Extension Neck Injury in Female DanceSport Competitors

Abstract

Context
The female dancer’s technique in DanceSport involves keeping the upper body and head poised in extension and left rotation. Attempting to maintain this position while dancing can lead to an extension neck injury (ENI).

Objective
The aim of this online survey was to discover the prevalence of ENI among female ballroom dancers.

Design and Participants
Female DanceSport competitors ( N = 127) completed an online survey.

Results
Twenty-fve percent reported having ENI, and 68% of ENI occurred at competitions. Younger dancers (mean age = 20 ± 4.8 years) were significantly ( p < .003) more likely to have ENI than older dancers (mean age = 34 ± 12.9 years).

Conclusions
ENI is prevalent in DanceSport competitors. Dance medicine professionals should consider this when designing injury prevention programs.

Full text

INJURY PREVENTION
Extension Neck Injury
in
Female DanceSport
Competitors
Teri Riding McCabe, MS, ATC
•
Brighann Young University; Jatin P. Ambegaonkar,
PhD,
ATC,
OT, CSCS
•
George Mason University; Matthew Wyon,
PhD •
University
of
Wolver-
hampton; Emma Redding, PhD
•
Trinity Laban Conservatoire
of
Music
and
Dance
Context: The female dancer's technique
in
DanceSport involves keeping the upper body
and
head poised
in extension
and
left rotation. Attempting to maintain this position while dancing can lead
to an
extension
neck injury (ENI). Objective: The
aim of
this online survey was
to
discover
the
prevalence
of
ENI among
female ballroom dancers. Design and
Participants:
Female DanceSport competitors
(N
=
127) completed an
online survey. Results: Twenty-five percent reported having ENI, and 68
%
of
ENI
occurred
at
competitions.
Younger dancers (mean age
= 20 +
4.8 years) were significantly
(p <
.003) more likely
to
have ENI than
older dancers (mean
age = 34 +
12.9 years). Conclusions: ENI
is
prevalent
in
DanceSport competitors.
Dance medicine professionals should consider this when designing injury prevention programs.
Keywords: DanceSport, ballroom dancing, neck injury, female dancers
r revious research in DanceSport, the com-
petitive form
of
ballroom dancing,
has
sug-
gested that injuries can be caused by muscu-
lar weakness,
flawed
dance technique, heavy
competition
and
train-
ing schedules,
or dys-
function
in the
kinetic
chain.'"' The
few
injury
studies
in
DanceSport
have found that
the
most commonly injured
anatomical sites are the
neck, back, shoulder,
knee,
lower
leg,
ankle,
and foot.'*"''
Because competitive
couples train together,
their training duration
KEY
POINT
DanceSport competitors
are predisposed
to
the
extension neck injury
(ENI)
given
the
position requirements
of the
head,
neck,
and
shoulders while
dancing.
Of the participants, Z5%
reported having
ENI.
Younger participants
were more likely
to
have
ENI
than older
participants.
is equal; however, their dancing techniques
are gender specific
in
ballroom-style Danc-
eSport.^
The
female dancer's technique
in
ballroom involves keeping
the
upper body
and head poised
in
extension
and
left rota-
tion.'"" A correctly held dance frame uses
the muscles
of the
neck, upper back,
and
core
to
carry
the
arms, neck,
and
spine.'^
While dancing, some female dancers
are
unable
to
maintain this position. Their head
will fall back into extension
and
left lateral
flexion, and they cannot return
the
head
to
an upright position (Figure 1). Typically,
the
male partner will adjust his hand to hold
the
neck semiupright until
the
competition
is
finished and
the
female dancer
can
receive
treatment
off
the dance
floor.'^
The etiology
of this extension neck injury (ENI)
in
female
o
ZOl/,
Human
Kinetics ^ IJÂTT 19(3),
pp.
3Z-36
http://dx.doi.org/10.1123/ijatt.2013-0083
32 I MAY 2014INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING

