Biopsychosocial Factors in Injury: From an Artists Perspective

Brittany N. Keefe LEAP Senior Study

Biopsychosocial Factors in Dance Injury

Table of Contents

Abstract.3 Preface...3 Introduction...4 Methods.5 Results...7 Discussion18 References20

Biopsychosocial Factors in Dance Injury

Abstract
A study was created using a survey and interviews to discern the impact of biopsychosocial factors on the incidence and rehabilitation of dance injuries. The survey had ninety-two, respondents reporting an injury affecting their participation in class or rehearsal for ten days or more. Of those, representing multiple dance genres from a national scope, the foot/ankle was the most prevalent site of injury. Using questions from established work-stress questionnaires, only 62% of the respondents reported feeling motivated at work, while 43% reported the need to hide their feelings while working. The results of the study pointed to perfectionist tendencies, lack of or underinsured healthcare access, and economic struggles being the primary sources of negative stress. When asked about income, 75% of the respondents reported wages low enough to qualify them at or below poverty level. The most conclusive finding from the survey was 73.4% of respondents stated troubles coping with their injury. Even with support, education, and assistance going through the process of injury, the majority of dancers struggle coping with being sidelined. Dance at an elite level is an all-encompassing experience; it is more than a job. As such, the entire institution of dance needs to support the role of the artist both physically and psychologically.

Preface
I am fortunate to have a limited history of injury from my 13 years as a professional dancer, but the first injury that prevented me from performing definitely had contributing psychological factors. This injury occurred when I joined a new ballet company, and was dealing with a new environment, colleagues, and direction. We were building up to a performance and after the morning rehearsals, my right calf felt tight and

Biopsychosocial Factors in Dance Injury stringy. The afternoon rehearsal brought an opportunity to dance the lead role in front of the entire company. I desired to prove that, although I was new, I deserved this role. At the end of the first dance, I felt my calf cramp. I still finished the dance, but I couldnt flex my foot. There were three more dances to do, so thinking it was just a cramp, I continued. I survived the run of the ballet, but couldnt stand or walk after. The next

morning, I still couldnt walk and went to the doctor to discover that I had torn my calf. I was afraid to tell anyone important, fearing it would prove that I wasnt capable of the role or would be replaced. In addition to the physical demands of the form, dancers commonly put many psychological stresses on their bodies, which contribute to the prominence of injuries. As I have continued in the field, I have been privy to witnessing many dance injuries. I have also personally known the people to whom these injuries happen, and, in many cases, have thought there must be some correlation between the stresses imposed by the job on the individual and the occurrence of the injury.

Biopsychosocial Factors in Dance Injury

Introduction
There are many epidemiological studies and research on the cost, occurrence, and contributing factors to sports and performing arts injuries (Garrick & Requa, 2005; Liederbach & Compagno, 2001; Thomas & Tarr, 2009). Unfortunately, the point where athleticism and art meet, that being dance, has a sparse database of research. Dance has fewer financial resources, but to keep the art form moving forward, there is a great need to support the study of psychological stresses on injuries. This research would serve to support better training and treatment for dancers and could potentially extend an artists career. Injury is an inevitable factor of a career in dance. Dance injuries stem from both intrinsic and extrinsic factors, such as: over training, repetition of similar movements, poor anatomical technique, fatigue, costumes, and slippery or hard surfaces. Injury can result in the loss of performances, career ascendance and income. Being injured can cause the dancer to feel worthless, depressed, or isolated (Hamilton, 2008; Mainwaring, Kerr, & Krasnow, 1993). Conversely, what if being sidelined from injury brings relief from competition? Perhaps the artist may desire an interruption in the constant perfectionist tendencies or a physical break from the rigors of training and performing. Some of the stresses and life circumstances present in a dancers life are unique to the field. These specific demands include the pressure of success for an upcoming performance, the attainment of better roles, the relationship to a teacher or choreographer, economic uncertainties in a fragile arts industry potentially leading to job loss, and maintaining an ideal aesthetic. The current study was created in an effort to deduce what

Biopsychosocial Factors in Dance Injury biopsychosocial factors may be present for a dancer, and if those factors could influence their potential for injury. Biopsychosocial is defined as the social, biological, and psychological aspects of illness in contrast with the biomedical aspects (Liederbach, 2010; Waddell, 2006). This study is administered from an artists perspective, versus a clinical one, in hopes that the artists would be more forthcoming in their response.

