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This article is an examination on the female athlete triad and suggestions for its management

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a definition of amenorrhea by MD Melissa Conrad Stoppler

Melissa Conrad Stoppler, MD. (2018). Secondary and Primary Amenorrhea Definition, Causes, Treatment. [online] MedicineNet. Available at: https://www.medicinenet.com/amenorrhea/article.htm [Accessed 12 Nov. 2018].

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Amenorrhea facts

Amenorrhea refers to the absence of menstrual periods; it may be either primary (meaning a woman never developed menstrual periods) or secondary (absence of menstrual periods in a woman who was previously menstruating).

Genetic or inborn conditions are the most common causes of primary amenorrhea.

Amenorrhea may result from disorders of the ovaries, pituitary gland, hypothalamus, or uterus.

Intensive exercising, extreme weight loss, physical illness, and stress can all result in amenorrhea.

Amenorrhea is a symptom and not a disease in itself, so amenorrhea can be prevented only to the extent that the underlying cause can be prevented.

Infertility and possible bone loss (osteoporosis) are complications of amenorrhea.

Treatments may include surgical correction of anatomical abnormalities, medications or hormone therapies, and treatment of any underlying conditions responsible for amenorrhea.

The outlook for amenorrhea varies according to the cause of the amenorrhea.

Definition of primary and secondary amenorrhea

Amenorrhea is the medical term for the absence of menstrual periods, either on a permanent or temporary basis. Amenorrhea can be classified as primary or secondary. In primary amenorrhea, menstrual periods have never begun (by age 16), whereas secondary amenorrhea is defined as the absence of menstrual periods for three consecutive cycles or a time period of more than six months in a woman who was previously menstruating.

The menstrual cycle can be influenced by many internal factors such as transient changes in hormonal levels, stress, and illness, as well as external or environmental factors. Missing one menstrual period is rarely a sign of a serious problem or an underlying medical condition, but amenorrhea of longer duration may signal the presence of a disease or chronic condition.

What causes amenorrhea?

The normal menstrual cycle occurs because of changing levels of hormones made and secreted by the ovaries. The ovaries respond to hormonal signals from the pituitary gland located at the brain's base, which, in turn, is controlled by hormones produced in the hypothalamus of the brain. Disorders that affect any component of this regulatory cycle can lead to amenorrhea. However, a common cause of amenorrhea in young females sometimes overlooked or misunderstood by the individual and others, is an undiagnosed pregnancy. Amenorrhea in pregnancy is a normal physiological function. Occasionally, the same underlying problem can cause or contribute to either primary or secondary amenorrhea. For example, hypothalamic problems, anorexia or extreme exercise can play a major role in causing amenorrhea depending on the person's age and if she has experienced menarche.

Primary amenorrhea

Primary amenorrhea is typically the result of a genetic or anatomic condition in young females that never develop menstrual periods (by age 16) and is not pregnant. Many genetic conditions that are characterized by amenorrhea are circumstances in which some or all of the normal internal female organs either fail to form normally during fetal development or fail to function properly. Diseases of the pituitary gland and hypothalamus (a region of the brain important for the control of hormone production) can also cause primary amenorrhea since these areas play a critical role in the regulation of ovarian hormones.

Gonadal dysgenesis, a condition in which the ovaries are prematurely depleted of follicles and oocytes (egg cells), leads to premature failure of the ovaries. It is one of the most common cases of primary amenorrhea in young women.

Another genetic cause is Turner syndrome, in which women are lacking all or part of one of the two X chromosomes normally present in the female. In Turner syndrome, the ovaries are replaced by scar tissue and estrogen production is minimal, resulting in amenorrhea. Estrogen-induced maturation of the external female genitalia and sex characteristics also fails to occur in Turner syndrome.

Other conditions that may be causes of primary amenorrhea include androgen insensitivity (in which individuals have XY (male) chromosomes but do not develop the external characteristics of males due to a lack of response to testosterone and its effects), congenital adrenal hyperplasia, and polycystic ovary syndrome ( PCOS).

Secondary amenorrhea

Pregnancy is an obvious cause of amenorrhea and is the most common reason for secondary amenorrhea. Further causes are varied and may include conditions that affect the ovaries, uterus, hypothalamus, or pituitary gland.

Hypothalamic amenorrhea is due to a disruption in the regulator hormones produced by the hypothalamus in the brain. These hormones influence the pituitary gland, which in turn sends signals to the ovaries to produce the characteristic cyclic hormones. A number of conditions can affect the hypothalamus:

Other types of medical conditions can cause secondary amenorrhea:

tumors or other diseases of the pituitary gland that lead to elevated levels of the hormone prolactin (which is involved in milk production) also cause amenorrhea due to the elevated prolactin levels;

hypothyroidism;

elevated levels of androgens (male hormones), either from outside sources or from disorders that cause the body to produce too high levels of male hormones;

ovarian failure (premature ovarian failure or early menopause);

polycystic ovary syndrome (PCOS); and

Asherman's syndrome, a uterine disease that results from scarring of the uterine lining following instrumentation (such as dilation and curettage) of the uterine cavity to manage postpartum bleeding or infection.

Post-pill amenorrhea

Women who have stopped taking oral contraceptive pills should experience the return of menstruation within three months after discontinuing pill use. Previously, it was believed that birth control pills increased a woman's risk of amenorrhea following use of the pill, but this has been proven not to be the case. Women who do not resume menstruation after three months have passed since oral contraceptive pills were stopped should be evaluated for causes of secondary amenorrhea.

What are the symptoms of amenorrhea?

Primary or secondary amenorrhea (respectively) is considered to be present when a girl has:

not developed menstrual periods by age 16; or

a woman who has previously had a menstrual cycle stops having menstrual periods for three cycles in a row, or for a time period of six months or more and is not pregnant.

Other symptoms and signs may be present, which are highly variable and depend upon the underlying cause of the amenorrhea. For example, symptoms of hormonal imbalance or male hormone excess can include irregular menstrual periods, unwanted hair growth, deepening of the voice, and acne. Elevated prolactin levels as a cause of amenorrhea can result in galactorrhea (a milky discharge from the nipples that is not related to normal breastfeeding).

When should I seek medical care for amenorrhea?

It is always appropriate to seek medical attention for amenorrhea. Amenorrhea that is not related to pregnancy or the menopausal transition (time when there has been no menstrual periods for 12 consecutive months and no other biological or physiological cause can be identified, and the female is at the end of her biologically-determined child bearing years) should be further investigated to rule out serious conditions that may result in amenorrhea.

How is amenorrhea diagnosed?

The diagnosis of amenorrhea requires a careful medical history to document the presence of amenorrhea as well as any other coexisting medical conditions that may be the cause of amenorrhea. A physical examination, including a pelvic examination is also performed.

Depending upon the results of the history and physical examination further diagnostic tests may be ordered. Blood tests may be ordered to examine the levels of ovarian, pituitary, and thyroid hormones. These tests may include measurements of prolactin, follicle-stimulating hormone (FSH), estrogen, thyrotropin, dehydroepiandrosterone sulfate (DHEA-S), and testosterone. For some individuals, a pregnancy test is the first test performed.

Imaging studies, such as ultrasound, X-ray, and CT or MRI scanning may also be recommended in certain individuals to help establish the cause of amenorrhea.

What is the treatment for amenorrhea?

Treatment of primary and secondary amenorrhea is determined by the specific cause. Treatment goals can be to relieve symptoms of hormonal imbalance, establish menstruation, prevent complications, and/or to achieve fertility, although not all of these goals can be achieved in every case.

In cases in which genetic or anatomical abnormalities are the cause of amenorrhea (typically primary amenorrhea), surgery may be recommended.

Hypothalamic amenorrhea that is related to weight loss, excessive exercise, physical illness, or emotional stress can typically be corrected by addressing the underlying cause. For example, weight gain and reduction in intensity of exercise can usually restore menstrual periods in women who have developed amenorrhea due to weight loss or overly intensive exercise who do not have additional causes of amenorrhea. In some cases, nutritional counseling may be of benefit.

In premature ovarian failure, hormone therapy may be recommended both to avoid the unpleasant symptoms of estrogen depletion as well as prevent complications (see below) of low estrogen level such as osteoporosis. This may consist of oral contraceptive pills for those women who do not desire pregnancy or alternative estrogen and progesterone medications. While postmenopausal hormone therapy has been associated with certain health risks in older women, younger women with premature ovarian failure can benefit from this therapy to prevent bone loss.

Women with PCOS (polycystic ovary syndrome) may benefit from treatments that reduce the level or activity of male hormones, or androgens.

Dopamine agonist medications such as bromocriptine ( Parlodel) can reduce elevated prolactin levels, which may be responsible for amenorrhea. Consequently, medication levels may be adjusted by the person's physician if appropriate.

Assisted reproductive technologies and the administration of gonadotropin medications ( drugs that stimulate follicle maturation in the ovaries) can be appropriate for women with some types of amenorrhea who wish to attempt to become pregnant.

While many companies and individuals have marketed herbal therapies as a treatment for amenorrhea, none of these have been conclusively proved to be of benefit. These therapies are not regulated by the U.S. FDA and the quality of herbal preparations is not tested. Herbal remedies have been associated with serious and even fatal side effects in rare cases, and some preparations have been shown to contain high levels of toxins. Before deciding to take a natural or alternative remedy for amenorrhea, it is wise to seek the advice of your health care practitioner.

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What are the complications of amenorrhea?

Infertility is a significant complication of amenorrhea for women who desire to become pregnant. Osteopenia (a reduction in bone density) or osteoporosis is a complication of low estrogen levels, which may occur with prolonged amenorrhea. Other complications of amenorrhea depend upon the underlying cause of the amenorrhea.

Can amenorrhea be prevented?

Amenorrhea is a symptom and not a disease in itself. Therefore, amenorrhea can be prevented only to the extent that the underlying cause can be prevented. For example, amenorrhea that results from genetic or inborn conditions cannot be prevented. On the other hand, amenorrhea that results from self-imposed stringent dieting or intensive exercise is typically preventable.

What is the outlook for a woman suffering from amenorrhea?

The outlook for amenorrhea varies widely and is dependent upon the cause of the amenorrhea. Hypothalamic amenorrhea that is a result of stress, exercise, or weight loss generally can be corrected if the responsible factors can be corrected. Medical and hormonal therapies can be of great benefit in preventing unpleasant side effects or complications of amenorrhea in many women.

Medically reviewed by Wayne Blocker, MD; Board Certified Obstetrics and Gynecology

REFERENCES:

Current evaluation of amenorrhea. Fertil Steril. 2006 Nov;86(5 Suppl):S148-55.

Davis AR; Kroll R; Soltes B; Zhang N; Grubb GS; Constantine GD. Occurrence of menses or pregnancy after cessation of a continuous oral contraceptive. Fertil Steril. 2008 May;89(5):1059-63.

MedscapeReference.com. Amenorrhea, Secondary.

MedscapeReference.com. Amenorrhea, Primary.

Complete List

Top Amenorrhea Related Articles

Ectopic Pregnancy

An ectopic pregnancy is a pregnancy located outside the inner lining of the uterus. The majority of ectopic pregnancies occur in the Fallopian tube. Signs and symptoms of an ectopic pregnancy may include:

Abdominal pain

Lack of menstrual period (amenorrhea)

Vaginal bleeding

Fainting

Dizziness

Low blood pressure

Treatment options for an ectopic pregnancy include observation, medication, or surgery.

Hormone Therapy

Estrogen therapy, estrogen/progestin therapy, and hormone therapy are terms that refer to the administration of estrogen or estrogen/progestin for the purpose of suppressing hot flashes. Side effects of hormone therapy include:

headaches,

nausea,

breast pain,

blood clots,

breast cancer,

heart disease,

abnormal vaginal bleeding,

stroke,

and uterine cancer.

Polycystic Ovary

Polycystic ovarian syndrome (PCOS), also known by the name Stein-Leventhal syndrome, is a hormonal problem that causes women to have a variety of symptoms including irregular or no menstrual periods, acne, obesity, and excess hair growth. Treatment of PCOS depends partially on the woman's stage of life and the symptoms of PCOS.

Pregnancy Planning (Preparing for Pregnancy)

Pregnancy planning is an important step in preparation for starting or expanding a family. Planning for a pregnancy includes:

Taking prenatal vitamins

Eating healthy for you and your baby

Disease prevention (for both parents and baby) to prevent birth defects and infections

Avoiding certain medications that may be harmful to your baby

How much weight gain is healthy

Exercise safety and pregnancy

Travel during pregnancy

Ultrasound

Ultrasound (and ultrasonography) is imaging of the body used in the medical diagnosis and screening of diseases and conditions such as:

TIAs,

stroke,

aneurysm's,

heart valve irregularities,

carotid artery disease,

heart disease,

gallstones,

kidney stones,

liver disease,

diseases of the female reproductive, and

diseases of the male reproductive organs.

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Secondary and Primary Amenorrhea Definition, Causes, Treatment

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Amenorrhea (including hypothalmic amenorrhea) is a condition in which there is an absense of menstrual periods in a woman. Treatment options differ for both primary and secondary amenorrhea. We go over the definition of amenorrhea, causes, and treatment options for amenorrhea.

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4.The Female Athlete Triad: Recommendations for Management

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4.The Female Athlete Triad: Recommendations for Management

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a journal of recommendations and a description of the female athlete triad

Chamberlain, R. (2018). The Female Athlete Triad: Recommendations for Management. [online] Aafp.org. Available at: https://www.aafp.org/afp/2018/0415/p499.html [Accessed 12 Nov. 2018].

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The Female Athlete Triad: Recommendations for Management

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Family physicians should be familiar with recommendations regarding the female athlete triad, because prevention and early intervention can significantly reduce morbidity from this disorder.