ballroom dancers has not been discovered, with only
one article in the literature mentioning this injury.'^ We
searched in the databases (CINAHL, Cochrane, Google
Scholar, Medline, MeSH, PubMed, SportsDiscus, and
Web of Science) with no success in finding previous
research about injury rates in DanceSport; therefore,
the occurrence of
EN I
is unknown. Thus, the primary
aim of this research was to discover the prevalence of
ENI among female ballroom dancers.
Methods
We developed a 42-question observational electronic
survey study design to examine the prevalence of ENI
in female ballroom dancers. Participants could omit
any question they did not want to answer. All study
procedures were approved by the university research
ethics committee. Participants were required to give
informed consent on the survey's first page and could
not proceed further without providing this approval.
The electronic survey instruments were collected using
a website specifically set up for the university using
Surveyor (ObjectPlanet AS, Oslo, Norway).
The electronic survey instrument was initially pilot
studied with a convenience sample of five female
former competitive ballroom dancers to comment
on its face validity. The comments helped modify
the survey in regard to clarity, format, redundancies,
relevance, and technical aspects of the survey. After
incorporating the comments, another five former
female competitive ballroom dancers completed the
pilot electronic survey to establish consistency of the
Fiqure
1
Example ot an extension neck injury
instrument. The survey consisted of a variety of ques-
tions including multiple-choice, short-answer, matrix,
and drop-down questions. Survey questions included
demographic and geographic information, DanceSport
experience, and injuries that occurred in the 6 months
before the survey. The injury questions were duplicated
from the previous Fit to Dance surveys.'"*""^
After the pilot study, a contact message with a
hyperlink to the open electronic survey instruments was
sent to the participants. Female DanceSport ballroom
dancers were recruited through a social networking
website, e-mail, competitions, and studios. Follow-up
messages were sent during a 4-month period. Inclusion
criteria consisted of any female dancer who competed
in ballroom DanceSport. Dancers were excluded from
the ENI category if their neck injury did not occur while
ballroom dancing. No geographic region was excluded
so that we could determine whether ENI was a local
phenomenon or a possible widespread injury; it was
also open to all ages, levels, and countries. There were
127 participants and 87 completed surveys, yielding a
completion rate of 69
%
.
Descriptive statistics were calculated as percent-
ages,
means, and standard deviations. An indepen-
dent t test was performed to examine the relationship
between ENI and non-ENl groups. A binary logistic
regression analysis was used to confirm that predic-
tor variables between ENI participants and non-ENI
participants were significant. The predictor variables
were as follows:
• Group
• Age
• Age when started DanceSport lessons
• Years dancing
• Years taking ballroom lessons
• Years competing in ballroom
• Number of teachers
• Number of partners
• Years dancing with current partner
• Years at competition level
• Competitions per year
• Whether they create their own elaborate hairstyles
for competitions.
We created three subgroups after examining the
ENI participants' answer to the question "When was
the last time you injured your neck?" The ENI partici-
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY S. TRAININGMAY 2014 153