Methods
A nationwide survey was distributed to discern whether or not stresses of perfectionism, economic pressure, relationship troubles, and other psychological stresses contributed to injury. In conjunction, a study from the Harkness Center for Dance Injuries (Liederbach & Compagno, 2001) theorizes that stressors affect the preponderance of injury by disrupting attention, increasing muscular tension, and reducing motor coordination. The present study was retrospective, and relied on the participants memory of a particular injury over an undetermined time frame. The working definition of injury was any affliction keeping the dancer from full participation in class or rehearsal for ten days or more. The survey was administered through the Survey Monkey website for a period of two-and-a-half weeks. The link to the survey was marketed through: personal email contacts, personal healthcare relationships, a dance community newsletter based in Minneapolis, MN, a link on the DanceNYC website, word of mouth, and the social networking tool Facebook.

Biopsychosocial Factors in Dance Injury

Results
Of the 113 completed responses, ninety-two respondents were determined to have an injury fitting the working definition. Of those ninety-two completed responses, 85.9% considered themselves professional dancers, 6.5% were college students, 3.3% were student dancers 18 years or younger, and 4.3% had another affiliation with dance. The participants were asked what were their primary genres of dance and 76.1% responded ballet, 32.6% responded modern, 9.8% responded musical theater and jazz, 2.2% responded folk/ethnic, and 9.8% responded with other forms (see figure 1). Although the diversity of forms in the survey was not broad, the demographics demonstrated a response coast-to-coast and represented over 27 states.

Figure 1- Primary dance genres.

In accordance with other studies (Liederbach, 2010), the foot/ankle was reported in the survey to be the highest occurring injury. A total of 75 % of the dancers reported

Biopsychosocial Factors in Dance Injury having a significant injury to this region. Subsequently, the back at 47.8%, the knee at 38%, the shoulder and the lower leg received 17.4%, and the neck totaled 16.3% of

reported injuries (see figure 2). Respondents submitted other injuries, not in the multiplechoice options: broken rib, strained intercostals muscle, pulled hamstring, groin, hand, and concussion.

Figure 2- Site of Injuries by Occurrence.

Numerous questions were created to determine the level of trust and empowerment the dancer felt over his/her career at the time of injury. The employment questions were adapted from the General Nordic (Kristensen, Hannerz, Hogh, & Borg, 2005) and Copenhagen PSychOsocial (Lindstrom et al., 2000) standard questionnaires for work-related stresses. The former aimed at assessing psychosocial risks, and the latter determined areas of work-related stresses. These questions discerned whether or not the

Biopsychosocial Factors in Dance Injury dancers felt they had control over their working/dancing environment. Ergonomic researcher Deeney & OSullivan (2009) observed, There is growing evidence that psychological risk factors exacerbate the effects of physical risk factors thereby increasing the risk and severity of musculoskeletal disorders (p. 245). Questioning the dancers feelings about their work could provide insight into their psychological state, which potentially affects physical injury risk.

When asked to reflect about their working environment at the time of injury, only 62% of the dancers reported feeling motivated in their work. For such a short-lived, yet, time and energy-consuming career, one would hope the degree of motivation would be higher. Young dancers rarely consider the option of pursuing activities other than dancing. Often this becomes a sacrifice of growing up without normal developmental milestones such as graduation ceremonies, prom, football games, and parties with friends. While these sacrifices for training may be true of any elite athlete, dance provides little monetary compensation, so the trade-off is imbalanced. When asked about emotional involvement in their place of work, 81.5% reported positively stating they were emotionally involved. However, it seems that this involvement is not completely transparent, because 43.5% of the dancers reported the need to hide their feelings at work. This shows a majority of the dancers have an emotional connection to their work, but are not always able to express themselves. Certainly, in any group endeavor, there is some degree of compromise. But, this finding suggests a need for greater empowerment of the artists through open communication channels and strong leadership. In accordance, the survey also showed the majority of the

