Original ResearchRisk factors for musculoskeletal injury in elite pre-professional modern dancers: A prospective cohort prognostic study
Introduction
Increasingly, best practice in dance healthcare includes preseason screening. However, the value of screening is questioned (Cavanaugh et al., 1995, Gamboa et al., 2008, Garrick, 2004). Recent efforts have been made to develop, validate, and implement appropriate screening tools that determine dancer readiness for the workloads to which they are subjected (Allen et al., 2013, Angioi et al., 2009, Bowerman et al., 2013, Bronner and Rakov, 2014, Gamboa et al., 2008, Gibbs et al., 2006, Karim et al., 2011, Kropa et al., 2015, Twitchett et al., 2010). Studies that seek to identify risk factors in dancers have generally suffered from small sample size, absence of exposure determination, need for prospective study design, diverse injury definitions, and self-report of injury rather than diagnoses determined by healthcare professionals. We continue to lack prospective evidence of injury risk factors (Caine, Goodwin, Caine, & Bergeron, 2015). There is weak evidence suggesting insufficient or forced turnout, excessive joint mobility, imbalances in strength and flexibility, poor postural alignment or motor-control, aerobic conditioning, disordered eating, and previous injury may be contributors to injury (Bowerman et al., 2015, Bronner et al., 2003, Coplan, 2002, Roussel et al., 2009)..
Emphasis is placed on the aesthetics of flexibility in dance, pushing lower extremity postures to increasing extremes (Daprati, Iosa, & Haggard, 2009). Without proper training and conditioning, such extremes can result in joint and ligament injuries. These forces, along with genetic predisposition, have important ramifications in the dancer with generalized joint laxity (GJL) or hypermobility. Previous studies focused on the prevalence of hypermobility in ballet (Klemp and Learmonth, 1984, McCormack et al., 2004, Sanches et al., 2015) and contemporary dancers (Roussel et al., 2009, Ruemper and Watkins, 2012), but none were found studying modern dancers. Prospective studies demonstrating the relationship of dancers to increased risk for injury due to increased GJL are lacking.
Several other risk factors that may contribute to injury such as muscle tightness, motor control, and previous injury, have been proposed in dancers and other athletes. Restrictions in hamstring and quadriceps flexibility were risk factors in athletes who developed hamstring and quadriceps injuries, or patellar tendinitis (Witvrouw et al., 2001, Witvrouw et al., 2003). Other studies reported no relationship between poor muscle flexibility and increased injury risk (Engebretsen et al., 2010, Yeung et al., 2009). Due to conflicting evidence, given the preoccupation of dancers concerning muscle extensibility, and to distinguish muscle tightness from joint hypo- or hypermobility, we analyzed flexibility in lower extremity muscle groups.
Faulty dance technique involving poor alignment and motor-control are frequently cited as possible risk factors for injury (Ahonen, 2008, Steinberg et al., 2012). Some screens include dance-specific movements (Gamboa et al., 2008, Steinberg et al., 2012). Others have employed core-specific tests (Roussel et al., 2009) or the Functional Movement Screen (FMS) (Allen et al., 2013, Kropa et al., 2015). In our injury clinics, we found that correction of errors in technique frequently eliminated musculoskeletal problems. Therefore, we selected common dance-specific movements for analysis of dance technique as a risk factor for injury.
Finally, previous injury is the most frequently cited risk for future injury (Fulton et al., 2014, Hagglund et al., 2006). This can include re-injury to the same tissue or injury elsewhere due to unaddressed muscle imbalances or altered proprioception, motor-control, and biomechanics.
The identification of risk factors for musculoskeletal injury is critical to reduce the incidence of injuries and related personal, organizational, and financial costs. The purpose of this study was to examine four risk factors for injury in pre-professional modern dancers. We hypothesized dancers at increased risk for musculoskeletal injury would have: i) high or low Beighton scores for hypermobility; ii) decreased dance technique motor-control; iii) muscle tightness (decreased lower extremity muscle flexibility); and iv) increased history of injury in the previous year.