pants were divided into subgroups
as (1)
participants
who last
had
ENI less than
1
year
ago
(n =
13), (2) par-
ticipants
who
last
had
ENI injury more than
1
year
ago
(n
=
5),
and
(3)
recurring
{n
=
2). Two
participants
in
the ENI group
did
not
respond
to
this question,
so
they
were dismissed from
the
analysis.
The
ENI
subgroups
were asked whether they
had
experienced numbness
and
how
many times they
had
ENI.
These
two
ques-
tions were added
as
predictor variables
for
the
analysis
among
the
three
ENI
subgroups.
A
one-way analysis
of variance, Bonferroni post
hoc
test,
and
Levene's
test were used
to
confirm whether
the
variables were
a significant factor
in
determining
the
prevalence
of
ENI when dancers have neck injury.
For
comparative
statistics,
p <
.05
determined significance using SPSS
Version
19
(IBM
Corp., Armonk,
NY).
Results
Sixty-five participants
(75%) did not
identify them-
selves
as
having
ENI,
and 22
participants
(25%) did
TABLE
1
.
DANCESPORT
COMPETITION CLASSIFICATIONS
Youth
junior
Novice
Prechampionship
Amateur
Rising
Star Professional
Professional
Non-ENI
Dancers
2 %
4%
8%
17%
60%
2%
8%
ENI Dancers
14%
7%
3%
10%
52%
3%
10%
Note:
ENI
=
extension neck injury.
identify themselves
as
having
ENI.
The
majority
of
the dancers
had
been competing
in the
amateur clas-
sification (Table
1) and had
been competing
at
their
current competition classification
for
4.3
± 4.2
years.
Age
was
the
only significant variable between
the
ENI
and non-ENI groups, i(45.67)
=
3.08,
p <
.003
(Table
2).
Younger dancers were significantly more likely
to
have
ENI,
0^(1,
N = 78) =
7.13,
p < .008
(Table
2).
\insert Table
1
here\
The ENI group reported this injury occurred
3.5 ±
2.1 times during their competitive career
and 3.2 +
2.1 times with their current competition partner
The
ENI group reported that
ENI
occurred
9%
during
per-
formance, 27
%
at
lessons, 45
%
at
practice,
and
68
%
at
competition.
Of the
ENI group, 77
%
reported creating
their
own
elaborate hairstyles
for
competitions. Five
(23%)
ENI
dancers reported having
had
numbness
with ENI.
ENI
occurred more times,
F{5,
18) =
4.180,
p
<
.021,
in
Subgroup
3
than
in
Subgroup
1
(p <
.01
5)
and Subgroup
2 (p <
.046;
Table
3).
Discussion
Our primary findings included
a
25%
prevalence
of
ENI among female ballroom dancers
who
participated
in this survey.
Age was the
only significant variable
between
the ENI and
non-ENI groups.
ENI
Subgroup
1
was
younger than Subgroups
2 and 3 and the non-
ENI group (Tables
2 and 3). In
addition. Subgroup
1
reported suffering from
ENI
more recently than
Sub-
group
2.
This
is not
surprising because Subgroup
1
were younger
and had not
been dancing
as
long
as
the
other subgroups (Table 3); therefore, they
had
a
shorter
dancing history
in
which
to
experience
an
ENI
and may
not have mastered ballroom technique. Moore' stated
that
a
middle-aged dancer
may not be
physically able
to hold
the
neck with ballroom technique. However,
the younger dancers were significantly more likely
to
TABLE 2. HYPEREXTENSION NECK INJURY DEMOGRAPHIC
AND
DANCESPORT INFORMATION (MEAN
± SD)
Age
(years)
HNl
Occurrence
Per
Year
Years
Dancing ™""'":Wf!f^H
Years
Dancing
w/
Current Partner
Group
1
'"
20 ± 4.8
2.9
+ 1.4
SKW
8.4 ± 3.6*
3.4
+ 3.0*
Group
Z
32
± 9.8
3.2
+ 1.6
17.3
± 6.8
9.4
+ 5.4
Group
3
27
± 10.0 ,j
7
5 ± 3 5
^^^
*
>.
J
*
Note:
*HNI Group
3
was
included
in
HNI Group
1
during statistical analysis
34 1 MAY
2014
INTERNATIONAL
JOURNAL
OF ATHLETIC THERAPY
&
TRAINING