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respondents (46.7%) felt that only sometimes they had a large degree of influence over their work. The lack of influence dancers feel over their work may be based in the hierarchical and dogmatic approach with which dance is taught. Students are first taught the basic positions and movements of dance through emulation. Eventually, as the student becomes more skilled, the dancer moves and is corrected in their experience. This correction is a criticism and carries the expectation that the movement will then be fixed. In a sort of reverse psychology, the dancer anticipates and craves the attention of the correction. This criticism becomes an important aim in assessing progress. In an interview with professional dancer Michelle deFemery, she supposes, Dance can be so negative.we see corrections/criticisms as compliments and spend so much time picking things apart in a mirror (M. deFemery, personal communication, December 29, 2010). If the instructing and leading of dance work instilled a higher degree of empowerment in its dancers, the dancers could see their degree of influence over the artistic product more clearly. The dancers quest to maintain peak physical condition and performance is a given stress of the art, but obviously dancers experience other daily struggles, which may influence their susceptibility of injury. A study through the Stanford University (Adam, Brassington, Steiner, & Matheson, 2004) assessed stress and self-esteem over an eightmonth period in thirty-nine female university students. At the end of the study, there was a strong correlation between the psychological stresses and total injury duration. There was also a distinction found between the influences of positive stress and negative stress. Negative events connected with longer injury duration, whereas positive events shortened

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the length of rehabilitation. These results paralleled other sports studies on the influence of psychological factors on injury. Specifically, Astrid Junge (2000) reported, it can be supposed that psychological stressors modify the emotional state, especially characteristics such as vigor, concentration, or attention (p. S-14). Dance requires all of these attributes for peak performance. Performance-decreasing external stressors can stem from both unique job demands and struggles for survival. Some of the sources reported in the present dancer survey included low income, feelings of inadequacy, lack of insurance, new job, and struggles with a boss. The American College of Sports Medicine recently made a public statement to various coaches and trainers stating stressed-out athletes are at least twice as susceptible to injury than their non-stressed peers (Hamilton, 2008, p 138.). Low income is a known issue for those pursuing a career in dance. Income is rarely steady and may include periods of unemployment. In the current survey the primary average monthly income was between $1000-$2000 for 28.3% of the dancers. The next highest percentage from respondents was 25% reported earnings in excess of $2000 per month; the next total being 22.8% of dancers earning $0-$250 per month (see figure 3). While the survey was limited in its ability to decipher earnings in excess of $2000 per month, even without the highest category, it demonstrated 75% of the respondents are living at or below the poverty level. The survey was conducted in the fall, a typically more lucrative season, so it should be noted that the results might be affected. The summer and late winter are times of more unemployment or fewer jobs. Still, these statistics demonstrate the reality of low income when considering that 85.9% of the respondents considered themselves professional dancers.

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Figure 3- Average monthly income.

The economic circumstances affect both the organizations and individuals contributing to dance. It is often difficult for small organizations to afford insurance for their dancers, let alone prevention or treatment programs. A study of 100 dance companies in the bay area (Garrick & Requa, 2005) of San Francisco, California, found that less than half of the 192 dancers included were covered by workers compensation. When the largest ballet company was excluded from the study, less than 10.2% of the dancers had any access to regular health insurance coverage (p. 81). The costs of healthcare then fall onto the individual dancer, most of who are already living and working just above the poverty level. In this study, 25% of the respondents reported that not having insurance or being under-insured, was a stress in their lifestyle.

