexes, more time-loss-injuries (TL-inj) occurred in performance , were traumatic in nature, with an action-causation of jumping/stomp-ing/relevé. Dancers of moderate professional-experience were 1.3-times more likely to sustain TL-inj, p = 0.026;. Identifying context-specific activities and repertory-style relationships to injury can provide insight into casting and rehearsal scheduling. Comprehending sex-specific musculoskeletal health needs allows improved dancer health management and injury prevention planning.
... Finally, a 5-year study of 1376 Cirque du Soleil performers revealed 7 concussions that each resulted in a time-loss of 15 days or more. 37 Interestingly, the investigators reported concussions under the category "Head and Neck," although such categorization makes capturing the true incidence of concussion impossible. Overall, then, currently available research reveals barriers to ensuring that head injuries in theater and circus are prevented when possible and identified and well-managed when they occur. ...
Dancers and other performing artists are subject to head impacts that result in concussion-like symptoms. In spite of this, performing arts do not have access to the continual, focused emphasis on the diagnosis, management, and prevention of concussions that is commonplace in sports. Performing arts present a unique environment in which concussions occur and must be managed. This article outlines what is known about performing arts concussions, describes mechanisms of head impacts sustained by participants in dance and the related artforms of theater, circus, and film and television stunts, and offers concussion management guidelines for these artistic fields.
... Dessen Verantwortliche sind sich in den vergangenen Jahren bewusst geworden, die Gesundheit ihrer angestellten Athleten und Künstler besser schützen zu müssen. Aus früheren Studien ist bekannt, dass beim CdS Verletzungsinzidenzen zwischen 7,3 und 9,7 Verletzungen pro 1000 artistischen Vorstellungen anfallen, was mit verschiedenen Risikosportarten vergleichbar ist (Shrier I, 2009;Orlando C, 2011;Wolfenden HE, 2017). Man kann hier durchaus Parallelen aufstellen zu den Anfängen der Industriekultur, bei der es auch einige Jahrzehnte gedauert hat bis die Arbeitgeber angefangen haben, die Sicherheitskultur am Arbeitsplatz systematisch zu verbessern. ...
... La práctica circense aérea se relaciona con una tasa de lesión de 7-9/1000, la columna y la rodilla son segmentos muy expuestos a sufrir lesiones (razón de probabilidades [odds ratio], 0,67 para la región toracolumbar), aunque la mayoría son leves, y la tasa de lesiones sin diagnóstico inicial es alta. 3,4 Un estudio de la cinemática de las lesiones vertebrales mostró que las lesiones más graves se asociaban con caídas de más de 6 m de altura. 5 La superficie de aterrizaje en las caídas juega un rol importante, ya que las superficies que producen un impacto corto, como el concreto, aumentan los grados de lesiones comparadas con superficies, como la nieve, el barro o la arena. ...
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Introducción: La acrobacia en tela es una práctica circense con muchos adeptos en la población urbana. Consiste en sostenerse en altura tomado por dos extremos de tela, para realizar posturas fijas y cambiar entre ellas mediante deslizamiento y caídas. La práctica profesional no está libre de lesiones. Objetivo: Conocer la naturaleza de la lesión, reconocer los factores predisponentes de lesión y las medidas de prevención utilizadas, evaluar la cinemática, clasificar la lesión y analizar el tratamiento. Materiales y Métodos: Se incluyeron seis pacientes. Se evaluaron la estructura física personal, la cinemática de la caída, los sistemas de protección, la clasificación de las fracturas según la nueva clasificación AO, el cuadro neurológico, el tratamiento y las complicaciones. Resultados: La muestra incluyó a 6 mujeres, con un promedio de edad de 24 años y un índice de masa corporal de 19,29. Caída de 3,08 m de altura, cuatro con colchoneta
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O circo – com destaque para as modalidades aéreas – vem ganhando espaço no Brasil. São poucas as investigações que analisam o rico e os acidentes no contexto circense de modo que o objetivo foi debater a formação dos responsáveis pela instalação dos aparelhos aéreos e descrever as ancoragens. Este estudo exploratório-descritivo teve dois instrumentos de coleta de dados: um questionário semiestruturado e o registro fotográfico das ancoragens. Os dados foram analisados a partir da Análise de Conteúdo e da Estatística Descritiva. Os achados indicam a escassez de formação específica e regulamentação dos equipamentos e processos dentro do circo. Assim, se faz importante a implementação de políticas públicas/normatização específica que favoreçam a qualificação profissional e a elaboração protocolos de trabalho no âmbito da segurança no circo.
