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Stress and Injury Risk in Professional Ballet Dancers: A Qualitative Study
Abstract and Figures
Professional ballet dancers report high injury rates, but research about potential risk factors and prevention strategies is sparse. While stress is recognized as a major injury risk factor in other sports, little is known about its influence on injuries in professional ballet. This study investigated in a qualitative approach whether an existing model about stress and injury is suitable to predict and prevent injuries in professional ballet. Two professional ballet dancers (f=1, m=1) were interviewed about the occurrence of their recently sustained overuse injuries and potential influencing factors. Four main themes were identified using thematic analysis: psychophysiological factors, history of stressors, personal factors, and coping resources. Fatigue was described as the underlying injury mechanism, which was influenced by various stressors inside and outside of ballet, personality traits, and ineffective coping. The results are discussed in relation to the model and existing dance research to give recommendations for future screening and intervention programs for professional ballet dancers.
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The aim of this study was to investigate the convergent validity of session rating of perceived exertion (s-RPE) with objective measures of internal training load (TL) in professional classical ballet dancers. Heart rate and s-RPE data were collected in 22 professional classical ballet dancers across a total of 218 ballet class or rehearsal sessions. Eleven participants completed at least 9 sessions, and were therefore included in analyses of individual relationships between s-RPE and objective measures. To calculate s-RPE, the session duration was multiplied by the RPE, measured using the modified Borg CR-10 scale. The Edwards summated heart rate zones (Edwards TRIMP) and Banister training impulse (Banister TRIMP) methods were used as criterion measures of internal TL. Pearson product-moment correlation coefficients were used to determine intra-individual relationships between s-RPE and objective measures. Repeated measures correlations were used to identify intra-individual relationships common across the cohort. Positive linear relationships were seen between s-RPE and objective measures across all session types [Edwards TRIMP: rrm (195) = 0.81, p < 0.001; Banister TRIMP: rrm (195) = 0.79, p < 0.001], in ballet class [Edwards TRIMP: rrm (58) = 0.64, p < 0.001; Banister TRIMP: rrm (58) = 0.59, p < 0.001], and in rehearsals [Edwards TRIMP: rrm (119) = 0.82, p < 0.001; Banister TRIMP: rrm (119) = 0.80, p < 0.001], as well as across both males [Edwards TRIMP: rrm (136) = 0.82, p < 0.001; Banister TRIMP: rrm (136) = 0.80, p < 0.001], and females [Edwards TRIMP: rrm (57) = 0.80, p < 0.001; Banister TRIMP: rrm (57) = 0.78, p < 0.001]. Intra-individual correlation coefficients ranged from 0.46–0.96 [Edwards TRIMP: mean r = 0.81 ± 0.11, p = 0.051 – < 0.001; Banister TRIMP: mean r = 0.78 ± 0.14, p = 0.13– < 0.001]. These results demonstrate that s-RPE is a valid and practical method for measuring internal TL in professional classical ballet dancers.
Background:
Dance involves movements of complexity and physical intensity which result in stress on the body. As a consequence, dancers are at risk of injury which can impact on their well-being. Screening tools are used for injury prevention to identify those dancers at risk of injury. The aim of this study was to investigate which screening tools can predict injury in dancers, encompassing all dance genres, levels and ages.
Methods:
An electronic search of seven databases from their inception to December 2017 was conducted. The databases were the Allied and Complementary Medicine Database (AMED), CINAHL, eBOOK Collection (EBSCOhost), MEDLINE, Cochrane Database of Systematic Reviews, SPORTDiscus and PEDro: the Physiotherapy Evidence Base. The following search terms were used: (i) Dance AND injury AND Screening, (ii) Screening AND dance and (iii) Musculoskeletal AND Screening AND Dance. Studies were assessed using a 20-point scoring tool, and eligible studies were included in a meta-analysis.
Results:
The mean methodological quality score was 12.2 points. Injured dancers had a significantly higher compensated turnout range of motion than non-injured dancers: pooled mean difference of compensated turnout (23.29°; 95% CI 14.85-31.73; P < 0.00001; I2 = 0%). Injured dancers had significantly greater functional turnout range of motion when compared to non-injured dancers: pooled mean difference of functional turnout (14.08°; 95% CI 7.09-21.07; P < 0.0001; I2 = 0%). There also some evidence for use of hip range of motion as a predictor of dance injury.