Biopsychosocial Factors in Dance Injury One of the dancers from the survey reported their struggle with insurance and how it directly related to the condition of their body. In an open-ended question the participant responded, I am currently still dealing with this injury. It has been very

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frustrating and I have not had the extra money or health care benefits to really take care of it. I have been dancing with pain for two months now. If I had insurance or savings I would be making an appointment with a doctor. While conventional wisdom would suggest the dancer should rest to help to heal an injury, it is possible this dancer cannot afford to stop dancing. Additionally, rest alone may not restore his/her function. In the present study, inadequate healthcare affects 33.3% of respondents in their delay of treatment paired with another 36% who saw money as an obstacle to seeking help. Workers Compensation is another avenue for treatment of injuries for the dancers contracted with larger dance companies. However, this is not without stress either for the organization or the individual. The premiums of insurance are often unrealistically high. Over the course of a five-year period the Boston Ballet generated a study (Solomon, Solomon, Lyle, & McGray,1999) on its insurance premiums and the potential savings that could be attained from supplementing care through other avenues. The impetus of the study was a proposed Workers Compensation Insurance premium of over $792,000. Through time and additional services, the premium was reduced to an average of $389,262 per season for the 60+ dancers (p. 168). If they can even afford to offer insurance, smaller organizations do not always have the resources to provide alternative treatment nor can they afford to have an increase in their premiums. In this survey, one dancer mentioned fighting with his/her employer to get Workers

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Compensation Insurance coverage for a ruptured ACL. It is likely this fight for care both delayed treatment and prolonged the rehabilitation. Fortunately, results from the survey demonstrated an expeditious path to treatment and diagnosis. In fact, only 2.2% of respondents did not seek help. Half the respondents did find medical assistance within the day of injury. Again this is in the context of injuries, which are defined as something keeping a dancer from full participation in class, rehearsal or performance. Additionally, 65% of injuries in dance result from repetitive overuse, or micro trauma, that can eventually progress to chronic injury (Liederbach, 2010). These types of injuries can often be prevented if caught early on, if the dancer has access to treatment and is willing to seek help. Physical Therapy Assistant Shannon Casati reports in her work with dancers there are still many injuries dancers are afraid to acknowledge or treat. Mrs. Casati supposes, There is often fear associated with stopping and taking care of an injury in the first place. Dancers dont want to seem vulnerable to a colleague or a boss Sometimes a dancer will decide that their injury is healed because it is more convenient (S. Casati, personal communication, December 28, 2010). It can be assumed these injuries are not yet the type to fulfill the working definition of injury, but it is possible they can develop into a more serious or chronic injury. The dancers dependency on how others view them creates a plethora of psychosocial issues. Perfectionism dominates the field of dance, which contributes constructively to a dancers drive toward constant work and technical growth. But more often, perfectionism may lead to a dancers decreased sense of self worth or control over his/her abilities. This can lead to eating disorders in an attempt to regain control over a career and the

Biopsychosocial Factors in Dance Injury primary tool- the body (Hamilton, 2008). Especially within the path of classical ballet, the ideal aesthetic is already prescribed. Dr. Linda Hamilton, the renowned dance psychologist has done significant research on eating disorders. She asserts that some of the stress stems from the reality that only 4% of the population naturally achieves the

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ideal ballet body type, the rest need to work at it (L. Hamilton, personal communication, November 13, 2010). That does not mean a stressful nor unhealthy end, but often the dancer takes it upon his/herself to meet the perceived aesthetic body type without knowing how to do so, or to whom to turn for help. From a study of a group of South African ballet dancers (van Staden, Myburgh, & Poggenpoel, 2009), one professional reported, When I was younger, when I just came into the company, there were times that I didnt allow myself to eat anymore. I wanted to look like the others (p. 22). It is not wrong for a dancer to want to fit in, but the safe and healthy means must be established for dancers to attain longevity and a life beyond dance. Another maladaptive sense of perfectionism can result in a feeling of inadequacy in their dancing. From the study of South African classical ballet dancers (van Staden, Myburgh, & Poggenpoel, 2009), one of the principal dancers commented, Dancers are their [own] worst enemies, because you get off stage and you could never be perfect. You will never ever be satisfiednever, (p.21). This dissatisfaction with oneself can create a negative psychological stress, which has been linked to affecting the onset of injury (Mainwaring, Kerr, & Krasnow, 1993). Perfectionism can also make a dancer fear showing vulnerability, or they often perceive there is no time for injury. It can lead a dancer to continue pushing in rehearsal or performance when their body is giving clear indications for the need of rest. A study