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This article discusses the "problems Caused by Extreme Exercise and Dieting

OrthoInfo (2018). Female Athlete Triad: Problems Caused by Extreme Exercise and Dieting - OrthoInfo - AAOS. [online] Available at: https://orthoinfo.aaos.org/en/diseases--conditions/female-athlete-triad-problems-caused-by-extreme-exercise-and-dieting/ [Accessed 12 Nov. 2018].

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Female Athlete Triad: Problems Caused by Extreme Exercise and Dieting

Sports and exercise are healthy activities for girls and women of all ages. Occasionally, a female athlete who focuses on being thin or lightweight may eat too little or exercise too much. Doing this can cause long-term damage to health, or even death. It can also hurt athletic performance or make it necessary to limit or stop exercise.

Three interrelated illnesses may develop when a girl or young woman goes to extremes in dieting or exercise. Together, these conditions are known as the "female athlete triad."

The three conditions are:

Disordered eating
Abnormal eating habits (i.e., crash diets, binge eating) or excessive exercise keeps the body from getting enough nutrition.

Menstrual dysfunction
Poor nutrition, low calorie intake, high-energy demands, physical and emotional stress, or low percentage of body fat can lead to hormonal changes that stop menstrual periods (amenorrhea).

Premature osteoporosis (low bone density for age)
Lack of periods disrupts the body's bone-building processes and weakens the skeleton, making bones more likely to break.

Females in any sport can develop one or more parts of the triad. At greatest risk are those in sports that reward being thin for appearance (such as figure skating or gymnastics) or improved performance (such as distance running or rowing).

Fashion trends and advertising often encourage women to try to reach unhealthy weight levels. Some female athletes suffer low self-esteem or depression, and may focus on weight loss because they think they are heavier than they actually are. Others feel pressure to lose weight from athletic coaches or parents.

Female athletes should consider these questions:

Are you dissatisfied with your body?

Do you strive to be thin?

Do you continuously focus on your weight?

If the answers are yes, you may be at risk for developing abnormal patterns of eating food (disordered eating), which can lead to menstrual dysfunction and early osteoporosis.

Eating a balanced diet is especially important during teenage years when our bodies are building the bone we will need through life.

Recognizing the female athlete triad is the first step toward treating it. See your doctor right away if you miss several menstrual periods, get a stress fracture in sports, or think you might have disordered eating.

Give the doctor your complete medical history, including:

What you do for physical activity and what you eat for nutrition.

How old you were when you began to menstruate and whether you usually have regular periods.

If you are sexually active, use birth control pills, or have ever been pregnant.

If you have ever had stress fractures or other injuries.

Any changes (up or down) in your weight.

Any medications you are taking or symptoms of other medical problems.

Family history of diseases (i.e., thyroid disease, osteoporosis).

Factors that cause stress in your life.

Your doctor will give you complete physical examination and may use laboratory tests to check for pregnancy, thyroid disease, and other medical conditions. In some cases, a bone density test will be recommended.

Treatment for female athlete triad often requires help from a team of medical professionals including your doctor (pediatrician, gynecologist, family physician), your athletic trainer, a nutritionist, and a psychological counselor.

A psychological counselor is essential for treating athletes with disordered eating.

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Female Athlete Triad: Problems Caused by Extreme Exercise and Dieting - OrthoInfo - AAOS

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Female Athlete Triad: Problems Caused by Extreme Exercise and Dieting Sports and exercise are healthy activities for girls and women of all ages. Occasionally, a female athlete who focuses on being thin or lightweight may eat too little or exercise too much. Doing this can cause long-term damage to health, or even death.

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An overview of osteoporosis "signs, symptoms treatment "

Catherine Burt Driver, M. (2018). Osteoporosis Treatment, Signs & Symptoms. [online] eMedicineHealth. Available at: https://www.emedicinehealth.com/osteoporosis/article_em.htm [Accessed 15 Nov. 2018].

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What Is Osteoporosis?

Osteoporosis is a disease characterized by low bone mass and loss of bone tissue that may lead to weak and fragile bones.

If you have osteoporosis, you have an increased risk for fractured bones (broken bones), particularly in the hip, spine, and wrist.

Osteoporosis is often considered to be a condition that frail elderly women develop. However, the damage from osteoporosis begins much earlier in life.

Because peak bone density is reached at approximately 25 years of age, it is important to build strong bones by that age, so that the bones will remain strong later in life. Adequate calcium intake is an essential part of building strong bones.

In the United States, many people already have osteoporosis. A large number of people also have low bone mass that places them at an increased risk for developing osteoporosis. As our population ages, these numbers will increase.

A majority of those with osteoporosis are women. Of people older than 50 years of age, one in two women and one in eight men are predicted to have an osteoporosis-related fracture in their lifetime.

Significant risk has been reported in people of all ethnic backgrounds. White and Asian racial groups, however, are at greatest risk.

The image on the left shows decreased bone density in osteoporosis. The image on the right shows normal bone density. Click to view larger image.

What Causes Osteoporosis?

Osteoporosis occurs when there is an imbalance between new bone formation and old bone resorption. The body may fail to form enough new bone, or too much old bone may be reabsorbed, or both. Two essential minerals for normal bone formation are calcium and phosphate. Throughout youth, the body uses these minerals to produce bones. Calcium is essential for proper functioning of the heart, brain, and other organs. To keep those critical organs functioning, the body reabsorbs calcium that is stored in the bones to maintain blood calcium levels. If calcium intake is not sufficient or if the body does not absorb enough calcium from the diet, bone production and bone tissue may suffer. Thus, the bones may become weaker, resulting in fragile and brittle bones that can break easily.

Usually, the loss of bone occurs over an extended period of years. Often, a person will sustain a fracture before becoming aware that the disease is present. By then, the disease may be in its advanced stages and damage may be serious.

The leading cause of osteoporosis is a lack of certain hormones, particularly estrogen in women and androgen in men. Women, especially those older than 60 years of age, are frequently diagnosed with the disease. Menopause is accompanied by lower estrogen levels and increases a woman's risk for osteoporosis. Other factors that may contribute to bone loss in this age group include inadequate intake of calcium and vitamin D, lack of weight-bearing exercise, and other age-related changes in endocrine functions (in addition to lack of estrogen).

Other conditions that may lead to osteoporosis include overuse of corticosteroids ( Cushing syndrome), thyroid problems, lack of muscle use, bone cancer, certain genetic disorders, use of certain medications, and problems such as low calcium in the diet.

The following are risk factors for osteoporosis:

Women are at a greater risk than men, especially women who are thin or have a small frame, as are those of advanced age.

Women who are white or Asian, especially those with a family member with osteoporosis, have a greater risk of developing osteoporosis than other women.

Women who are postmenopausal, including those who have had early or surgically induced menopause, or abnormal or absence of menstrual periods, are at greater risk.

Cigarette smoking, eating disorders such as anorexia nervosa or bulimia, low amounts of calcium in the diet, heavy alcohol consumption, inactive lifestyle, and use of certain medications, such as corticosteroids and anticonvulsants, are also risk factors.

Rheumatoid arthritis itself is a risk factor for osteoporosis.

Having a parent who has/had osteoporosis is a risk factor for the offspring.

What Are Symptoms and Signs of Osteoporosis?

Early in the course of the disease, osteoporosis may cause no symptoms. Later, it may cause height loss or dull pain in the bones or muscles, particularly low back pain or neck pain.

Later in the course of the disease, sharp pains may come on suddenly. The pain may not radiate (spread to other areas); it may be made worse by activity that puts weight on the area, may be accompanied by tenderness, and generally begins to subside in one week. Pain may linger more than three months.

People with osteoporosis may not even recall a fall or other trauma that might cause a broken bone, such as in the spine or foot. Spinal compression fractures may result in loss of height with a stooped posture (called a dowager's hump).

Fractures at other sites, commonly the hip or bones of the wrist, usually result from a fall.

When Should Someone Seek Medical Care for Osteoporosis?

If you are past menopause and have constant pain in areas such as the neck or lower back, consult your doctor for further evaluation. If you are at risk for developing osteoporosis (see risk factors above), also consult your doctor for a medical assessment and bone density screening.

Go to the hospital if you feel severe pain in your muscles or bones that limits your ability to function. Go to the hospital's emergency department if you have sustained trauma or suspect fractures of your spine, hip, or wrist.

What Exams and Tests Do Health-Care Professionals Use to Diagnose Osteoporosis?

The doctor will usually begin with a careful history to determine if you have osteoporosis or if you may be at risk for the disease. You will be asked a variety of questions regarding lifestyle and other conditions that you may have. The doctor will also ask if you have a family history of osteoporosis or a history of previous broken bones. Often blood tests are used to measure calcium, phosphorus, vitamin D, testosterone, and thyroid and kidney function.

Based on a medical examination, the doctor may recommend a specialized test called a bone mineral density test that can measure bone density in various sites of the body. The diagnosis of osteoporosis or osteopenia can be made based on the results of these tests. Osteopenia is lower-than-normal bone density not severe enough to be classified as osteoporosis and is considered by many experts to be a precursor to osteoporosis. A bone mineral density test can detect osteoporosis before a fracture occurs and can predict future fractures. A bone mineral density test can also monitor the effects of treatment if the tests are performed a year or more apart and may help determine the rate of bone loss.

A. Normal spine, B. Moderately osteoporotic spine, C. Severely osteoporotic spine. Click to view larger image.

Several different machines measure bone density. All are painless, noninvasive, and safe. They are becoming more readily available. In many testing centers, you don't even have to change into an examination robe. Central machines may measure density in the hip, spine, and total body. Peripheral machines may measure density in the finger, wrist, kneecap, shinbone, and heel.

The DXA (dual-energy X-ray absorptiometry) measures the bone density of the spine, hip, or total body. With your clothes on, you simply lie on your back with your legs on a large block. The X-ray machine moves quickly over your lower spine and hip area.

SXA (single-energy X-ray absorptiometry) is performed with a smaller X-ray machine that measure bone density at the heel, shinbone, and kneecap. Some machines use ultrasound waves pulsing through water to measure the bone density in your heel. You place your bare foot in a water bath, and your heel fits into a footrest as sound waves pass through your ankle. This is a simple way to screen large numbers of people quickly. You might find this type of screening device at a health fair. Bone loss at the heel may mean bone loss in the spine, hip, or elsewhere in the body. If bone loss is found in this test, you might be asked to have the DXA to confirm the results and get a better measurement of your bone density.

The result of the bone mineral density is compared to two standards, or norms, known as "age matched" and "young normal." The age-matched reading compares your bone mineral density to what is expected of someone of your age, sex, and size. The young normal reading compares your density to the optimal peak bone density of a healthy young adult of the same sex. The information from a bone mineral density test enables the doctor to identify where you stand in relation to others your age and to young adults (which is presumed to be your maximum bone density). Scores significantly lower than "young normal" indicate you have osteoporosis and are at risk for bone fractures. The results will also help the doctor to decide the best way to manage your bone health. For patients who have borderline results, an especially helpful new method of determining the 10-year probability of fracturing bone can be determined using a program called FRAX. This computation method is available online and takes into account all risk factors for a given individual to determine their personal risk for fracture and, therefore, need for treatment.

What Is the Medical Treatment for Osteoporosis?

Treatment for osteoporosis focuses on slowing down or stopping the mineral loss, increasing bone density, preventing bone fractures, and controlling the pain associated with the disease.

Some 40% of women will experience a broken bone (fracture) due to osteoporosis during their lifetime. In those who have a vertebral fracture (in their back), one in five will suffer another vertebral fracture within one year. This condition potentially leads to more fractures. This is called a "fracture cascade." The goal of treatment is to prevent fractures.

Diet: Young adults should be encouraged to achieve normal peak bone mass by getting enough calcium (1,000 mg daily) in their diet (drinking milk or calcium-fortified orange juice and eating foods high in calcium such as salmon), performing weight-bearing exercise such as walking or aerobics (swimming is aerobic but not weight-bearing), and maintaining normal body weight.

Specialists: People who have spinal, hip, or wrist fractures should be referred to a bone specialist (called an orthopedic surgeon) for further management. In addition to fracture management, these people should also be referred to a physical and occupational therapist to learn ways to exercise safely. For example, someone with spinal fractures would avoid touching their toes, doing sit-ups, or lifting heavy weights. Many types of doctors treat osteoporosis, including internists, generalists, family physicians, rheumatologists, endocrinologists, and others.

Exercise: Lifestyle modification should also be incorporated into your treatment. Regular exercise can reduce the likelihood of bone fractures associated with osteoporosis.

Studies show that exercises requiring muscle to pull on bones causes the bones to retain, and perhaps even gain, density.

Researchers found that women who walk a mile a day have four to seven more years of bone in reserve than women who don't.

Some of the recommended exercises include weight-bearing exercise, riding stationary bicycles, using rowing machines, walking, and jogging.

Before beginning any exercise program, make sure to review your plan with your doctor.

Are There Home Remedies for Osteoporosis?

If you suspect that you have signs or symptoms of osteoporosis or have risk factors for osteoporosis, see your doctor for further evaluation and treatment.

Which Doctors Treat Osteoporosis?

Osteoporosis may be treated by a number of different medical specialists. Endocrinologists, rheumatologists, family practitioners, generalists, internists, geriatricians, and gynecologists all treat osteoporosis.

Can Any Foods Help Prevent Osteoporosis?

Many foods can help prevent osteoporosis. A number of scientific studies have shown that eating more fruits and vegetables leads to stronger bones. Low-fat dairy products are high in calcium, and many are fortified with vitamin D and help strengthen bones. Fatty fish such as salmon, mackerel, tuna, and sardines are high in vitamin D. Canned sardines and salmon (with bones) are high in calcium.

What Foods Should Be Avoided With Osteoporosis?

Foods that are high in sodium (salt) cause the body to lose calcium and can lead to bone loss.

Drinking too much alcohol can lead to bone loss. Limit alcohol intake to two drinks a day or less.