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Variations in definitions and methodologies have created differences in the results and conclusions obtained from studies of football (soccer) injuries; this has made interstudy comparisons difficult. An Injury Consensus Group was established under the auspices of Fédération Internationale de Football Association Medical Assessment and Research Centre. Using a nominal group consensus model approach, a working document that identified the key issues related to definitions, methodology, and implementation was discussed by members of the group during a 2-day meeting. After this meeting, iterative draft statements were prepared and circulated to the members of the group for comment before the final consensus statement was produced. Definitions of injury, recurrent injury, severity, and training and match exposures in football, together with criteria for classifying injuries in terms of location, type, diagnosis, and causation are proposed. Proforma for recording players' baseline information, injuries, and training and match exposures are presented. Recommendations are made on how the incidence of match and training injuries should be reported and a checklist of issues and information that should be included in published reports of studies of football injuries is presented. The definitions and methodology proposed in the consensus statement will ensure that consistent and comparable results will be obtained from studies of football injuries.
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To obtain more information about injuries of Broadway performers, 313 performers appearing in 23 Broadway companies were surveyed. The percentage of performers injured was 55.5%, with a mean of 1.08 injuries performer. Lower extremity injuries were the most common. Sixty-two percent of performers believed that their injuries were preventable. As this study reports factors that significantly increase the risk of injury for dancers and actors, it may help to heighten concern with reducing the incidence of injuries to professional performers, theatrical students, and nonprofessionals worldwide.
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To obtain more information about injuries of West End performers. A retrospective survey of 269 performers appearing in 20 West End productions (12 dramas and eight musicals). In current productions, 46% of all performers sustained at least one injury for an average of 0.87 injuries per performer. Lower extremity injuries were the most common for dancers (52.2% of injuries) and actors (43.2%) with neck and back injuries the second most common. Sprains and strains were the most common diagnoses. 61% of performers thought that their injuries were preventable. Most performers consulted nonphysician healthcare providers. Factors significantly influencing the risk of injuries for performers include female sex, a history of previous injuries, missed performances due to previous injuries, more physically demanding roles, and performing on raked (angled) stages. West End performers commonly sustain injuries. Although primary prevention of most theatrical injuries is not possible, modification of raked stages may reduce the incidence. This study may be helpful to the growing number of healthcare providers who practice performing arts medicine and may stimulate additional concern and research in the medical and theatrical communities about the performance injuries of professionals, amateurs, and theatrical students worldwide.
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Unlabelled: Clinical, epidemiological and basic research evidence clearly supports the inclusion of regular physical activity as a tool for the prevention of chronic disease and the enhancement of overall health. In children, activities of a moderate intensity may enhance overall health, and assist in preventing chronic disease in at-risk youth. The numerous health benefits of regular exercise are dependent on the type, intensity and volume of activity pursued by the individual. These benefits include reduction of low density lipoproteins while increasing high density lipoprotein; improvement of glucose metabolism in patients with type II diabetes; improved strength, self esteem and body image; and reduction in the occurrence of back injuries. In addition, a progressive, moderate-intensity exercise program will not adversely effect the immune system and may have a beneficial effect on the interleukin-2/natural killer cell system. Furthermore, by decreasing sedentary behaviors and, thus, increasing daily physical activity, individuals may experience many stress-reducing benefits, which may enhance the immune system. Conclusion: Moderate intensity exercise of a non-structured nature seems to facilitate most of the disease prevention goals and health promoting benefits. With new guidelines promoting a less intense and more time-efficient approach to regular physical activity, it is hoped that an upward trend in the physical activity patterns, and specifically children at risk for chronic disease, will develop in the near future.