Conclusions:
Some evidence exists for the potential use of dance-specific positions as a predictor of injury. A number of studies were limited by a lack of prospective injury design, injury definition and self-reporting of injury.
Dancers are clearly athletes in the degree to which sophisticated physical capacities are required to perform at a high level. The standard complement of athletic attributes - muscular strength and endurance, anaerobic and aerobic energy utilization, speed, agility, coordination, motor control, and psychological readiness - all are essential to dance performance. In dance, as in any athletic activity, injuries are prevalent. This paper presents the research background of dance injuries, characteristics that distinguish dance and dancers from traditional sports and athletes, and research-based perspectives into how dance injuries can be reduced or prevented, including the factors of physical training, nutrition and rest, flooring, dancing en pointe, and specialized health care access for dancers. The review concludes by offering five essential components for those involved with caring for dancers that, when properly applied, will assist them in decreasing the likelihood of dance-related injury and ensuring that dancers receive optimum attention from the health care profession: (1) screening; (2) physical training; (3) nutrition and rest; (4) specialized dance health care; and (5) becoming acquainted with the nature of dance and dancers.
Eating disorders in dancers are thought to be common, but the exact rates remain to be clarified. The aim of this study is to systematically compile and analyse the rates of eating disorders in dancers. A literature search, appraisal and meta-analysis were conducted. Thirty-three relevant studies were published between 1966 and 2013 with sufficient data for extraction. Primary data were extracted as raw numbers or confidence intervals. Risk ratios and 95% confidence intervals were calculated for controlled studies. The overall prevalence of eating disorders was 12.0% (16.4% for ballet dancers), 2.0% (4% for ballet dancers) for anorexia, 4.4% (2% for ballet dancers) for bulimia and 9.5% (14.9% for ballet dancers) for eating disorders not otherwise specified (EDNOS). The dancer group had higher mean scores on the EAT-26 and the Eating Disorder Inventory subscales. Dancers, in general, had a higher risk of suffering from eating disorders in general, anorexia nervosa and EDNOS, but no higher risk of suffering from bulimia nervosa. The study concluded that as dancers had a three times higher risk of suffering from eating disorders, particularly anorexia nervosa and EDNOS, specifically designed services for this population should be considered. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.
Compared to other athletic activities, research on injury incidence and risk factors in dance is limited. There is also a need for more research evaluating the impact of intense training on elite adolescent athletes. The aim of this study was to evaluate the rates and risk of injuries, the hours of dance exposure and the characteristics and consequences of injuries among elite pre-professional ballet students.
Prospective epidemiological study.
266 (112 male) full-time students aged 15-19 years from three elite pre-professional ballet schools were followed prospectively over one school year. Injury rate was reported per 1000h of dance and 1000 dance exposures (DEs). Injury details collected included type and anatomical location of injury.
The clinical incidence of injury was 1.42 injuries per dancer and the risk of injury was 76% over the one-year period. The rate of injury was 1.38/1000h of dance and 1.87/1000 DEs. Joints were the most commonly injured structures and the ankle was the most commonly injured body area. Overuse injuries were more common than traumatic injuries. Bony injuries (e.g. stress fractures), and injuries to the knee were associated with the greatest time loss per injury. Injury risk and rate increased as students progressed through their three years of training.
In comparison with other adolescent athletic populations, participants in this study had a similar injury rate but a higher risk of injury. This may be attributable to the high level of training exposure in pre-professional ballet students.