Caffeine found in coffee, tea, and soda decreases calcium absorption and can lead to bone loss.

Soft drinks. The caffeine and phosphorous found in colas may contribute to bone loss. It is not clear if the link to bone loss is because people choose soft drinks over milk and other calcium-containing beverages, or if cola directly causes bone loss.

What Medications Treat Osteoporosis?

Estrogen: For newly menopausal women, estrogen replacement is one way to prevent bone loss. Estrogen can slow or stop bone loss. And if estrogen treatment begins at menopause, it can greatly reduce the risk of hip fracture. It may be taken orally or as a transdermal (skin) patch (for example, Vivelle, Climara, Estraderm, Esclim, Alora).

Many women past menopause also choose estrogen replacement therapy because of its proven usefulness in slowing the progression of, or preventing, osteoporosis.

Recent studies question the safety of long-term estrogen use. Women who take estrogen have an increased risk for developing certain cancers. Although it was once thought that estrogens confer a protective effect on the heart and blood vessels, recent studies have shown that estrogens cause an increase in coronary heart disease, stroke, and venous thromboembolism (blood clots). Many women who take estrogens have side effects (such as breast tenderness, weight gain, and vaginal bleeding). Estrogen's side effects can be reduced with proper dosing and combination. If you have had a hysterectomy, estrogen alone is needed. For women with an intact uterus, progestin is always part of hormone replacement therapy. Ask your doctor whether estrogen is right for you.

SERMs: For women who are unable to take estrogen or choose not to, selective estrogen receptor modulators (SERMs) such as raloxifene (Evista) offer an alternative. For example, many women who have first-degree relatives with breast cancer will not consider estrogen. The effects of raloxifene on bone and cholesterol levels are comparable to those of estrogen replacement. There appears to be no estrogen stimulation of the breasts or uterine lining, which reduces the risk profile of hormone replacement. Raloxifene may cause hot flashes. Its risk of blood clots is at least comparable to the risks with estrogen. Tamoxifen (Nolvadex), commonly used in the treatment of certain breast cancers, also inhibits bone breakdown and preserves bone mass.

Calcium: Calcium and vitamin D are needed to increase bone mass in addition to estrogen replacement therapy.

A daily intake of 1,200-1,500 mg (through diet and supplements) is recommended. Take calcium supplements (calcium carbonate, calcium citrate) in doses of less than 600 mg. Your body can only absorb so much at one time. The best way may be to take one supplement with breakfast and another with dinner.

A daily intake of 800-1,000 IU of vitamin D is needed to increase bone mass. Vitamin D is available over the counter as vitamin D2 and vitamin D3 (cholecalciferol).

Bisphosphonates and Other Hormones

Bisphosphonates: Other treatments for osteoporosis are available. Bisphosphonate medications taken by mouth include alendronate, risedronate, etidronate; intravenous medications include the bisphosphonate zoledronate (Reclast). These drugs slow down bone loss, and in some cases, they actually increase bone mineral density. Doctors can measure the effects of these drugs by obtaining DXAs every year or two and comparing the measurements. When taking these drugs, it is important to stand or sit upright for 30 minutes after swallowing the medication. This helps decrease the risk of heartburn and ulcers in the esophagus. After taking bisphosphonates, you must wait 30 minutes to ingest food, beverages (except water), and other medications, including vitamins and calcium. Before beginning to take a bisphosphonate, your doctor will determine if you have enough calcium in your blood and if your kidneys are functioning well.

Alendronate (Fosamax): This medication is used to treat osteoporosis and to prevent bone loss in women. In clinical trials, alendronate has been shown to reduce the risk of new spinal and hip fractures by 50%. Gastrointestinal problems, such as nausea, acid reflux symptoms, and constipation, are the most common side effects. You must take this medication first thing in the morning with a large glass of water and not lie down or eat for 30 minutes. Some women find this restriction difficult. This medication is taken daily or once a week.

Risedronate (Actonel): This medication is used for the treatment and prevention of osteoporosis. Gastrointestinal upset is the most common side effect. Women with severe kidney impairment should avoid this drug. Results from a recent study showed that daily risedronate use can lead to a significant reduction in new vertebral fractures (62%) and multiple new vertebral fractures (90%) in postmenopausal women with osteoporosis, compared with a similar group who did not take this medication.

Etidronate (Didronel): This drug has been approved by the U.S. FDA for the treatment of Paget's disease, another bone condition. Doctors have been using this drug successfully in clinical trials to treat women with osteoporosis.

Ibandronate (Boniva): This drug is an FDA-approved bisphosphonate and is used to prevent or treat osteoporosis in postmenopausal women.

Zoledronate (Reclast): This is a powerful intravenous bisphosphonate that is given once a year. This can be especially beneficial for patients who cannot tolerate oral bisphosphonates or are having difficulty with complying with the required regular dosing of oral medications.

Other hormones: These hormones help regulate calcium and/or phosphate levels in the body and prevent bone loss.

Calcitonin (Miacalcin): Calcitonin is a hormone (extracted from salmon) that slows bone loss and may increase bone density. You may be given this drug as an injection (every other day or two to three times a week) or as a nasal spray.

Teriparatide (Forteo): Teriparatide contains a portion of human parathyroid hormone. It primarily regulates calcium and phosphate metabolism in bones, which promotes new bone formation and leads to increased bone density. This drug is given as a daily injection.

For more information, see Understanding Osteoporosis Medications.

Is Follow-up Needed After Osteoporosis Treatment?

If you are being treated with estrogen replacement therapy, be sure to have routine mammograms, pelvic exams, and Pap smears as recommended to monitor the possible medication side effects. If you are on non-hormonal treatment, have urine and kidney function tests and routine follow-up visits with your doctor.

Arrow indicates vertebral fractures Click to view larger image.

Is It Possible to Prevent Osteoporosis?

Building strong bones during childhood and adolescence can be the best defense against developing osteoporosis later. The average woman has acquired 98% of her skeletal mass by 30 years of age.

There are four steps to prevent osteoporosis. No one step alone is enough to prevent osteoporosis.

Eat a balanced diet rich in calcium and vitamin D and high in fruits and vegetables.

Engage in weight-bearing physical exercise.

Adopt a healthy lifestyle with no smoking or excessive alcohol intake.

Take medication to improve bone density when appropriate.

What Is the Prognosis for Osteoporosis?

With adequate treatment, the progression of osteoporosis can be slowed, stopped, or reversed. Nevertheless, some people become severely disabled as a result of weakened bones. Some patients will fracture their hip, pelvis, vertebrae, wrist, humerus, or leg in the year following an osteoporotic vertebral fracture. Hip fractures are a frequent fracture and leave about half of those who break a hip unable to walk independently. Women who have a hip fracture are at fourfold greater risk for a second hip fracture. There is a significant overall increase in mortality (death rate) in the year after a hip fracture. By 80 years of age, 15% of women and 5% of men have hip fractures. Thus, osteoporosis is a serious disease that requires better efforts at prevention, detection, and treatment.

Osteoporosis FAQs

Osteoporosis (meaning porous bone) is a bone disease in which bone loss occurs, so that bones become weak and are more likely to break. Without prevention or treatment, osteoporosis can progress without pain or symptoms until a bone breaks (fractures). Fractures from osteoporosis commonly occur in the hip, spine, ribs, and wrist.

From

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Osteoporosis Treatment, Signs & Symptoms

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What Is Osteoporosis? Osteoporosis is a disease characterized by low bone mass and loss of bone tissue that may lead to weak and fragile bones. If you have osteoporosis, you have an increased risk for fractured bones (broken bones), particularly in the hip, spine, and wrist.

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6. The Female Athlete Triad – The role of nutrition

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6. The Female Athlete Triad – The role of nutrition

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an extensive paper on the role of nutrition in the female athlete triad

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7. Common Dance Injuries and Prevention Tips

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7. Common Dance Injuries and Prevention Tips

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An article by Johns Hopkins Medicine discussing ways to avoid injury in dance

Hopkinsmedicine.org. (2018). Common Dance Injuries and Prevention Tips. [online] Available at: https://www.hopkinsmedicine.org/health/articles-and-answers/ask-the-expert/common-dance-injuries [Accessed 16 Nov. 2018].

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Sports Injuries Fitness and Performance Exercise-Related Injuries and Exhaustion Sports Injuries

Featured Experts:

Dance may look effortless, but it requires a lot of strength, flexibility and stamina. It also comes with a high risk of injuries. Whether you are a dancer, the parent of a dancer or a dance teacher, you should be aware of the most common dance injuries and learn how to avoid them.

Johns Hopkins performing arts physical therapists Andrea Lasner and Amanda Greene share valuable information about dance injury treatments and prevention tips. Lasner and Greene, both dancers, have turned their love for the art into a means of helping injured dancers.

What are some common dance injuries?

A few studies that looked into dance injuries found that injuries from using your joints and muscles too much ( overuse injuries) are the most common in dancers. The majority of these overuse injuries involve an ankle, leg, foot or lower back. Some common dance injuries are:

Hip injuries: snapping hip syndrome, hip impingement, labral tears, hip flexor tendonitis, hip bursitis and sacroiliac joint dysfunction

Foot and ankle injuries: Achilles tendonitis, trigger toe and ankle impingement

Knee injuries: patellofemoral pain syndrome

Stress fractures: metatarsals, tibia, sesamoids and lumbar spine

Dancers are also likely to develop arthritis in the knee, hip, ankle and foot

Generally, dancers have a much lower rate of anterior cruciate ligament (ACL) injuries than other athletes. One explanation could be that dance training involves much more intense jumping from an earlier age than other sports, which helps improve muscle control.

How do I know if the pain is from an injury?

In most cases, the pain you experience after dancing is muscle soreness that usually subsides within 24 to 48 hours. Sometimes, it takes a few days for muscles to get sore, which is also normal. However, if you experience the following types of pain, you may have suffered an injury:

Pain that wakes you up at night

Pain that is present at the start of an activity

Pain that increases with an activity

Pain that makes you shift your weight or otherwise compensate your movements

If you experience such pain, consult with a medical specialist - preferably a physical therapist or physician with experience in treating dancers. They will be able to determine whether additional testing is needed and will formulate an appropriate treatment plan.

Why do dance injuries happen?

Dance is a physically demanding activity. Dancers perform repetitive movements for several hours a day. Studies have shown that dancing five hours a day or longer leads to an increased risk of stress fractures and other injuries.

On top of the intensive training, many dancers get little time to recover between the sessions and have no "offseason." Restrictive diets and unhealthy body weights may also contribute to dance injuries. Proper nutrition is important for dancers of all ages.

How do dancers get ankle sprains?

Ankle sprains are the number one traumatic injury in dancers. Traumatic injuries are different from overuse injuries as they happen unexpectedly. When an ankle is sprained, ligaments on the inside or outside of your foot get twisted or overstretched and may experience tears. Ankle sprains often happen due to improper landing from a jump, misaligned ankles (when they roll in or out) or poorly fitted shoes. Torn ligaments never heal to their preinjury condition. Once you've sprained your ankle, you are at risk of doing it again. It's important to build muscle strength to prevent further injuries.

Dance Injury Prevention

How can dance injuries be prevented?

The majority of overuse injuries and even some traumatic dance injuries can be prevented. Follow these guidelines to reduce your risk of injury:

Eat well and stay hydrated before, during and after class.

Get enough rest and avoid overtraining.

Do cross-training exercises to build strength and endurance in all parts of your body.

Always wear proper shoes and attire.

Always warm-up before training or performances.

Lead a healthy lifestyle and get to know your body.

When injuries happen, address them immediately and get advice from a doctor or physical therapist.

What are good cross-training exercises for dancers?

Core and hip strengthening exercises like Pilates and stability-based yoga are great for dancers. And so are aerobic and cardiovascular activities, such as running, swimming or biking. They get your heart rate up and help build stamina for long performances.

Many dancers don't do enough cardio during their regular training. Just 30 minutes three to four times a week is usually enough to improve your endurance. As always, do this in moderation and in short intervals to avoid stressing your joints. Being screened by a physical therapist with experience treating dancers will help you identify individual areas of weakness to address with specific exercises.

How much rest should a dancer get?

While many experts stress the importance of proper rest, there are no specific guidelines on the frequency and amount of rest. However, we know that dancing five hours a day or longer is linked to an increased risk of injury. It is also known that intense activity leads to microdamage, which peaks in recovery 12 to 14 hours after a workout. So it would make sense to take the next day off after a high-intensity activity. Dancers should work at their highest intensity a couple of times per week and then take at least two days off, preferably in a row. Also, a three- to four-week period of rest after the season is ideal for recovery.

Dance Injury Treatment

Should I ice or heat after a dance injury?

If it's a sudden injury, it's best to apply ice first to reduce swelling and inflammation. RICE treatment is a common approach that involves rest, ice, compression and elevation. After a few days, you can switch to heat to increase blood flow to the area and promote healing. However, every person is different. If you feel that ice helps you better than heat, then there is nothing wrong with continuing to ice. But be careful not to ice before dancing or stretching, because you want those muscles to be warmed up to prevent re-injury.

What are my treatment options for a dance injury?

It depends on the type of injury, your level as a dancer and many other factors. For example, for traumatic injuries like ankle sprains, your doctor may recommend RICE, joint protection and physical therapy. For stress fractures you may need to limit weight on your foot by using crutches, wearing a leg brace or walking boots. Surgery is typically used as the last resort. It is best to discuss your treatment options with a doctor who specializes in dance injuries. And if you are working with a physical therapist, make sure he or she is experienced in treating dancers. A big part of physical therapy is correcting the training technique that led to the injury. Otherwise, you risk hurting yourself again by making the same mistake.

What should be in the first aid kit for dance injuries?