Section snippets
Study design
This study was a retrospective review of a prospectively designed cohort study. Determination of the a priori sample size needed for Goodness-of-fit, X2 tests, effect size = 0.40, df = 4, power (1-β) = 0.95, and α = 0.05, was N = 117 participants. This study was approved by the University Internal Review Board for retrospective analysis of data.
Participants
Participants were enrolled in a university Bachelor of Fine Arts (BFA) pre-professional modern dance program. This program is part of a larger
Preseason screening
Dancers’ mean age was 18.14 ± 0.68 yrs with 10.89 ± 3.85 years of dance training. There were differences between genders in height, mass, BMI, years of dance training, (p = 0.001) but not age (Table 1). Dancers reflected a mixture of ethnicities: 89 (50%) Caucasian, 54 (30%) African American, 15 (8%) Hispanic, 9 (5%) Asian, and 13 (7%) Other. There were no differences between genders in Beighton or dance technique scores, lower extremity tightness, or previous injuries. Females demonstrated
Discussion
This analysis contributes robust support for the value of preseason screening in pre-professional modern dancers. Our results support all four hypotheses regarding injury predictors of musculoskeletal injury. Dancers with either high or low Beighton scores, high composite technique scores reflecting decreased technique motor-control, lower extremity muscle tightness, or two or more previous injuries in the past year were more likely to sustain musculoskeletal injury. These findings are
Conclusions
This research contributes positive information on the value of preseason screening. Four risk factors demonstrated significance as injury predictors. Dancers with either high or low Beighton scores, technique scores reflecting decreased technique motor-control, lower extremity muscle tightness, or two or more injuries in the past year were more likely to sustain MAI. High or low Beighton scores were also significant predictors for TL-inj. This study also provides new information on
Ethical approval
This study was approved by Northeastern University Internal Review Board under protocol number 13-08-31.
Funding
None declared.
Conflicts of interest
None declared.
Acknowledgements
The authors thank the dancers and administrative staff of The Ailey School for their participation and support of the annual preseason screening and Injury Clinic programs. We also thank all the physical therapists, athletic trainers, dance faculty, and other volunteers that assisted us in our annual screenings, particularly Dana Hash-Campbell, Sheyi Ojofeitimi, Sara Rakov-Aingorn, and Tracye Rawls Martin. We thank Katherine Pierce, Brielle Barclay, Daniella De La Fuente, Emily Coombes, Jessica
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2021, Physical Therapy in SportCitation Excerpt :Synthesis of risk factors for dance injuries has been difficult because of heterogeneity in risk factor measurement, injury definition, and surveillance systems (Bronner & Wood, 2017; Jacobs et al., 2012; Kenny et al., 2016, 2018b; Liederbach et al., 2012). To date, level 2 evidence (Group∗ OLoEW, 2011) suggests that previous injury (Bronner & Bauer, 2018; Gamboa, Roberts, Maring, & Fergus, 2008; Hiller, Refshauge, Herbert, & Kilbreath, 2008; Wiesler, Hunter, Martin, Curl, & Hoen, 1996; Wong et al., 2008), insufficient psychological coping skills (Noh et al., 2005, 2007; van Winden, van Rijn, GJP, Oudejans, & Stubbe, 2020), low body mass index (Benson, Geiger, Eiserman, & Wardlaw, 1989), and an increase in training hours (Fuller, Moyle, & Minett, 2020) are significantly associated with higher risk of injury in pre-professional dancers (Kenny et al., 2016). There have been calls to better understand how to predict, prevent, and manage injuries in dancers (Bahr, 2009; Fuller et al., 2006; Liederbach et al., 2012).
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2020, Journal of Science and Medicine in SportCitation Excerpt :It is also to our knowledge one of few studies5,12 to report on subsequent injuries in pre-professional dance, and one of few studies9,26–31 to consider subsequent injuries using SIC.9,13 The medical attention injury incidence of 2.71 (95% CI:2.22, 3.20) per 1000 h was lower than that of Bronner and Bauer32 investigating pre-professional modern dancers, though higher than injury incidences reported in other studies4,5 on pre-professional ballet and contemporary dance cohorts, also using a medical attention injury definition. It is worth noting that the clinic available to students in this investigation, is complimentary, available once per week, which may influence the presentation of injuries.
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