The objective of this study was to examine the association of scholastic performance with physical activity and fitness of children. To do so, school ratings of scholastic ability on a five-point scale for a nationally representative sample of 7,961 Australian schoolchildren aged 7-15 years were compared with physical activity and fitness measurements. Consistently across age and sex groups, the ratings were significantly correlated with questionnaire measures of physical activity and with performance on the 1.6-kilometer run, sit-ups and push-ups challenges, 50-meter sprint, and standing long jump. There were no significant associations for physical work capacity at a heart rate of 170 (PWC170). The results are concordant with the hypothesis that physical activity enhances academic performance, but the cross-sectional nature of the observations limits causal inference, and the disparity for PWC170 gives reason to question whether the associations were due to measurement bias or residual confounding.
This study examined the relationships between children's reported levels of physical activity, body-mass index, self-esteem, and reading and mathematics scores, while controlling for sex, family structure, and socioeconomic status. The data were collected from the full population of Grade 6 students (N = 6,923) in New Brunswick (NB), Canada in 1996, as part of the Elementary School Climate Study, and the NB Department of Education's Grade 6 Assessment. Physical activity had a negative relationship with body-mass index. Physical activity had a positive relationship with self-esteem, and a trivial negative relationship with academic achievement. The analysis revealed that both females and males who were more physically active had considerably higher levels of self-esteem. The study suggests that the relationship between physical activity and academic achievement is weak. For some children, physical activity may be indirectly related to enhanced academic performance by improving physical health and self-esteem.
Notwithstanding the healthy influence of sporting activities on risk factors, in particular those of cardiovascular disease, it is becoming increasingly apparent that sports can present a danger to health in the form of sports injuries. The extent of the sports injury problem calls for preventative action based on the results of epidemiological research. For the interpretation of these facts uniform definitions are needed and limitations of research designs should be known. Measures to prevent sports injuries form part of what is called the ‘sequence of prevention’. Firstly the extent of the sports injury problem must be identified and described. Secondly the factors and mechanisms which play a part in the occurrence of sports injuries have to be identified. The third step is to introduce measures that are likely to reduce the future risk and/or severity of sports injuries. This measure should be based on the aetiological factors and the mechanism as identified in the second step. Finally the effect of the measures must be evaluated by repeating the first step. In this review some aspects of the first and second step of the sequence of prevention are discussed. The extent of the sports injury problem is often described by injury incidence and by indicators of the severity of sports injuries. Sports injury incidence should preferably be expressed as the number of sports injuries per exposure time (e.g. per 1000 hours of sports participation) in order to facilitate the comparability of research results. However, one should realise that the outcome of research applying this definition of sports injury incidence is highly dependent on the definitions of ‘sports injury’ and ‘sports participation’. The outcome of such research also depends on the applied research design and research methodology. The incidence of sports injuries depends on: the method used to count injuries (e.g. prospective vs retrospective); the method used to establish the population at risk; and on the representativeness of the sample. Severity of sports injuries can be described on the basis of 6 criteria: the nature of the sports injury; the duration and nature of treatment; sporting time lost; working time lost; permanent damage; and cost. Here also uniform definitions are important and necessary in order to enhance the comparability of research data. In the second step of the ‘sequence of prevention’ the aetiological factors that play a role in the occurrence of a sports injury have to be identified by epidemiological studies. Epidemiological research on the aetiology of sports injuries requires a conceptual model. The most commonly applied model is a stress/capacity model in which internal (personal) and external (environmental) aetiological factors are identified. In this model stress and capacity must be in balance and preventative measures must be designed to achieve or maintain this balance. However, merely to establish the aetiological factors is not enough; the mechanism by which sports injuries occur must also be identified. Athletes are in constant interaction with their environment and aetiological factors must be