Ballet dancers are high-performance athletes who are particularly susceptible to a wide variety of musculoskeletal injuries. However, they are relatively understudied, and data on their injury rates are lacking. This retrospective study features the largest aggregate data on professional ballet dancers to date and aims to identify the most common diagnoses and areas of injury in this unique population to better direct preventative and clinical practices. The study encompassed a 10-year period from January 2000 to December 2010 of dancers from a single company. Data regarding the dancers' age, gender, location of injury, and diagnosis were collected from workers' compensation claims, company records, and medical records maintained by the treating doctors. These were analyzed to determine metrics on injury incidence, frequency, and diagnosis. Over the 10-year span, 574 injuries occurred. There were approximately 52 dancers per year for a total of 153 who danced at least one complete season during the study period. The average age was 27, and 53% were female. Given turnover with retirement and replacements, the total number of dancer-years was 520, indicating an injury incidence per annum of 1.10 (574 injuries per 520 dancer-years). The most common locations of injury were foot and ankle and the lumbar spine, with the three most common diagnoses making up greater than a third (37%) of the total. As the current largest study in professional ballet, the findings set the benchmark metrics for musculoskeletal injury to the foot, ankle, and lumbar spine sites. Future studies should aim to identify injury risk factors and modalities for prevention of these injuries.
This study examined the associations between conscientious perfectionism (high standards), self-evaluative perfectionism (self-criticism) and eating psychopathology among dancers. A sample of 244 female dancers, with a mean age of 20.11 years (standard deviation = 1.97) completed the Perfectionism Inventory and Eating Disorder Examination Questionnaire. Self-evaluative perfectionism predicted eating psychopathology (eating restraint, eating concern, weight concern and shape concern). This relationship was not moderated by conscientious perfectionism. The mediation analyses showed that although conscientious perfectionism predicted eating psychopathology, this relationship was fully mediated by self-evaluative perfectionism. These findings demonstrate the greater influence of self-evaluative perfectionism, rather than conscientious perfectionism, on eating psychopathology in dancers. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.
In a controlled, prospective, randomized study, half of the dancers in a professional ballet company were asked to do extra self-administered fitness training, while the other half became the control group. The aim was to examine if the dancers in the training group would be able to keep up the extra training during a regular season and to examine its effect on their maximum oxygen uptake and on their self-estimated musculoskeletal pain. The training group increased their oxygen uptake more than the control group. The self-estimated functional inability because of pain (SEFIP) indicated significantly less pain the week after the premiére for the study population taken as a whole, but not for the two groups when considered separately. The training group claimed that the fitness training had helped them to cope with the psychological strain during rehearsals.
Dancers are expected to maintain consistently high levels of performance capability and to perform on demand. To meet these expectations, they subject their bodies to long hours of intensive physical training. Such training regimens are often combined with tight rehearsal and performance
schedules, which over time can lead to persistent fatigue, psychological distress, performance decrements, and injury. A similar process has been observed as a consequence of high-intensity training in many different sports, and considerable sport-related research has been devoted to identifying
the antecedents, the symptoms that are experienced, and the most cost-effective ways of monitoring symptom development. This paper presents a general heuristic framework for understanding this "training distress process" and discusses the framework with specific reference to dance.
Objective:
The aim of this study was to determine whether an intervention with individualized conditioning program based on injury history and functional movement screening would be effective in reducing ballet injury incidence.
Design:
Prospective 3-year epidemiological study.
Setting:
Professional ballet company and its in-house medical facility.
Participants:
Dancers from a professional ballet company over the 3-year study period. Participant numbers ranged from 52 to 58 (year 1: 52; year 2: 58; year 3: 53).
Interventions:
The intervention consisted of individual conditioning programs developed using injury history and functional movement screening. Analysis was undertaken of the all dancers who were present in the company during the study period. The significance of change in injuries over a 3-year period was determined using a Poisson distribution model.
Main outcomes measures:
To determine whether individual conditioning programs resulted in a decrease in injury incidence over the study period.
Results:
The injury count reduced significantly in years 2 and 3 (P < 0.001). Injury incidence for male dancers declined from year 1 (in year/1000 h) (4.76/1000 h) to year 2 (2.40/1000 h) and year 3 (2.22/1000 h). For women, a reduction in the injury incidence was observed from year 1 (4.14/1000 h) to year 2 (1.71/1000 h) and year 3 (1.81/1000 h).
Conclusions:
Through prospective injury surveillance, we were able to demonstrate the benefit of individualized conditioning programs based on injury history and functional movement screening in reducing injuries in ballet.
Clinical relevance:
The implementation of well-structured injury surveillance programs can impact on injury incidence through its influence on intervention programs.