Biopsychosocial Factors in Dance Injury published in the Journal of Dance Medicine (Liederbach & Compagno, 2001) detailed how fatigue related to injury. In the study, 79% of injured dancers reported having danced in excess of 5 hours prior to injury, (p. 118). Similarly, all of the qualified

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healthcare professionals interviewed in this study cited stubborn dancers pushing beyond their bodies warnings. Dr. Hamilton mentioned that sometimes teachers are also responsible for forcing students to work beyond the bodys limits. She stressed the importance of the student/teacher (or student/parent) relationship. She hypothesized sometimes pleasing the teacher or parent is so strong that the early warning signs of injury go unnoticed in pursuing the dream job or role. The dancer feels pressured to work through pain and abuse, which is ultimately sabotaging (L. Hamilton, personal communication, November 13, 2010). While perfectionism is a known psychological stress for dancers, it is also a key factor in the success of a dancer. However, an important determining factor of how likely an injury will occur because of stress or perfectionism lies in how a dancer responds, or what mechanisms they have to help cope. The most conclusive finding from the survey was that 73.4% of respondents stated troubles coping with their injury. Even with support, education, and assistance going through the process of injury, the majority of dancers struggle coping with being sidelined. Assistance during rehabilitation was primarily sought from family and friends, with 92% of the respondents citing outside aid. Other sources included spirituality and meditation. Additionally, 62% of the dancers reported that the injury negatively affected other aspects of their lives. Clearly, preventative measures would be well warranted for helping dancers to deal with injury,

Biopsychosocial Factors in Dance Injury but more pressing is the need for resources to aid an injured dancer to deal with the implications of being injured. During the interviews, it was repeatedly mentioned that subsequent injuries are

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often easier psychologically than the first. Michelle deFemery utilized the knowledge she had gained from her first injury as a coping mechanism to ease the fear and frustration of the second injury. Senior Physical Therapist Faye Dilgen, PT, DPT of the Harkness Center for Dance Injuries correlates, Unfortunately, I think the dancers who deal best with an injury have been injured before. They know what to expect, they know how to rehab their injury and respect the time frame of healing. Dancers who have never been injured may have expectations that are not realistic - the learning curve is much steeper (F. Dilgen, personal communication, December 13, 2010). A pointed question was asked in all of the interviews about the creation of injury, which couldnt be shown through the survey. The question read: Have you ever considered that injury might be self-created or even an opportunity for psychological healing? None of the respondents thought that a dancer would knowingly injure him/herself but they all noted the possibility of self-created injury. Things mentioned included the opportunity for release from a stressful lifestyle, time-away from a negative environment, an opportunity to focus on other aspects of life, and even physical time off. Faye Dilgen replied, There are dancers who prefer to have an injury especially if they are looking for attention and want to keep coming to PT as this is a person who listens to them, touches them, and gives them undivided attention for a treatment session. This can facilitate psychological healing, but I have rarely seen an instance when there was not true injury (F. Dilgen, personal communication, December 13, 2010). One dancer

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agreed that while there may be some need for attention, not unlike an eating disorder, the injury was probably already a potential; a chicken before the egg scenario (M. deFemery, personal communication, December 29, 2010). The question leads back to the need for attention and a high degree of care for a dancer to consistently achieve an elite level of performance.