approached from this point of view. In a second, more dynamic, conceptual model on the aetiology of sports injuries, the importance of the determinants of sports behaviour, as well as the interaction between the various aetiological factors, is discussed. Whether or not a sports injury results from sports behaviour largely depends on the extent to which ‘prevention’ is incorporated in the determinants of sports behaviour. The drawback of both conceptual models is the fact that neither of them incorporate a time perspective. They can therefore not be applied to research on the aetiology of overuse injuries. In this perspective the application of a stress/strain/capacity model can be useful. This is a more dynamic and time-based 3-phase sequential model in which behaviour, amongst other aetiological factors, plays an important role. In this model an athlete is seen as an active manipulator of stress by whom the amount of strain evoked by sports participation can be altered, thereby influencing the capacity to perform in a certain sports situation, but also influencing the risk to sustain a sports injury, either acute or long term. Finally, despite the importance of the model of choice in studying the aetiology of sports injuries one should realise that again the choice of research design influences the outcome of such research. Case series usually give no information on the underlying population at risk, so they are of no value in drawing valid conclusions on the risk factors of injuries. Only by relating the injuries to corresponding population denominators can one estimate injury rates and identify important risk factors and high risk sportspeople. As in research on sports injury incidence; research on risk factors should be undertaken on groups that are homogeneous with regard to age, sex, level of competition and type of sport.
To examine smoking patterns, smoking initiation, and the relationship of sports participation and age at smoking initiation to regular and heavy smoking among adolescents. Survey. A nationally representative sample of US high school students. Prevalences of smoking patterns, prevalence and incidence of smoking initiation, and prevalences and odds of regular and heavy smoking in relation to sports participation and age at smoking initiation. Seventy-two percent of students reported experimenting with, formerly, or ever smoking cigarettes, and 32% reported smoking in the past 30 days. Students who had participated in interscholastic sports were less likely to be regular and heavy smokers than were others who had not participated. Smoking initiation rates increased rapidly after age 10 years and peaked at age 13 to 14 years. Students who began smoking at age 12 years or younger were more likely to be regular and heavy smokers than were students who began smoking at older ages. These data suggest that smoking initiation at a young age can increase the risk of nicotine addiction during adolescence and that sports participation may influence smoking behavior. Interventions to prevent smoking should be available before age 12 years to help combat the smoking epidemic among youth.
Bootstrapping is a computer-intensive statistical technique in which extensive computational procedures are heavily dependent on modern high-speed digital computers. The payoff for such intensive computations is freedom from two major limiting factors that have dominated classical statistical theory since its beginning: the assumption that the data conform to a bell-shaped curve, and the need to focus on statistical measures whose theoretical properties can be analysed mathematically. The name "bootstrap" was derived from an old saying about pulling oneself up by one's bootstraps. In this case, bootstrapping means redrawing samples randomly from the original sample with replacement. The key idea, computations, advantages, limitations, and application potential of bootstrapping in the field of physical education and exercise science are introduced and illustrated using a set of national physical fitness testing data. Finally, an example of a bootstrapping application is provided. Through a step-by-step approach, the development and implementation of the bootstrap statistical inference are illustrated.
The effects of a 2-year health-related school physical education program on standardized academic achievement scores was assessed in 759 children who completed Metropolitan Achievement Tests before and after the program. Schools were randomly assigned to condition: (a) Specialists taught the Sports, Play, and Active Recreation for Kids curriculum; (b) classroom teachers were trained to implement the curriculum; and (c) controls continued their usual programs. The Trained Teacher condition was superior to Control on Language, Reading, and Basic Battery. The Specialist condition was superior to Control on Reading, but inferior on Language. Despite devoting twice as many minutes per week to physical education as Controls, the health-related physical education program did not interfere with academic achievement. Health-related physical education may have favorable effects on students' academic achievement.