TABLE 3. EXTENSION NECK INJURY DEMOGRAPHIC
AND
DANCESPORT INFORMATION (MEAN
± SD)
Age
(years)
ENI
Occurance
Years
Dancing
Years
Dancing
w/
Current Partner
Sub-group
1
20
± 4.8
2.9
+ 1.4
7.9
+ 3.5
3.1
+ 2.6
Sub-group
2
32
± 9.8
3.2
+ 1.6
17.3
± 6.8
9.4
+ 5.4
Sub-group
3
27
+ 10.0
7.5
+ 3.5
11.5
± 2.1
6.0
+ 5.7
have
had
this neck injury. This could suggest that some
younger dancers may not
be
physically strong enough
to hold
the
neck extension necessary
for
ballroom
technique. Because this
is one
survey about ENI prev-
alence,
it is
hard
to
know whether
the
older dancers
have weathered
the
storm or whether former ballroom
dancers dropped
out of
dancing because they suffered
from
ENI. We
suggest
a
longitudinal study following
female ballroom dancers
to see why
ENI occurs.
The
ENI
group reported that
ENI
occurred
9% in
performance,
27% at
lessons,
45% at
practice,
and
68
%
at
competition.
In
DanceSport,
a
lesson typically
lasts
45
min, during which
the
female dancer
and her
male partner
are
taught
by a
teacher
and
learn
new
choreography
or
correct technique. Practice
is
when
a
studio plays music
for all
five ballroom dances (waltz,
tango,
Viennese waltz, foxtrot,
and
quickstep) multiple
times
for
approximately
an
hour
so the
dancers
can
practice
the
things they have been learning
in
their
lessons.'^""
A
performance
is
when
the
ballroom
couple performs
for an
audience instead
of
judges,
which means they
do not
have
to
follow competi-
tion rules
and can add
choreography
not
allowed
in
competition.'^"''' A competition
is
when
the
ballroom
couple competes
in
front
of a
panel
of
judges against
other couples. There can
be
multiple rounds
of
the five
ballroom dances depending
on
how small
or
large
the
competition
is.
In this study,
50% of the
adolescent participants
reported having
ENI. Two
DanceSport studies about
adolescent dancers found the upper back to
be the
first
(53.8
% ;
beginners)^"
and
second (36.7
% ;
adolescents
and young adults with international experience)^ most
commonly painful body parts. By knowing where
the
pain begins, medical professionals might be able to pre-
dict where
an
injury may occur. Of the total
82
injuries
reported by the dancers
in
this study, 21 were reported
by adolescent dancers. In the third Fit
to
Dance survey,
adolescent female dancers were more likely
to
have
ankle,
knee, lower back, neck,
and
shoulder injuries.'*
This
is
similar
to the
adolescent dancers
in our
study,
for whom
the
neck and ankle were the most commonly
injured anatomical sites. This information
can
help
teachers
to
know what technique
and
conditioning
activities
to
focus
on to
help prevent
ENI and
other
injuries, especially
in
younger dancers.
A limitation
to
this study
is
that
it was
only
in
the English language; thus, only dancers
who
could
read
and
type
in
English completed
the
survey.
The
participants stated that they were from several differ-
ent countries,
but
mainly from
the
United States
and
United Kingdom.
Another limitation
is
that self-reporting injury
sur-
veys
are
typically
not as
accurate
as
prospective^'
or
retrospective studies;^^'^^ however, there
has not
been
an injury cohort study
in
previous DanceSport research.
Also,
this survey
was
limited
to the
prevalence
of
ENI
and
did not
include
its
pathogenesis, frequency,
or
prevention. Another limitation could
be the
only 25%
prevalence
of
ENI among respondents
(n = 22) to
this
survey,
but the
history
of low
sample size
in
dance
medicine research should
be
noted.'^'^'"^' Because this
study
was
restricted
to the
prevalence
of
ENI instead
of
the
pathogenesis, frequency, prevention,
or
inves-
tigation
of
when female ballroom dancers experience
ENI
for the
first time,
the
findings
are
constrained
to
age
at the
time participants filled
out the
survey.
Conclusions
Ours
is the
first study,
to our
knowledge,
to
examine
ENI prevalence
in
female ballroom dancers. We found
a
25
%
prevalence
of
ENI among female ballroom danc-
ers.
Younger dancers were more likely
to
experience
INTERNATIONAL
JOURNAL
OF ATHLETIC THERAPY
&.
TRAINING
MAY
2014
135