Your regular first aid kit might already have many of the essentials for handling a medical emergency. However, when it comes to common dance injuries, you may want to include a few additional items, such as:

Instant cold pack

Pre-wrap and athletic tape (if qualified providers are available to apply)

Elastic bandages (to be used only for compression, not support while dancing)

Crutches

Topical pain reliever

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Common Dance Injuries and Prevention Tips

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Learn from a Johns Hopkins orthopedist and performing arts physical therapists about how to minimize your risk of common dance injuries.

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An examination of the relationship between hypermobility and injury from the british society for rheumotology

Bird, H. and Foley, E. (2012). Hypermobility in dancers. Rheumatology, 52(4), pp.585-586.

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this article focuses on the 3 common causes of injury in dancers and how to prevent them

Back in Action. (2018). 3 Common Causes of Dance Injuries and How to Prevent Them. [online] Available at: http://biaphysicaltherapy.com/3-common-causes-dance-injuries-prevent/ [Accessed 16 Nov. 2018].

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Dance continues to grow in popularity. So does the level of commitment required from its participants. Children are beginning dance classes at younger ages, and competitive dancers may train five to six days per week in a year-round setting, placing them at high risk for injury with little time for rest and recovery.

Especially in adolescent dancers, the significant time commitment to training may over-stress the dancer's growing body.

Common Injuries

The most common dance injuries are soft tissue or overuse injuries that arise. We call this cumulative microtrauma, meaning it's a lot of little overuse over time that can cause big problems. Still, acute injuries such as ankle sprains are also common.

Not surprisingly, foot and ankle injuries make up the largest set of injuries in dancers, with knee, hip, and back injuries also prevalent.

What causes dance injuries?

Compensation - One common cause of injuries in dancers is compensating in one area to achieve the desired appearance for a dance skill. Dancers are trained to achieve a certain "look" in the way their feet are pointed, the legs are extended, and hips are turned out. However, if a dancer lacks external rotation at the hip, they will often compensate by pronating at the ankle or pushing the ankle forward to achieve the appearance of turnout. This contributes to foot and ankle injuries, often in the Achilles tendon.

Footwear - The lack of supportive footwear used in dance may also contribute to injury. Dance shoes often provide no extra shock absorption; dancers may transmit up to six times their body weight while jumping on the forefoot. Ways to combat this additional stress on the body include training on properly sprung dance floors as well as learning proper jumping and landing mechanics to reduce stress through the joints. A physical therapist can help teach improved landing mechanics to reduce the risk of injury from repetitive impact.

Dancing "cold" - Insufficient warm up is another factor. The amount of time devoted to warm up and the dance instructor's knowledge of appropriate warm-up techniques vary widely within dance studios. A proper warm-up should include at least five to 10 minutes of both low-intensity large muscle activity and stretching. A good warm-up will increase blood flow, increase body temperature, and stretch the muscles you are about to use. The warm-up will not only help prevent injury, but improve performance because warm muscles can create more power than cold muscles. Keep in mind: Even dancers who warm up sufficiently in practice or before a competition may fail to warm up again after a long waiting time in between dances in a competition or recital.

Prevent Injuries

Cross training can be extremely beneficial in preventing injury in dancers and developing a stronger and more powerful dancer. Cross training involves participating in a variety of exercise activities and reduces the potential of overuse injuries by varying the types of stress to the joints and allowing time for muscles used in dance to recover.

Strengthening opposing muscle groups also creates more stable joints that are less likely to fatigue. Develop core and hip strength to improve jumping mechanics, improve power, and reduce the risk of injury.

Talk to a physical therapist about ways to incorporate cross training into your dance routine. Physical therapists can help dancers and teachers structure their training schedules to allow for relative rest and recovery time while incorporating supplemental strength training for muscles at risk for injury.

Most importantly, don't try to push through or ignore a dance injury. Get help from a physical therapist immediately so we can help you get back in action soon!

***

by Dr. Megan Barrett, PT, DPT

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3 Common Causes of Dance Injuries and How to Prevent Them

# data[].attributes.attachment_link.description
Dance continues to grow in popularity. So does the level of commitment required from its participants. Children are beginning dance classes at younger ages, and competitive dancers may train five to six days per week in a year-round setting, placing them at high risk for injury with little time for rest and recovery.

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an extensive journal on wellness within the performing arts school

Archive of physical medicine and rehabilitation. (2004). Sports and performing arts medicine. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3871955/table/t1-oajsm-4-199/?report=objectonly [Accessed 7 Dec. 2018].

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Abstract

Wellness programs are being increasingly employed with performing artists. Given their aim of reducing injuries, injury tracking is commonly employed as an outcome measure. Evaluating the development and process of a wellness program can also enhance its effectiveness. Developmental evaluation offers one methodological framework within which to conduct such investigations. This paper reports on a 2-year process involving feedback from professional ballet dancers, management and artistic staff, and healthcare providers at a ballet company in order to develop a dancer screening and wellness program. Following a consultation phase, an initial program composed of an expanded medical team and annual injury prevention screen was proposed. Alongside implementation with 30 professional ballet dancers, formal and informal feedback was sought from stakeholders and members across all levels of the ballet company to facilitate ongoing development, evaluation, and revision of the wellness program. The use of a process informed by developmental evaluation helped identify strengths and limitations within the screening process. The collective expertise of the assessors was used to modify the components and process of the screen to strive for ecological appropriateness. The process also fostered buy-in from all involved. Participant feedback helped refine the medical team available to the dancers and influenced the treatment and referral pathways via which dancers are able to access each member of the medical team. Furthermore, reflective discussions with artistic and management staff brought to light potential interactions between repertoire programming, fitness, and injury patterns. This prompted a reconsideration of how artists are trained and supported. Evaluation methods that focus on experiences and insight gained during program development stand to result in more efficient screening programs and health-promotion models and, ultimately, healthier performing artists.

Keywords: performing artists, wellness programs, developmental evaluation, screening, health

INTRODUCTION

Due to the physical and mental demands inherent in pursuing their art, performing artists are at a significant risk of sustaining performance-related injuries. Incidence rates for professional ballet dancers range from 0.62 to 4.4 injuries per 1000 h of exposure to dance activities when examined prospectively ( Nilsson et al., 2001; Allen et al., 2012). Although no prospective injury incidence data for musicians exist, retrospective data indicate that 56% of musicians will sustain a music-related injury throughout their careers ( Zaza, 1998; James, 2000; Spahn et al., 2004). This research also indicates that the types of mental and physical health problems that performing artists experience are varied and complex. Anxiety and perfectionism are common among musicians ( Marchant-Haycox and Wilson, 1992) and have been acknowledged to influence the likelihood of physical as well as psychological injury. For example, they have been found to increase susceptibility to musicians' dystonia ( Jabusch and Altenmüller, 2004). Similarly, it has been suggested that stress hardiness can moderate musicians' susceptibility to injury and performance anxiety ( Salmon et al., 1995). The prevalence of body image problems and inappropriate eating attitudes and behaviors has been found to be significantly higher among ballet dancers than controls ( Ravaldi et al., 2003). Set against the backdrop of a profession in which "sick-days" are rarely an option, performing artists do not always achieve full rehabilitation following their injuries as evidenced by studies demonstrating impaired proprioception following injury among dancers ( Leanderson et al., 1996; Clark and Redding, 2012).

Often deeply entrenched in tradition, performing arts institutions are at the early stages of recognizing their role in supporting the health and wellbeing of their artists ( Brandfonbrener, 2004). At the tertiary level, many music schools still consider their primary role as training skilled, competitive, and successful musicians ( Perkins, 2011). As we appreciate the complexity of these environments, research interest is being increasingly devoted to understanding the cultures within which performing artists are trained and developed ( Burt and Mills, 2007; Welch, 2007; Jørgensen, 2009; Lewton-Brain, 2012).

In order to address the prevalence of health problems among performing artists, a growing number of arts institutions are developing and offering wellness programs to their artists ( Chesky et al., 2006; Manchester, 2007; Potter et al., 2008; Atkins, 2009). The goal of many wellness programs is to improve artists' health; but how to achieve this goal and determine the most effective strategy to tackle this complex challenge remains uncertain. A number of methodological options are available, such as on-site healthcare and support, screening programs, and educational initiatives, for example. However, given the idiosyncrasy of each environment within which these programs are implemented in terms of the perceptions and expectations of the people involved (i.e., dancers, artistic staff, management, healthcare providers) and the resources (i.e., financial, time, staffing) that the organization may be able to devote to a potential wellness program, it is unlikely that there will be a single "optimal" wellness program that is appropriate for all settings. That said, it is not our intention to suggest that methodologies such as those informed by the Sequence of Prevention Model are not applicable to a wide range of performing arts organizations ( van Mechelan, 1997). Rather, what we are trying to suggest is that the method by which injury prevention interventions can be implemented will vary and be dependent upon situational constraints particular to each organization which need to be considered.

In response to this situation, this paper will introduce and discuss an ongoing research project designed to develop, evaluate, and revise a dancer wellness program with a professional ballet company. To clarify, in the present situation the term "medical team" refers to physicians and healthcare practitioners including physiotherapists, chiropractors, psychologists, naturopathic doctors, massage therapists, and Pilates instructors.

PERFORMING ARTIST WELLNESS PROGRAMS

Although not a new concept, multi-faceted wellness programs for dancers and musicians have received scant discussion in the literature to date. What literature exists typically focuses on educational initiatives at post-secondary institutions ( Chesky et al., 2006; Redding and Quested, 2006; Manchester, 2007; Atkins, 2009, 2013). In general, this body of literature demonstrates that an increasing number of performing arts schools offer a wide range of health and wellbeing provisions for their students. However, the literature also reveals that many students do not feel able to make use of the full benefit of health and wellbeing provisions within their institutions ( Atkins, 2009). This could be resulting, in part, from the lack of clearly defined policies and strategies for how best to cohesively utilize available on-site health and wellbeing services at many post-secondary institutions ( Atkins, 2013). However, recent initiatives such as Dance UK's Healthy Dancer Program, Conservatoires UK's Musical Impact Project, and the Performing Arts Medicine Association and the National Association of Schools of Music's Health and Safety Accreditation Program are working to develop united, national strategies to address this.

Injury screening programs are becoming increasingly employed within the performing arts as key components of wellness programs at both the student and professional levels ( Liederbach, 1997). In addition to facilitating health promotion and injury prevention among a cohort ( Fuller and Peirce, 2009), effective screening programs can provide a variety of benefits to artists and those in charge of supporting and ensuring their health ( Clark et al., 2013). At the most basic level, screening programs are useful for identifying intrinsic risk factors that might predispose an individual to injury ( Molnar and Esterson, 1997; Solomon, 1997). Screening programs can provide an assessment of the health status of a group, be that a professional ballet company or a year cohort within a higher education arts institution ( Potter et al., 2008). Longitudinal screening programs can help establish norms for performance-related parameters ( Fuller and Peirce, 2009), helping develop a clearer understanding of the physical and mental demands of training and performing ( Williamon et al., 2009). Finally, screening programs can be useful from a programmatic perspective, depending upon how they are implemented, in that they can be used to assess the impact of training and performing programs on student or professional performing artists across time ( Redding and Quested, 2006).

EVALUATING WELLNESS PROGRAM DEVELOPMENT AND EFFICACY

Given that one of the main objectives of many wellness programs is a reduction of injuries, injury tracking is a common component ( Ojofeitimi and Bronner, 2011; Allen et al., 2012, 2013; Liederbach et al., 2012; Ekegren et al., 2013). Assessing the development of the overall wellness program and the process of the components within it can also contribute to enhancing the effectiveness of a wellness program. Such assessment, together with the ensuing discussions, can also help foster buy-in and engagement to the wellness program from all involved. The collection of stakeholder (i.e., artist, healthcare provider, management, and artistic staff) feedback can be used to help inform the development of the overall wellness program, such as the content and process by which a screening program is implemented, its interaction with broader health-promotion activities, and the content and delivery of those broader health-promotion activities. Once considered, however, all components of a wellness program should be subjected to the necessary empirical evaluation to ensure validity and warrant continued use. As such, collecting stakeholder feedback can help increase the overall efficiency and efficacy of a wellness program.

Developmental evaluation offers one methodological framework through which to conduct such investigations. Developmental evaluation has been defined as " evaluation processes and activities that support program, project, product, personnel and/or organizational development" ( Patton, 1994, p. 317). Developmental evaluation was initially developed for use with social innovations within complex environments and is underpinned by the complexity theory ( Patton, 2011). In the light of this, Patton (2011, p. 7) notes that " Developmental evaluation tracks and attempts to make sense of what emerges under conditions of complexity, documenting and interpreting the dynamics, interactions, and interdependencies that occur as innovations unfold." Developmental evaluation recognizes that identifying the solutions to complex problems, such as determining the best methods to support performing artists' health and wellbeing, is not a linear process. Instead, the process involves jumping back and forth between problem and solution, continually revising the approach as new information is obtained ( Gamble, 2008).

In discussing the "doing" of developmental evaluation, Gamble (2008) identifies three key features of a developmental evaluation within social innovation:

Framing the issue: " As innovators work on [an issue], their understanding moves from a vague understanding to increased clarity" ( Gamble, 2008, p. 20). Insight gained along the way may result in a shift in thinking, prompting another phase of uncertainty and clarification.

Testing iterations: " New ways of doing something are tried, often based on feedback loops and perspective about changing needs and demands, which can lead to improvements" ( Gamble, 2008, p. 20). Developmental evaluation helps identify and make clear the feedback loops and perspective that contribute to greater clarity and understanding.

Tracking the trajectory of the innovation: " Developmental evaluation records the roads not taken, unintended consequences, incremental adjustments, tensions and sudden opportunities" ( Gamble, 2008, p. 20). This insight can then be of value to others trying to solve similar problems, or in the application of the lessons learned to other scenarios.

Recognizing that developmental evaluation may not be an appropriate methodological choice within all contexts or for addressing all issues, it has been recommended that a number of characteristics exist within an organization in order for developmental evaluation to be effectively implemented ( Gamble, 2008, p. 19):

* Innovation is identified as a core value.