Discussion
Given that the study relied on the respondents recall, it can be questioned whether the results are affected by the dancers current physical condition or state of mind. In recording the artists psyche by recollection, this study may have positive bias. However, the data correlates to existing research about types of injury sustained in the field, and it further exposed the need for care of the artists. Perhaps also the results would prove different if the format was more personal, such as an interview type format, versus an online survey. Regardless to the surveys imperfections, it is clear dance at an elite level is an all-encompassing experience; it is more than a job. When a dancer cant do their job, they often have troubles dealing with the rest of their life psychologically and financially. The results of the survey demonstrated a strong link to coping strategies and injury. There is a need for future studies to discern what programs best serve dancers coping with injury and how the dancers find such resources. The repeated mention of subsequent injuries being easier to cope with also demonstrates an avenue for future studies. Dancers do not enter the field anticipating financial stability. But how can schools or companies aide their artists with managing finances and dealing with lost income

Biopsychosocial Factors in Dance Injury during injury? Similarly, what resources can be made available to dancers to be able to

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afford and utilize healthcare? Without these resources dancers are less able to deal with injury. The entire institution of dance needs to support the role of the artist both physically and psychologically. This support comes in the form of readily available heath care resources, sympathetic directors and teachers, healthy schedules that maximize exertion when the dancer is warm and not fatigued, and appropriate spaces and surfaces for the dancers to safely train and perform. Until we empower and support the whole dancer, injuries will continue to plague the artists more than necessary.

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References
Adam, M., Brassington, G., Steiner, H., & Matheson, G. (2004). Psychological factors associated with performance- limiting injuries in professional dancers. Journal of Dance Medicine and Science, 8(2), 43-46. Byhring, S., Bo, K. (2002). Musculoskeletal injuries in the Norwegian National Ballet: a prospective cohort study. Scandinavian Journal of Medicine and Science in Sports, 12, 365-370. Deeney, C., & O'Sulivan, L. (2009). Work related psychosocial risks and musculoskeletal disorders: potential factors, causation and evaluation methods. Scandinavian Journal of Work, Environment and Health, 239-248. Garrick, J., & Requa, R. (2005). Do professional dancers have medical insurance? company-provided medical insurance for professional dancers. Journal of Dance Medicine and Science, 9(3&4), 81-83. Hamilton, L., Hamilton, W., Meltzer, J., Marshall, P., Molnar, M. (1989) Personality, stress and injuries in professional ballet dancers. The American Journal of Sports Medicine, 17:2, 263-267. Hamilton, L. (2008) The Dancers Way: The New York City Ballet Guide to Mind, Body and Nutrition. New York: St Martins Griffin. Junge, A. (2000). The influence of psychological factors on sports injuries: review of literature. The American Journal of Sports Medicine, 28(5), S10-S15. Kristensen, T., Hannerz, H., Hogh, A., & Borg, V. (2005). The copenhagen psychosocial questionnaire- a tool for the assessment and improvement of the psychosocial work environment. Scandinavian Journal of Work, Environment and Health, 31(6), 438-449. Liederbach, M. (2010). Injuries in dance: biopsychosocial considerations. Power point presentation at the Harkness Center for Dance Injuries principles of dance CME course. July 15, 2010. Liederbach, M., & Compagno, J. (2001). Psychological aspects of fatigue-related injuries in dancers. Journal of Dance Medicine and Science, 5(4), 116-120. Lindstrom, K., Elo, A., Skoggard, A., Dallnee, M., Hattinen, F., Knardahl, S., Orhede, E. & Gamberale, F. (2000). User guide to qps nordic: general nordic questionnaire for psychological and social factors at work. Nordic Council of Ministers, 8(2), 239-248.

Biopsychosocial Factors in Dance Injury Mainwaring, L., Kerr, G., & Krasnow, D. (1993). Psychological correlates of dance injuries. Medical Problems of Performing Artists, 3-6. Solomon, R., Solomon, J., Lyle, J., & McGray, E. (1999). The "cost" of injuries in a professional ballet company. Medical Problems of Performing Artists, 164-170. Thomas, H., Tarr, J. (2009). Dancers perceptions of pain and injury - positive and negative effects. Journal of Dance Medicine and Science, 13(2), 51-59. Waddell, G. (2006). Preventing incapacity in people with musculoskeletal disorders. British Medical Bulletin, 77 & 78, 56- 69.

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van Staden, A., Myburgh, C., & Poggenpoel, M. (2009). A psycho-educational model to enhance the self-development and mental health of classical dancers. Journal of Dance Medicine and Science, 13(1), 20-28.

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