ENI. A recommendation for future research includes
investigating when female ballroom dancers expe-
rience ENI for the first time and the pathogenesis,
frequency, and prevention of
ENI.
I
References
1.
Miletic: A, Kostic R, Bozanic A, Miletie; D. Pain status monitoring in
adolescent dancers. MedProbl Perform Art. 2009;24(3);119-.123.
2.
Miletic A, Kostic R, Miletic D. Pain prevalence among competitive
international dancers. IntJAthlTher
Train.
2011;
16(1): 13-16.
3.
HowseJ, McCormack M. Dance
Technique &
Injury Prevention. 4th ed.
London: Methuen Drama; 2009.
4.
Wanke E. Shall we dance? Physiological profile and injury prevention
of elite formation dancers. Paper presented at: 10th Annual Meeting
of the International Association for Dance Medicine and Science;
October 27-29, 2000; Miami. FL.
5.
Nuttall R, Thomas K. Dance injuries: their frequency, treatment, and
prevention in a collegiate dance medicine and training facility. Paper
presented at: 14th Annual Meeting of the International Association for
Dance Medicine and Science; October 15-17, 2004; San Francisco,
CA.
6. Tsung PA, Mulford Gj. Ballroom dancing and cervical radiculopathy: a
case repon. Arch Phys MedRehabil. 1998;79(10):1306-1308. PubMed
doi:10.1016/S0003-9993(98)90281-7.
7.
Tsien C, Trepman E. Internal rotation knee injury during ballroom
dance: a case report. J Dance Med Sei. 2001;5(3):82-86.
8. Stresková E, Chren M. Balance ability level and sport performance
in Latin-American dances. Facta Universitatis Phys Educ Sport.
2009;7(l):91-99.
9. Moore A. Ballroom Dancing. 10th ed. London:
A
&
C
Black Publishers
Ltd; 2002.
10.
Imperial Society of Teachers of Dancing. The Ballroom Technique.
London: Lithoflow Ltd; 1994.
11.
Trimble K. Creating illusions, breaking myths. Dance Teach Now.
1998;20(9):70.
12.
Trimble K. Train without pain. Dance
Teach
Now. 1998;20(7):28-29.
13.
McCabe TR, Hopkins T, Vehrs P, Draper DO. Contributions of muscle
fatigue to a neuromuscular neck injury in female standard ballroom
dancers. Med Probl Perform Art. 2013;28(2):84, PubMed.
14.
Brinson P, Dick
F.
Fit to
Dance?
The Report of the National Inquiry Into
Dancers'
Health
and
Injury.
London: CalousteGulbenkian Foundation;
1996.
15.
Laws
H.
Dance
UK's
Fit
to Dance
2:
Report of the Second
National
Inquiry
Into Dancers' Health and Injury in the UK. London: Newgate Press;
2005.
16.
McCabe TR, Wyon M, Redding E, Ambegaonkar
jP.
Fit to dance survey;
A comparison with dancesport injuries. Med Probl Perform Art. In
press.
17.
USADance. DanceSport rulebook 2013-A. 2013; http;//usadance.org/
dancesport/forms-and-resources/rules-policies-and-bylaws/. Accessed
January 12, 2013.
18.
National Dance Council America. National Dance Council of Amer-
ica rulebook master 2013. http://www.ndca.org/rules-and-results/.
Accessed January 12, 2013.
19.
World Dance Council. World Dance
Council
Competition Rules. London:
World Dance Council; 2011.
20.
Miletic
A,
MileticD, Males
B.
Morphological differences and pain status
monitoring in dance training. Facta Universitatis Phys Educ Sport.
2008;6(2):159-168.
21.
Allen N, Nevill A, Brooks
j.
Koutedakis Y, Wyon M. Ballet injuries:
injury incidence and severity over
1
year.
J Orthop Sports Phys Ther.
2012;42(9):781 -790. PubMed doi: 10.2519/jospt.20l 2.3893.
22.
Gamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns in
elite preprofessional ballet dancers and the utility of screening
programs to identify risk characteristics. / Orthop Sports Phys Ther.
2008;38{3): 126-136. PubMed doi: 10.2519/jospt.2008.2390.
23.
Baker
j.
Scott D, Watkins K, Keegan-Turcotte S, Wyon M. Self-reported
and reported injury patterns in contemporary dance students. Med
Probl Perform Art. 2010;25(l):10-15. PubMed.
TeriRiding
McCabe
is an Adjunct Professor with the Dance Medicine
Training Facility at Brigham Young University, Provo, UT.
Jatin
P.
Ambegaonkar is an Associate Professor at the Sports Medi-
cine Assessment Research and Testing Laboratory at George Mason
University, Manassas, VA.
Matthew Wyon is a Professor in Dance Science at the University of
Wolverhampton, Wolverhampton, UK.
Emma Redding is the Head of Dance Science and Acting Head of
Taught Postgraduate Studies at Trinity Laban Conservatoire of Music
and Dance, Creekside, London, UK.
Scott Cheatham, PT, DPT, PhD(c), OCS, ATC, CSCS, is with California
State University, Dominguez Hills, and the report editor for this article.
36 I MAY 2014INTERNATIONAL JOURNAL OF ATHLETIC THERAPY S. TRAINING

CopyrightofInternationalJournalofAthleticTherapy&TrainingisthepropertyofHuman
KineticsPublishers,Inc.anditscontentmaynotbecopiedoremailedtomultiplesitesor
postedtoalistservwithoutthecopyrightholder'sexpresswrittenpermission.However,users
mayprint,download,oremailarticlesforindividualuse.