* There is an iterative loop of option generation, testing, and selection.

* Board and staff are in agreement about innovation and willing to take risks.

* There is a high degree of uncertainty about the path forward.

* There are resources available for ongoing exploration; and

* The organization has a culture suited to exploration and enquiry.

Unlike formative or summative methods of evaluation that are useful to improve and evaluate the effectiveness of established models, developmental evaluation is useful for situations in which the end point, and/or methods of reaching the end point, is not well known or understood (for comparisons of developmental evaluation with traditional evaluation approaches, see Fagan et al., 2011; Patton, 2011). While many professional performing arts organizations and performing arts schools have a desire to support the health and wellbeing of their artists, the optimal methods for achieving this goal remain as yet unclear. Hence, a novel, innovative approach to understanding effective injury prevention and health promotion for student and professional performing artists is required.

RESEARCH AIMS

The overarching aim of this project is to develop and evaluate a dancer wellness program within a professional ballet company. Features of developmental evaluation have been utilized to facilitate this process. Specifically, this paper reports on a unique, 2-year, developmental process involving feedback from professional ballet dancers, management, artistic staff, and healthcare providers at a ballet company in order to develop a comprehensive wellness program that includes on-site dancer screening. As well, the potential utility of developmental evaluation as a methodological approach to facilitate this process will be explored.

MATERIALS AND METHODS

RESEARCH SETTING

This initiative takes place within a North American full-time professional ballet company of 32 contracted dancers. The repertoire performed by the company is a mixture of classical ballet and contemporary works. For the 2013-2014 season, the company has a total of 46 contracted weeks and will give 61 performances, both at home and on tour throughout Canada. For the present discussion, a performance refers to either a full-length production or a series of smaller works presented within a single mixed-bill event whereby the mixed-bill refers to one performance. The dancers take part in 30 h of contracted dance activities (rehearsals and performances) each week.

In satisfying Gamble's (2008) recommended organizational characteristics, embracing innovation, and risk taking are at the core of the ballet company. This is reflected in the company's mission statement and is evidenced through their mounting of classical repertoire and the regular creation of new repertoire. While improving the health of their dancers is of fundamental concern to the company, there is a high degree of uncertainty over how best to achieve this. In working toward this initiative, key stakeholders across the company have expressed a willingness to engage in a collaborative, iterative process. Finally, three years of funding have been secured to facilitate the development and evaluation of this site-specific dancer wellness program.

This initiative stemmed from a joint interest between the ballet company and the University of Calgary to create an innovative, interdisciplinary wellness program for the ballet company's dancers, with a clinical goal to address the often times underserved physical and psychosocial issues of the dancers, and a research goal to study the impact of the implementation of a wellness program within the ballet company. This led the ballet company to connect with the Division of Physical Medicine and Rehabilitation (PM&R) within the Department of Clinical Neurosciences. They approached the Division of PM&R because of their unique skill set that encompassed both specialty in rehabilitation and sports medicine. These shared interests and goals created the framework to facilitate the presently reported initiative. Furthermore, this collaboration was instrumental for securing the three years of funding mentioned above.

RESEARCH DESIGN

The research reported in the present manuscript is longitudinal in design and is site-specific to this particular ballet company. Rather than testing the efficacy of a set model of health promotion (a dancer wellness program in this case), this research focuses on the continual development of the wellness program as new insight and knowledge emerges. This is in contrast to traditional formative and summative methods of evaluation. Instead, this research employs features of developmental evaluation ( Patton, 2011) to guide the ongoing evaluation and development of a novel wellness program.

Referring to Gamble's (2008), three key features of conducting a developmental evaluation, the following overarching questions have been formed to guide the development of this initiative:

Framing the issue: What are the needs and problems to be addressed specifically within this ballet company?

Testing iterations: What methods exist to allow us to address these needs and problems?

Tracking the trajectory of the innovation: (a) What impact are our activities having on everyone involved in the program; and (b) What new opportunities and challenges are emerging as the program progresses and how might we be able to respond to them?

Specifically, the following activities have been undertaken over the past two years in order to develop, implement, evaluate, and revise the overall wellness program:

* Ten months of initial meetings were held with the management and artistic staff of the ballet company to ascertain wants and needs. Fundamentally, the ballet company was concerned about the level and frequency of injuries that their dancers were sustaining. Due to this, they were seeking specialist musculoskeletal care to aid in the treatment of and rehabilitation from those injuries. Additionally, they aimed to develop and implement a long-term health-promotion and injury prevention strategy to decrease the number of injuries occurring.

* From this, we proposed to develop and make available to the dancers an expanded medical team and conduct an annual injury prevention screen and injury surveillance.

* Prior to the implementation of any aspect of this program, ethical clearance was obtained from the relevant institutional human research ethics board. Each participant was provided with an information letter and signed an informed consent prior to commencing any further aspect of the initiative.

* In the 2012-2013 season, 22 of the company dancers took part in the first round of screening which utilized the Dance/USA Taskforce on Dancer Health Annual Post-Hire Health Screen protocol (Dance/USA Task Force on Dancer Health, 2013), conducted by eight assessors (physicians, allied health professionals, and one researcher). This screening protocol collects the following information: medical and orthopedic history, mental health, body composition, aerobic fitness, postural assessment, hypermobility, range of motion, strength, balance, and functional movement analysis. Prior to conducting the screen, each assessor was trained on how to complete the assessments they were responsible for using an instructional video created by the Dance/USA Taskforce on Dancer Health. Seven of the eight assessors who conducted the screen were healthcare practitioners who consulted to the ballet company and provided on- or off-site treatments for the dancers. The eighth assessor was a researcher. None of the assessors were employees of the ballet and all received payment for treatments either from the dancers themselves, from the dancers' health insurance provider, or through billing the regional healthcare service.

* Following dissemination of results back to the dancers by the team physician and researcher, who were two of the eight screening assessors, all dancers and assessors were asked to complete an evaluation survey of the screening process. The dancers' evaluation contained 10 short answer questions pertaining to perceived enjoyment, usefulness, applicability, and appropriateness of the components and process of the screen. The assessors' evaluation contained 6 short answer questions addressing areas similar to those in the dancers' form.

* The screening and survey results were next presented back to members of the management and artistic staff as well as dancer representatives by the researcher and team physician for discussion. These discussions, and the data upon which they were based, resulted in modifications to the screening protocol and the overall wellness program for the following season.

* Thirty of the company dancers took part in the second round of screening in the 2013-2014 season, again conducted by the same eight assessors. The 30 dancers comprised the 22 dancers from the first round of screening, six dancers who were new to the company, and two returning dancers who was not able to participate in the first round of screening due to illness.

* Following dissemination of results back to the dancers, again by the team physician and researcher, all assessors were again surveyed.

* Survey and screening results were presented back to members of the management, artistic staff, and dancer representatives by the researcher and team physician in order to continue developing the screening protocol and the overall dancer wellness program. Alongside these more formal evaluation activities, informal evaluation and feedback was sought from all parties involved in an ongoing process.

QUALITATIVE DATA TREATMENT

As the goal of collecting formal and informal feedback was to establish contextualized perspectives of the thoughts and perceptions regarding the developing dancer wellness program from those involved, the analysis of the data obtained was data-driven rather than theory-driven ( Charmaz, 2003). Specifically, content analysis involved identifying individual points of interest, or comments representing a single idea, within the written and verbal feedback obtained ( Côté et al., 1993). These points of interest were labeled and grouped into categories with other similar points of interest. Finally, these categories were grouped together into general themes. Anonymized quotes representing these categories and general themes are presented below in section "Results."

No identifiable screening or survey data were presented back to the management, artistic staff, or dancer representatives at any point. All data were blinded so as to ensure anonymity. The dancers did receive their own screening results back during private consultations, but these were the only occasions during which identifiable data were ever discussed.

RESULTS

Through these formal and informal evaluation activities, a wide range of feedback and information was obtained. Thematically, this feedback was grouped into three overarching areas: (1) continued development of the screening protocol; (2) continued development of the wellness program; and (3) continued development of the ballet company's approach to rehearsal. The results are presented below according to these three areas.

CONTINUED DEVELOPMENT OF THE SCREENING PROTOCOL

Evaluation of the two rounds of screening identified strengths and benefits of the protocol, as well as challenges or limitations requiring further consideration.

Reported strengths and benefits

Dancers and assessors enjoyed taking part in the screen with assessors appreciating the collaborative nature of the process. Assessors also enjoyed the opportunity to evaluate the dancers' movements in ways they would not normally be able to do:

"It gave me time to evaluate the dancers' movements in a way that I would not otherwise check unless they were having a problem. It was a great chance to identify any health and musculoskeletal issues that a dancer may have before it leads to an injury (assessor)."

Reported challenges or limitations

Dancers and assessors both expressed concerns regarding the dissemination of the findings following the first round of screening. Dancers felt they did not receive sufficient feedback and were unclear about how to follow up on personal recommendations: " The screening felt more for the medical team than for the dancers this first time around. I understand that has to happen in the beginning, I just look forward to when we get to hear more about the results and diagnoses (dancer)." Also, assessors requested more of the results so that they would feel better equipped to work with the dancers in pre/re-habilitation scenarios: " If we received more of the results of the tests we would be able to link deficiencies with injuries which would help us when creating pre/rehabilitation plans for the dancers (assessor). "

Concerns were also raised regarding the location of the screening sessions. The first round of screening was conducted at the clinic of the company physician. This was chosen because all required equipment was at the clinic and it was felt that bringing all of the dancers to the clinic would provide them with a good opportunity to see the clinic, hence increasing comfort and familiarity with it. However, many of the dancers do not own a car and public transportation is limited which meant that getting to the clinic proved complicated.

Feedback obtained from the assessors following the second round of screening identified specific tests within the screening protocol that warrant further investigation to confirm their relevance and validity, as well as potentially useful aspects that were not being assessed in the protocol. The decision was made to follow this particular protocol for the first two rounds of screening so as to facilitate the aims behind its creation, namely the use of a standardized protocol that would contribute to a large pool of anonymous data that could contribute to knowledge of injury and illness and dance ( Dance/USA Task Force on Dancer Health, 2013). However, going forward there is the desire to either modify or add to the protocol so as to ensure that it is appropriate for use with this particular company. Future research identifying balance assessments that are valid and reliable for use with dancers seems warranted. Static and dynamic balance assessments, such as the star excursion balance test, have shown potential utility for use with adolescents, however their validity for use with professional ballet dancers remains unknown as yet ( Emery et al., 2005; Batson, 2010). Additionally, the dance Aerobic fitness test ( Wyon et al., 2003) and subsequent high-intensity dance-specific fitness test ( Redding et al., 2009) have been demonstrated to be capable of assessing cardiovascular fitness levels of dancers. Furthermore, given the prevalence of disordered eating among ballet dancers ( Ravaldi et al., 2003, 2006; Thomas et al., 2005), research examining eating behaviors, body image, and psychological co-morbidities in dancers, together with an identification of validated assessment tools, could offer a significant contribution to the field.

Development of the protocol

Through reflection and discussion regarding these strengths and limitations, modifications were made to the protocol through the identification and trialing of new strategies and approaches and are discussed below. Some of these new strategies, such as modifications to the location and logistics of the screen, were implemented for the 2013-2014 screen while others, such as new assessment protocols within the screen, will be implemented in the 2014-2015 screen.

The second round of screening was held at the company's studios as opposed to the clinic of the company physician, a change greatly appreciated by the dancers. The timings and logistics of the screening process were also changed which resulted in a quicker, smoother progression through the screen for the dancers.

The process by which the results and findings were provided to the dancers was changed for the second round of screening as well. In the first round, the dancers met with the company physician to debrief their results as a final station at the conclusion of their screen. During the second round, the dancers met with the company physician two weeks after their screen. This allowed the medical team time to compile all of the results from the screen and discuss and create summaries and recommendations for each dancer. This resulted in a more comprehensive conversation between each dancer and the company physician about their individual results and the potential implications of those results. Greater discussion of the results with the medical team following the second screen facilitated the development and delivery of pre-habilitation treatment plans for the dancers.

As discussed above in section "Reported Challenges and Limitations," the identification of questionable tests and gaps within the screening protocol will form the basis of future investigations in order to improve the efficacy and ecological validity of the screening protocol. Such investigations will aim to identify the aspects most relevant for assessment (i.e., physiological, biomechanical, and psychological abilities and capacities) and the most appropriate methods for testing those areas.

CONTINUED DEVELOPMENT OF WELLNESS PROGRAM

In addition to helping develop the screening protocol, the evaluation process has also assisted with the development of the overall wellness program. Acquiring a clearer understanding of the physical and mental health needs of the dancers has helped to identify the types of healthcare practitioners required to support those needs. For instance, 7 out of 21 dancers in the first round of screening scored positive on elements of the mental health portion of the screen. In the second round of screening, 7 out of 30 dancers expressed an interest in nutritional counseling and another 7 out of 30 dancers requested assistance with smoking cessation. This has resulted in an expanded medical team available to the dancers, both on-site and by referral. In particular, the medical team now includes members who are able to address mental health concerns, offer nutritional counseling, and provide assistance with smoking cessation.

As the medical team has expanded, a necessary issue to consider has been ensuring that the treatment and referral pathways by which the dancers are able to access the various members of the medical team are clarified and well communicated to the dancers. Not only is this information of value to the dancers, it also helps the medical team and the artistic and management staff understand how dancers move through the treatment and rehabilitation process.

Aside from the evaluation activities, the screening process itself identified a number of common areas of concern, or potential deficits, among the dancers. During the second round of screening, 11 and 15 out of 30 dancers scored positive for postural instability when balancing on their left and right ankles, respectively. Postural stability was assessed using a one-leg static balance task in which the dancer stands on one leg in parallel position with the opposite foot off the ground in a hip flexed/knee flexed position in which the raised leg does not make contact with the standing leg with their eyes closed. Further evaluation is recommended for any dancer who is not able to balance for at least 30 s ( Dance/USA Task Force on Dancer Health, 2013). The dancers' cardiovascular fitness was assessed using a 3-min step test (adapted from Golding et al., 1989). On a grading scale from 0 to 6 where 0 is "Excellent" and 6 is "Very Poor," seven dancers scored 1 or lower and three dancers scored 3 or lower. For dancers scoring 3 or lower, supplemental aerobic training is recommended ( Dance/USA Task Force on Dancer Health, 2013). In addition to these common areas of concern, individual points of concern were identified for many of the dancers. These included time-loss injuries in the 12 months prior to the screen as self-reported by 14 out of 30 dancers and 21 of the 30 dancers reporting experiencing ongoing musculoskeletal-related issues at the time of screening.

For many of these individual and common areas of concern, there is the possibility for them to be addressed on either an individual or a group basis, both of which present logistical pros and cons. While individual remedial work ensures specificity and detailed attention for each dancer, it is also financially prohibitive. Although more cost-effective, scheduling group supplemental training classes for all dancers becomes difficult when needing to work around busy rehearsal schedules. Group supplemental training classes also risk lacking the necessary specificity to adequately address each dancer's particular area of concern. The screening process assists with identifying relevant areas of focus for supplemental training for the dancers; determining the most appropriate way to implement such classes, however, requires further exploration.

CONTINUED DEVELOPMENT OF THE BALLET COMPANY'S APPROACH TO REHEARSAL

Over time, health surveillance via screening and injury tracking activities, together with ongoing evaluation and reflection, will allow for the development of a better understanding of some of the intrinsic and extrinsic risk factors faced by the dancers in this company. This in turn is facilitating a reconsideration of how dancers are trained and supported.

Reflective discussions with the artistic staff regarding the screening findings, such as the cardiovascular fitness results discussed above, have brought to light issues pertaining to dancers' typical rehearsal processes. This has led to questioning potential interactions between repertoire programming, fitness, and injury patterns. The first performance of the 2012-2013 season was a mixed bill which saw many, if not all, of the company dancers rehearse and perform technically and physically demanding roles. The first performance of the 2013-2014 season, meanwhile, was a classical ballet which saw only a few dancers rehearsing and performing technically and physically demanding roles. Comparing the early parts of these two seasons, the artistic staff noted considerably poorer physical fitness levels in many of the dancers during the 2013-2014 season compared with the 2012-2013 season. Coincidentally, injury rates (as perceived by the artistic staff) appeared to be much higher during the 2013-2014 season compared with the 2012-2013 season. Although prospective injury tracking was not in place during the early part of the 2012-2013 season to confirm these perceived differences in injury patterns, this is still an interesting observation that concurs with the following research.

Research has noted that typical dance training and rehearsal do not inherently impact significantly upon dancers' fitness and strength capacities ( Baldari and Guidetti, 2001; Angioi et al., 2007). This is thought to be due to the intermittent, stop-and-start types of activities common within dance rehearsal that do not place significant stress on the aerobic system ( Chatfield et al., 1992; Wyon et al., 2007; Twitchett et al., 2009, 2010a). As a result, classes and rehearsal are thought to place difference demands on the dancers' cardio-respiratory system than performances ( Wyon et al., 2004; Wyon and Redding, 2005). It is becoming increasingly clear that dancers, and performance quality, benefit from increased fitness and strength levels ( Brown et al., 2007; Koutedakis et al., 2007). Furthermore, lower levels of fitness and strength have been linked to increased injury susceptibility and severity ( Koutedakis et al., 1997; Twitchett et al., 2010b).

The observations from the ballet company's artistic staff discussed above, when taken together with earlier research, raise potential implications for the programming of a ballet company's season. Furthermore, it impacts how a company prepares and supports its dancers in terms of their fitness. The potential health and performance benefits obtainable through the employment of supplemental training programs and principles of periodization for dancers are being increasingly discussed ( Koutedakis et al., 1999; Twitchett et al., 2010a, 2011; Wyon, 2010).

DISCUSSION

The primary aim of the initiative reported in this paper is the ongoing development and evaluation of a site-specific dancer wellness program within a professional ballet company. This longitudinal process has been facilitated by developmental evaluation ( Patton, 2011) and, more specifically, the three key features of a developmental evaluation as identified by Gamble (2008): (1) Framing the issue; (2) Testing iterations; and (3) Tracking the trajectory of the innovation. As such, this paper has also sought to explore the potential utility of developmental evaluation as a methodological approach to facilitate the above aim.

Following an initial consultation phase (Framing the issue), existing models of best practice were identified in the literature and subsequently trialed and evaluated (Testing iterations). Throughout this process, formal and informal feedback was sought from stakeholders and members across all levels of the ballet company via reflective discussions. The insight gained has facilitated the development and ongoing revision of the screening protocol, the wellness program, and the ballet company's approach to rehearsal. The insight has subsequently impacted how the physical and mental health of the dancers is supported and prompted a reconsideration of how the dancers train throughout the season. All these have resulted in a reframing of the issue as a clearer understanding of the mental and physical health needs of this cohort are obtained. This clearer understanding of the dancers' health needs, when considered within the context of this particular company, will facilitate greater clarity in terms of how best to address the emerging health needs (Tracking the trajectory of the innovation).

It is not the intention of this paper to suggest that more traditional forms of evaluation, such as formative and summative methodologies, are not appropriate for use in the development and evaluation of wellness programs for performing artists. Given that many wellness programs aspire to improve the health and wellbeing of performing artists, an indicator of changes to artists' health will remain an essential component. Indeed, in the present scenario the ballet company management stated their primary objective in this initiative as supporting the health and wellbeing of their dancers. Further to this, they wanted to ensure as much as possible that their dancers would be adequately equipped to meet the requirements presented by the artistic staff and guest choreographers. To this end, prospective injury tracking was implemented at the ballet company at the beginning of the 2013-2014 season in order to better understand injuries and injury patterns within this cohort and any changes to those injuries and patterns. While the use of a reliable method of injury surveillance will be central to these aims ( Liederbach et al., 2012), the employment of methods that can shed light upon why changes to artists' health are occurring-or are not occurring-are also required. The use of a methodological approach informed by developmental evaluation can assist with obtaining this level of information.

Demonstrating the value of combining outcome- and process-focused methodologies, Redding and Quested (2006) discuss how reflection and discussion between dance scientists and teachers facilitated advancements in learning and teaching within a dance conservatoire. Following the collection of screening data at the beginning of the student' academic year, discussions between research and teaching staff were held which resulted in the development and implementation of supplemental training programs in an effort to address some of the areas of concern identified within the screening program. The screening program was then used again at the conclusion of the students' academic year to evaluate the effectiveness of the supplemental training programs for effecting change. Concluding, Redding and Quested (2006) point to the heightened collaboration between researchers and teaching staff and the personal empowerment of staff and students that resulted from the implementation of these combined methodologies. This conclusion concurs with the value of employing a mixed-method, iterative process such as that used in the present investigation.

FUTURE RESEARCH

The developmental process employed in the present investigation has brought to light a number of areas that could benefit from further investigation. The assessor evaluation of the screening protocol questioned the validity of some of the tests employed and has identified other aspects that could benefit from being assessed. While sports science has produced a wealth of information that can be used to inform screening protocols for performing artists ( Allen et al., 2013), research within the performing arts has highlighted how such methods require testing to ensure adequate ecological validity prior to implementation ( Quin et al., 2008; Clark et al., 2010). Furthermore, as our understanding of the specific physical and mental capacities most relevant to performing artists increases, ensuring that screening protocols employ appropriate tests for assessing those capacities will be essential ( Batson, 2010; Ruemper and Watkins, 2012).

Performing artists are susceptible to a range of psychosocial concerns in addition to physical complaints ( Noh et al., 2003, 2005; Adam et al., 2004). While the screening protocol employed in the present investigation does include seven questions pertaining to mental health, further research in order to identify psychometrically valid tools capable of identifying potential psychosocial health concerns remains needed. The Athletic Coping Skills Inventory (ACSI-28) has been employed previously with Korean ballet dancers ( Noh et al., 2005). However, the reliability and validity of the ACSI-28, or any other existing questionnaire, for use with professional ballet dancers has yet to be demonstrated.

As mentioned above, screening and injury tracking activities are useful for helping to identify common areas of concern or deficits in the capacities of a specific cohort that would benefit from remedial action. What screening and injury tracking are less capable of determining are the most appropriate methods for addressing these areas of concern or deficits. Limited resources of time and finances will always be issues for performing arts organizations. Furthermore, pre-existing perceptions of what should be included in a student or professional artist's typical activities can either facilitate or impede the implementation of new activities ( Redding and Quested, 2006). Knowledge translation activities that can assist in the implementation of evidence-based knowledge gained in the treatment room and research laboratory into the studio are sorely needed in the performing arts ( Clark and Lisboa, 2013).

CONCLUSION

When used in conjunction with a robust injury tracking protocol, collecting feedback from all parties involved in a wellness program for performing artist can provide a range of benefits. In the present study, the use of a process informed by developmental evaluation facilitated the ongoing development of a site-specific screening protocol, wellness program, and approach to supporting and training dancers. More specifically, participant feedback helped identify limitations or challenges within the screening process. The collective expertise of the assessors was used to modify the components and process of the screen to strive for ecological appropriateness. The process also fostered buy-in from all involved. Participant feedback helped refine the medical team available to the dancers and influenced the treatment and referral pathways via which dancers are able to access each member of the medical team. Furthermore, reflective discussions with artistic and management staff brought to light potential interactions between repertoire programming, fitness, and injury patterns. This prompted a reconsideration of how the artists are trained and supported. The present iterative process, involving a focus on the experiences and insight gained during the development of a wellness program, stands to result in contextually relevant, efficient screening programs and health-promotion models and, ultimately, healthier performing artists.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors thank all of the dancers who participated in this study, the management and artistic staff at the ballet company, Dawn McDonald, and Dr. Wayne Giles from the University of Calgary. The authors also thank the members of the medical team who contributed: Dr. Amber Wiens, Dr. Stephanie Andrews, Jo-Anne Repond Bunbury, Catriona Davies, Carmen Dunn, Brandon Thome, Dr. Jordan Raugust, Nic Allen, Sam Kereim, and Sarah Kenny. Funding for this project was provided by the Division of Physical Medical and Rehabilitation and the Department of Clinical Neurosciences at the University of Calgary and by private donors.

REFERENCES

Dance/USA Task Force on Dancer Health. (2013). Annual Post-Hire Health Screen for Professional Dancers: Guidelines 2013. Available at:http://www.danceusa.org/tfodh-screening-project [accessed June 20 2013]

Gamble J. A. A. (2008). A Developmental Evaluation Primer. Montreal: J. W. McConnell Family Foundation

Golding L. A., Myers C. R. Sinning W. E. (1989). The Y's Way to Physical Fitness 2nd Edn Champaign, IL: Human Kinetics

James I. M. (2000). "Survey of orchestras," in Medical Problems of the Instrumentalist Musician eds Tubiana L. A., Amadio P. C., editors. (London: Martin Dunitz; ) 195-201 10.1201/b14694-10

Lewton-Brain P. (2012). Conversation with a clinician: William G. Hamilton, MD - Is more always more for young dancers? Int. Assoc. Dance Med. Sci. Newsletter 19 4

Patton M. Q. (2011). Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use. New York: The Guilford Press

Perkins R. (2011). The Construction of 'Learning Cultures': An Ethnographically-Informed Case Study of a UK Conservatoire. Ph.D. thesis, Cambridge University, Cambridge

Potter K., Kimmerle M., Grossman G., Rijven M., Liederbach M. J., Wilmerding V. (2008). Screening in a Dance Wellness Program. Available at:http://www.iadms.org/ [accessed April 15 2011]

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Developing a dancer wellness program employing developmental evaluation

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Wellness programs are being increasingly employed with performing artists. Given their aim of reducing injuries, injury tracking is commonly employed as an outcome measure. Evaluating the development and process of a wellness program can also enhance its effectiveness. Developmental evaluation offers one methodological framework within which to conduct such investigations.

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an overview of terms used when discussing anatomy in a  dance setting

Artsalive.ca. (2018). Dance 101 | ArtsAlive.ca Dance. [online] Available at: http://www.artsalive.ca/en/dan/dance101/anatomy.asp [Accessed 16 Nov. 2018].

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Glossary of Human Anatomy Terms

Human anatomy is the branch of science concerned with the structure and function of the body.

The human body is the dancer's instrument of expression. Understanding how the body works can help a dancer stay in shape, improve performance, increase confidence and add longevity to his or her performing career. It can also help a dancer avoid injury. If an injury does occur, knowledge of human anatomy can contribute to a safe process of healing and recovery.

I. General Anatomical Terms

Anatomical position: Descriptions in human anatomy are expressed in relation to anatomical position. These positions describe where different body parts are found or what the direction of a movement is relative to the midline of the body or to another body part. Anatomical positions are referred to according to their orientation:

1. Superior - toward the head

2. Inferior - toward the feet

3. Anterior - toward the front of the body

4. Posterior - toward the back of the body

5. Medial - toward the midline of the body

6. Lateral - away from the midline of the body

Body cavity: Houses the internal organs. There are three main body cavities:

1. The thoracic cavity is the space above the diaphragm. It encloses the heart and lungs within the ribcage, sternum (breastbone) and twelve thoracic vertebrae.

2. The abdominal cavity, which houses the abdominal viscera, begins below the diaphragm and ends at the top of the pelvis, at about waist level.

3. The pelvic cavity extends from the end of the abdominal cavity to the pelvic floor.

Organ: A group of tissues that perform a particular function. For example, the heart, lungs, liver and kidney are all organs.

Pelvic floor: A group of muscles that reach from the pubic bone back to the sacrum. One function of the pelvic floor is to support the internal organs.

Tissue: A group or collection of similar cells and their intercellular substance that act together to perform a particular function. The primary tissues are epithelial, connective, skeletal, muscular, glandular and nervous.

Viscera: Any internal organ.

II. The Systems of the Body

System: Organs that work together to perform major body functions like breathing, digesting, moving and reacting to external stimuli. Some examples of systems include:

1. Cardiovascular: composed of the heart, blood and blood vessels (arteries, veins and capillaries)

2. Digestive: composed of the oral cavity, pharynx, stomach and intestines

3. Endocrine: involving glands that secrete hormones

4. Integumentary: composed of skin, hair and nails

5. Muscular: composed of skeletal, smooth and cardiac muscles

6. Nervous: composed of the brain, spinal cord, peripheral nerves and sensory organs

7. Respiratory: composed of airways and lungs

8. Skeletal: composed of bones and cartilage

All systems are important for normal body functioning but, for a dancer, sound knowledge of the following systems is particularly helpful:

1. The muscular and skeletal systems are often grouped together and called the musculoskeletal system. This system's primary function is movement.

2. The nervous system is comprised of three main parts:

1. The central nervous system involves the brain and the spinal cord. It is the control centre of the nervous system.

2. The peripheral nervous system consists of any nervous tissue that is not encased in the skull or vertebral column. It includes the peripheral nerves and the sensory organs they stimulate in different parts of the body. The peripheral nervous system is important in balance.

3. The autonomic nervous system is chiefly concerned with the regulation of visceral activity. It is involuntary.

III. Bones

Bone (osseus tissue): A specialized form of dense connective tissue consisting of bone cells (osteocytes) embedded in a matrix of calcified intercellular substance. The main functions of bone are to:

1. Protect vital structures

2. Support the body

3. Provide a basis for movement through muscle and tendon attachments

4. Provide attachment points for ligaments

5. Store important mineral salts such as calcium

6. Produce red blood cells which transport oxygen and carbon dioxide to and from tissues

Bones give shape and structure to the body. They provide points of attachment for muscles and become the levers making movement possible. Bones are classified as follows:

1. Flat, e.g. scapula (shoulder blade) and sternum (breast bone)

2. Irregular, e.g. talus (ankle bone) and vertebrae (spinal bones)

3. Long, e.g. femur (thighbone) and ulna (one of the forearm bones)

4. Short, e.g. navicular (a small bone in the arch of the foot)

5. Sesamoid, e.g. patella (knee cap, where the bone is free but a tendon runs through it)

Trochanter: A bony protuberance by which muscles are attached between the pelvis and the upper part of the thighbone (femur).

IV. Muscles and Related Terms

Core: The dancer's centre, or core, involves a balance of stability and strength between the abdominal muscles (transversus abdominis, rectus abdominis, and internal and external obliques), the back muscles and the pelvic floor muscles. The diaphragm is also an important part of the dancer's core. A strong core is very important in maintaining good posture and control of limb movement.

Diaphragm: The diaphragm is the most important breathing muscle. It spans from front to back and side to side at the level of the lower ribs. After exhaling, the diaphragm is shaped like a dome. The lungs sit on top of the dome and when they fill with air the dome flattens. This flattening pushes the ribs up and out, and also pushes down on the abdominal contents, which is why the belly gets pushed out when a deep, diaphragmatic breath is taken.

Hip joint muscles:

1. The adductors (e.g. adductor longus, adductor brevis and adductor magnus) are the muscles running along the inside of the leg from the groin area. Flexibility in the adductors makes it possible to do side splits.

2. The lateral rotators (e.g. piriformis and posterior fibres of gluteus medius) are found deep in the buttock region. They are often very well developed in the ballet dancer who performs many movements in the "turned-out" position.

3. The medial rotators (e.g. gluteus minimus and anterior fibres of gluteus medius) have the dual function of internal rotation (opposite to the turned-out position) and abduction (moving the leg away from midline). They are the antagonistic, or opposite, muscle group to the lateral rotators.

4. The extensors (e.g. gluteus maximus and the hamstrings) are used in moving the leg backwards, in jumping and in straightening from a crouched position.

5. The flexors (e.g. iliopsoas and rectus femoris) bring the leg forward or the knee toward the chest.

Iliotibial band: A fibrous muscle structure running from the outside of the hip joint to the lower leg just below the knee joint. It is a continuation of the gluteus maximus muscle, which is the largest muscle in the buttock.

Hamstring: A group of muscles found along the back of the leg running from the pelvis to just below the knee that effect hip and knee movements. The semitendinosus and the semimembranosus are found on the medial side and the biceps femoris is found on the lateral side.

Muscle: Composed of contractile tissue with elastic properties. The special characteristics of muscle include shortening and contracting, and also stretching. In general, an overstretched or lengthened muscle is weak. There are three kinds of muscle:

1. Smooth muscle acts involuntarily and is found principally in the internal organs.

2. Cardiac muscle also acts involuntarily and is found around the heart.

3. Skeletal muscle is striated because of different groups of fibres bundled together. It is usually found in the limbs. Skeletal muscles, which produce voluntary movement, are the ones a dancer uses to gain and maintain a certain posture, to start and stop limb movement, and to stretch or strengthen.

Posture: Involves maintaining a certain alignment of the body. A dancer's ability to achieve certain postures requires muscle strength and flexibility of the musculoskeletal system, as well as balance and body awareness involving the nervous system.

Respiration (breathing): A means of revitalizing tissues. When a dancer takes in air, he or she is taking in oxygen, or fuel, bringing energy to the muscles and vital organs. Without oxygen it would be impossible to move and control the body. Breathing also helps the dancer gain awareness of physical states like muscle tension and relaxation.

Rotator cuff: A group of four muscles extending from the scapula (shoulder blade) to the head of the humerus (shoulder). These muscles are very important for stability and mobility of the shoulder throughout all movements. The four individual muscles of the rotator cuff are the supraspinatus, infraspinatus, teres minor and subscapularis.

Tendon: The longer fibrous end of a muscle that serves to attach it to the periosteum (outer layer of bone). Tendons are strong, but inelastic. They are slow to heal if injured. A well-known tendon is the Achilles tendon, which attaches the calf group of muscles (the medial and lateral gastrocnemius and soleus muscles) to the heel bone (the calcaneum).

V. Joints and Related Structures

Bursa: A padlike sac usually found near a joint. It is lined with a synovial membrane and contains synovial fluid that reduces friction between tendon and bone, tendon and ligament, or other structures where friction is likely to occur. [See: Bursitis ]

Cartilage: Dense, bluish-white or grey connective tissue, like what is seen at the end of a chicken bone. There are different types of cartilage, including:

1. Articular, a thin layer of smooth, elastic cartilage located on the joint surfaces of bone. It protects the end of the joint.

2. Semilunar, found in-between the joint like the middle of a sandwich. Two good examples are the intervertebral discs, and the medial and lateral menisci in the knee joint.

3. Cricoid, the lowermost cartilage of the larynx (throat).

4. Costal, connects the ends of the first ten ribs (true ribs) with the sternum (breast bone).

Joint ( articulation): The area where two or more bones are joined together along with their associated structures, such as ligaments. Joints are classified into three types according to the material uniting the articulating bones:

1. Fibrous joints: united by fibrous tissue (e.g. sutures of the skull bones).

2. Cartilaginous joints: united by cartilage (e.g. vertebrae and their intervertebral discs) or a combination of cartilage and fibrous tissue (e.g. sacroiliac joint).

3. Synovial joints: united by cartilage with a synovial membrane enclosed in the joint cavity. These are the most common joints and are the ones that provide free movement between the bones they join. They are typical of nearly all the joints of the limbs. Synovial joints are named after the synovial fluid they contain. This lubricating substance allows the dancer's joints to move freely and smoothly.

Joint axes: Joints may move in one (uniaxial) or several directions. A hinge-type joint such as the elbow or the knee is a bi-axial joint and permits movement in two directions: flexion or extension only. A ball-and-socket-type joint such as the hip or shoulder is a multi-axial joint as it allows movement in several directions.

Joint capsule: A sleeve that is over the joint. Made of fibrous tissue, it helps keep everything in the joint together, such as the cartilage, synovial fluid and some ligaments.

Ligament: A band of strong, fibrous connective tissue that connects one bone to another. Ligaments either allow or prevent a specific movement between two bones. They are passive structures so we do not have voluntary control over them. Examples of ligaments are the ACL (anterior cruciate ligament) and PCL (posterior cruciate ligament). These two ligaments are found in the knee and are called "cruciate ligaments" because they cross.

VI. Common Dance-Related Injuries

Bursitis: An acute, painful inflammation of the bursa usually caused by repetitive friction from a tight muscle or a poorly executed movement. Hip bursitis occurs when the tendon of the iliotibial band rubs the greater trochanter of the femur (thighbone).

Joint sprain: A tear of the ligament classified from a Grade 1 (minor) to a Grade 3 (total tear). Joint sprain occurs when a ligament is overstretched or when a joint is bent in the wrong direction. A classic example is rolling over on the ankle. It is not uncommon for more than one ligament to be injured at a time.

Muscle strain: A muscle tear that can range from a Grade 1 (minor) to a Grade 3 (total tear). Muscle strain often occurs from quick movements requiring a sudden, hard muscle contraction, especially when a dancer is not completely warmed up.

Shin splints: Pain in the front of the lower leg. Their cause is unclear, but they tend to develop after prolonged and/or repetitive use of the legs in weight-bearing activities like running and jumping.

Stress fractures: An incomplete break in the bone. In dance they are often caused by repetitive landings from jumps. On an X-ray they appear as a thin line through the bone. In order to heal a stress fracture it is necessary to rest and reduce impact on the fractured bone, which usually means taking a break from dancing for a period of time. Shin splints are one result of stress fractures.

VII. Anatomical Tidbits

The arch of the foot is formed by: the structure of the bones, the navicular being the high point of the arch; the plantar fascia, a fibrous band extending from the heel to the ball of the foot; ligaments, the main one being the spring ligament acting as a supporting sling to the navicular bone; and muscles both starting and ending in the foot, as well as muscles originating from the lower leg area. The primary role of the long arch of the foot is to absorb shock.

The arm is divided into two parts: the upper arm and the forearm. The long bone of the upper arm is called the humerus and extends from the ball-and-socket multi-axial-type shoulder joint to the hinge-type elbow joint. The forearm consists of two bones, the ulna and the radius, which extend from the elbow to the wrist. The main muscles in the upper arm are the deltoids, triceps and biceps. The muscles of the forearm mostly start at the elbow and continue into the hand controlling movement of the wrist and hand.

Arteries are blood vessels containing oxygenated blood that is pumped from the heart to other organs of the body. After the organs have taken the oxygen out of the blood for fuel, another set of blood vessels called veins carry the de-oxygenated blood back to the heart, thereby completing the circuit.

Normal body temperature for a healthy adult at rest is 37 degrees Celsius.

The scapula or shoulder blade acts like a pulley and has muscle attachments to the head, neck, spinal column, sacrum and upper arm.

The spine is made up of seven cervical, twelve thoracic and five lumbar vertebrae; the sacrum (five fused vertebrae); and the coccyx (four fused vertebrae), which is the remnant of the human tail. The spinal cord running down the centre of the vertebrae is a continuation of the brain and ends at L1-L2 (the 1st and 2nd lumbar vertebrae). The rest of the spinal column after L2 is filled with a bunch of nerves that look like a horse's tail and is called the cauda equina.

The human body has different structural levels of organization. These levels start with atoms, molecules and compounds, increasing in size and complexity to cells, tissues, organs and, finally, systems.

VIII. References

Calais-Germain, Blandine. Anatomy of Movement. Seattle: Eastland Press, 1993

Calais-Germain, Blandine and Anderson, Stephen. Anatomy of Movement:
Exercises, Seattle: Eastland Press, 1996

Carola, R., Harley, J.P., and Noback, C. Human Anatomy. New York: McGraw
Hill, 1992

Kapit, Wynn and Elson, Lawrence M. The Anatomy Coloring Book, 3rd edition.
Benjamin Cummings, 2001.

Lesson Planning: The Human Body, Online Resources

Human Anatomy Online

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Human anatomy is the branch of science concerned with the structure and function of the body. The human body is the dancer's instrument of expression. Understanding how the body works can help a dancer stay in shape, improve performance, increase confidence and add longevity to his or her performing career.

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an article from dance life Australia discussing anatomy for dancers and the importance of knowing ones body and its capabilities

Dance Life. (2018). Anatomy for Dancers | Dance Life. [online] Available at: https://www.dancelife.com.au/anatomy-for-dancers/ [Accessed 16 Nov. 2018].

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As a dancer, your body is your tool, your instrument, your livelihood, your passion and your constant collaborator. This is why it is so important for dancers to have a well-rounded working knowledge of their anatomical structure, limitations, and unique peculiarities. Every BODY is different, and comes with its own set of gifts and obstacles. And while technique and training can mould and shape the body, it can only go as far as the body's natural, physical capacity.
With that being said, it is not really practical to expect dancers to be anatomy experts, but all dancers should have a good frame of reference when it comes to their anatomy. It ought to be a basic foundational aspect of dance training, and dance teachers especially should be able to instruct within safe, anatomically correct perimeters. To that end, this series of articles will focus on building a solid, easy to use, method for communicating anatomical concepts and creating a dialogue between dancers and their bodies.
So with this open-minded, no-fear approach to learning, one of the first, and biggest hurdles is to simply engage people in the LANGUAGE of anatomy. "Anato-speak" is really like learning a new language, but once you master a few basics, the complex words and phrases that sounded so foreign suddenly start to make a whole lot more sense. In essence, learning to speak this language is simply a far more articulate way of describing the body's geography ... so lets look at a few examples.
LATERAL AND MEDIAL: This might seem obvious to some people, but for many it might be an eye-opener. Whenever you see the words "Lateral" or "Medial"...it is a like a direction marker. If you drew a line down the middle of your body so you looked like a half-n-half, this would be your "mid-line." Now imagine you are standing with your arms at your sides. Which is closer to the "mid-line," your right hip or your right elbow? The hip is closer...and therefore "Medial" while the elbow is "Lateral." See? Not so confusing!! OK now, lets look at your RIGHT knee joint. You have two ligaments on either side of the knee joint that keep your bones in place. The one on the right side of your knee is called the "Lateral Collateral Ligament." The one on the left side of your RIGHT knee is called the "Medial Collateral Ligament." Now that we know this, when someone says "laterally rotate in the hip joint" a light bulb appears...hmmmmm, this is what dancers commonly refer to as "turning out!" As Oprah says, "this might be an Ah Ha moment" for you. The idea is not to suddenly become an anatomy expert overnight...but little by little we can start to talk about our body in a more articulate way, move past the fear and discomfort of "Anato-speak," and enjoy a deeper understanding of what is really going on underneath our skin!
ANTERIOR AND POSTERIOR: Your nose is anterior and the back of your head is posterior. Your chest is anterior and your spine is posterior. Your toes are anterior and your heels are posterior. Anterior refers to a body part that is closer to the front of the body, while posterior refers to a body part that is closer to the back. Many times we use this term to compare body parts under the skin. For example, your collarbone is closer to the front than your shoulder blade...so in "Anato-Speak" we might say "your clavicle is anterior to your scapula"...try saying this sentence out loud and simply understand that this is a more articulate, anatomically correct way to describe your own body.
PROXIMAL AND DISTAL: The human body can be divided into two main entities...the Axial body(head, torso, pelvis) and the Extremities(hands, arms, hips, legs, feet)...This pair of "Anato-terms" only applies to the extremities. When a body part is proximal, it means that it is closer to the axial body, while something that is distal is further away. Your hand is further from your axial body than your elbow joint...so in "Anato-speak" we would say, "your hand is DISTAL to your elbow joint." How would you compare the position of your knee-bone to your anklebone in "Anato-speak"? The answer is at the bottom of this article!!!
FRONTAL, SAGITTAL, TRANSVERSE PLANES: We are going to imagine two large plates of glass. If we pressed one against our face and chest, and another against our back, we would look like a dancer sandwich between two windows of glass. Any movement we could do to the between these plates of glass, to the side, or above our head, would be considered "Frontal Plane" movements. Now if we moved the glass to touch our right shoulder and left shoulder, we would look like a dancer in a very narrow glass hallway. Any movement we could do to the between these plates of glass, to the front, or to the back, would be considered "Sagittal Plane" movements. Finally, if took one of those plates and cut a hole in the middle, wiggled through the hole and rested the window around our waist, we would look like a dancer popping up through a glass table! Any twisting, turning, revolving side to side movements along the surface of this glass table around us would be called "Transverse Plane" movements.
Over the next few weeks and months, we will gradually look at more and more terms and concepts. By continuing to add to our "Anato-vocabulary," we will start becoming much smarter, educated dancers. For now, see if you can start to incorporate the terms we looked at today into your teaching and choreographing. When you do an arabesque to the back, realize that your body is working in the SAGITTAL plane. A pirouette is a perfect example of movement in the TRANSVERSE plane. If you feel pain in your ankle, ask yourself if it is on the LATERAL or the MEDIAL side. By practicing your "Anato-speak" on a regular basis, you will begin to communicate in this wonderful new language with increased confidence and ability. CHEERS TO YOUR HEALTH AND EDUCATION...

ANSWER TO QUIZ: "your patella is proximal to your maleolus"

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As a dancer, your body is your tool, your instrument, your livelihood, your passion and your constant collaborator. This is why it is so important for dancers to have a well-rounded working knowledge of their anatomical structure, limitations, and unique peculiarities. Every BODY is different, and comes with its own set of gifts and obstacles.

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14. Injury edition: Good pain vs Bad pain

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14. Injury edition: Good pain vs Bad pain

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a website explaining the differences between good and bad pain. This web page includes a useful diagram of the muscle, tendon,  bone connection and also includes a video that shows a student how to self massage the lower body.

EasyFlexibility. (2018). Injury Edition: Good Pain VS Bad Pain - Muscles. [online] Available at: https://www.easyflexibility.com/blogs/dance-life/injury-edition-pain-vs-pain-muscles [Accessed 24 Nov. 2018].

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More often than not, dancers focus on flexibility and strength in order to avoid injury.

A dancer constantly pushes the body to the extreme and if this intense regime is not carefully monitored, injury is more likely to occur. "No pain, no gain" is not always the best mantra, but many dancers, known for their commitment to the art, keep pushing through.
How can you tell if you are simply feeling sore or if you are feeling the pangs of an injury?
It takes experience and a keen sense of body awareness to sift out injury from daily soreness and dancers become especially tuned in to these differences. Imagine a regular person trying a new fitness routine for the first time. There are challenges, but adrenaline kicks in and they are pushed to new limits and feel great...at least for the next handful of hours.

This person wakes up the next day and can barely roll out of bed because their body is unusually sore from working in this brand new dimension.

For a dancer, this is everyday life. It is a rarity to wake up and not acknowledge at least one kink within the body. Knowing what to look for is key when deciding what can be overcome with a good warm up or what needs a doctor's attention.

Muscle Soreness

Muscles are made up of tiny interconnected fibers as noted on the diagram below. It may be surprising to know that stretching and strengthening, no matter the specific activity, causes microscopic tears along the muscle. This allows the muscle to expand and is also the primary cause of soreness.

Many athletes are well-aware of the beloved term "second-day soreness", which is completely normal, as there is usually a one-to-two-day window when it comes to feeling the aftermath of physical activity. The technical term for this effect is Delayed Onset Muscular Soreness (DOMS).

A sore muscle has a tight, aching feeling when at rest, is tender to the touch much like a bruise, and feels tired when moving around. A textbook sore muscle can last up to a few days depending on the intensity of activity, which for dancers, explains why being sore is such a normal state of being.

The best remedy for sore muscles is to keep them warm and moving. The more blood flows through the muscle, the faster the recovery.

Check out our video on Lower Body Massage for Warming Up and Recovery of your muscles:

Muscle Injury

Muscle soreness does not have much effect on everyday life. A good warm up and a session with a handy foam roller and a dancer can be on their way.

Muscle injury, however, can stop a dancer in their tracks.

Unlike soreness, a telling sign of injury is immediate discomfort while dancing or pain that develops within the day. " Pulling a muscle" is the most common type of overuse injury. When a muscle is pulled or strained, it has been stretched too far to the point where the tendons that connect the muscle to the bone have been affected. This type of injury often feels like a deep ache or sharp pain close to the bone whether moving or at rest.

Because an injury can be career-ending, or at least career-pausing, it is imperative to treat it immediately, starting with a visit to the doctor. A dancer who is stubborn and does not get a potential injury looked at, can expect further delays in recovery.

The best way to treat an injury until it is assessed by a medical professional is good ol' rest and ice. Even though dancers have a hard time sitting still, it is so important to take a break and rest so the body is able to properly heal.

Take Care

If you are experiencing signs of muscle soreness or injury, take a moment to care for yourself and do not hesitate to visit the doctor when needed. Keep an eye out for future Injury Edition articles, where we will take a closer look at specific injuries throughout the body. Have a topic in mind? Comment below!

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Injury Edition: Good Pain VS Bad Pain - Muscles

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More often than not, dancers focus on flexibility and strength in order to avoid injury. A dancer constantly pushes the body to the extreme and if this intense regime is not carefully monitored, injury is more likely to occur.

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13. Introduction to Terminology and Anatomical Terms

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13. Introduction to Terminology and Anatomical Terms

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A paper that discusses anatomy and the terms used in dance movement.. includes useful images of the muscoskeletal system .

Virginia Commonwealth University. (2018). Introduction to Terminology and Anatomical Terms. [online] Available at: https://courses.vcu.edu/DANC291-003/unit%201.htm [Accessed 24 Nov. 2018].

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a brief outline and diagram of the types of muscles that pertain to the human body

tissue, T. (2018). Types of muscle tissue: MedlinePlus Medical Encyclopedia Image. [online] Medlineplus.gov. Available at: https://medlineplus.gov/ency/imagepages/19841.htm [Accessed 24 Nov. 2018].

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Updated by: Neil J. Gonter, MD, Assistant Professor of Medicine, Columbia University, NY and private practice specializing in Rheumatology at Rheumatology Associates of North Jersey, Teaneck, NJ. Review provided by VeriMed Healthcare Network. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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Types of muscle tissue: MedlinePlus Medical Encyclopedia Image

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The 3 types of muscle tissue are cardiac, smooth, and skeletal. Cardiac muscle cells are located in the walls of the heart, appear striped (striated), and are under involuntary control. Smooth muscle fibers

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a brief discussion on spraining /ligament tearing

Physioworks.com.au. (2018). Ligament Injury. [online] Available at: https://physioworks.com.au/Injuries-Conditions/Regions/ligament-injury [Accessed 24 Nov. 2018].

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Your optimal outcome will result from well-informed and specifically-guided physiotherapy. Depending upon your ligament injury, you may not return to your full level of activity for 3 to 4 months or even up to 12 months. Very severe ligament injuries can even take longer.

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17. preventing dance injuries a current perspective

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17. preventing dance injuries a current perspective

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a table that outlines Contributors to dance injury what are General causes? Specific causes ? and are the Alterable with conservative management?

Archive of physical medicine and rehabilitation. (2004). Sports and performing arts medicine. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3871955/table/t1-oajsm-4-199/?report=objectonly [Accessed 7 Dec. 2018].

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Abstract

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.

Keywords: dance, injuries, injury prevention, fitness, wellness, health

Introduction

Among activities in the realm of sports, dance is typically not included. Nonetheless, dancers are clearly athletes in the degree to which they require sophisticated physical capacities 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 - are all essential for dance performance. In dance, as in any athletic activity, injuries are prevalent. However, as is also true in traditional sports, the prevention of injury is preferable to the management of injury; ie, maximizing a participant's ability to engage in his or her chosen pursuit without injury is the ultimate goal.

In light of these assertions, the purposes of this review are: (1) to highlight the current state of knowledge about injuries in dance with a view toward injury prevention; (2) to equip clinicians, researchers, and others who work with dancers with information that will assist them in providing optimum care; and (3) to offer motivation for additional health, wellness, and health care personnel to embrace the practice of caring for dancers. The main approach taken herein is to elucidate many of the idiosyncrasies and challenges inherent in dance medicine that are typically not seen in sports medicine. This will serve as a means to provide the reader with an appreciation for how to approach dance injury prevention and management.

The nature of dance, injury, and dance injury research

The prevention of dance injuries hinges in part on an adequate research foundation about the incidence of these injuries, yet there are several aspects of such research that present obstacles. Dance as an art form is a collective of a variety of genres, some of which are becoming increasingly difficult to categorize because they are influenced by two or more styles. Thus, the term "dancer" is often troublesome to delineate secondary to participants commonly possessing skills in multiple genres or to the differences in skills required among genres. For example, "dancer" may be applied to anyone who participates in genres such as ballet, modern, contemporary, jazz, tap, hip-hop, ballroom, musical theater, and a variety of ethnic forms like flamenco, Irish, African, and countless other versions subscribed to virtually every nation. Nonetheless, it is tenuous at best to imply that research on "ballet dancers" generalizes across all "dancers." Furthermore, particularly in dance practice outside of professional, pre-professional, and ethnic groups (eg, individuals in university dance training), it is common for dancers to regularly engage in several genres.

A simple, cursory search of the Medline database easily indicates that, to date, ballet has received the greatest scientific research focus; just the article title search term "ballet" generates more than 350 articles since 1952. This is followed in level of attention in the literature, perhaps surprisingly, by break dance 1- 21 (usually referred to as breaking by its participants, who are called "b-boys" and "b-girls"), and modern/contemporary dance. 22- 40 Other dance genres that have received research consideration, though comparatively not as much, include hip-hop, 41 flamenco, 42- 44 ballroom, 45- 51 Highland, 52, 53 and Irish. 54- 60 Investigation of some of these is becoming more frequent.

One of the difficulties with the current dance injury literature is its history of multiple definitions for what constitutes an injury and the lack of a standard injury reporting system, problems addressed in detail by the Standard Measures Consensus Initiative of the International Association for Dance Medicine and Science. 61 This group of researchers offers three primary purposes of its work:

1. Establish uniform methodology for tests and measures used to assess dancer capacities and intrinsic and extrinsic risk factors for injury;

2. Establish common protocols for reporting injuries;

3. Assist the dance medicine community in applying these recommendations [via] all applicable technologies. 61

Noting that identification of an occurrence as an "injury" only if it results in time lost from an individual's activity is the typical model for epidemiological reporting, the consensus statement also specifies several caveats that may affect injury reporting data, such as a participant's motivation, pain tolerance, and peer influence, as well as a team's coaching philosophy (or, in the case of dance, teaching philosophy). 61 Access to proper medical care and a facility's or practitioner's relative attentiveness to recordkeeping also may affect both the quality and quantity of injury data collection.

While ideal data may not be available, dance is undoubtedly associated with numerous injuries. 23, 24, 39, 41, 60, 62- 84 In research reporting the percentage of dancers injured out of a studied sample, the range was 42%-97% across a variety of genres and skill proficiencies. 63, 64, 66, 68, 69, 71, 73, 85- 88 The lower extremities have been shown repeatedly to be the most commonly injured region of the body in dancers. 63, 64, 67, 68, 71, 75, 76, 79, 80, 82, 83, 85, 88- 90 Nonetheless, the physical requirements of specific genres may dictate injury location, such as a higher proportion of injuries occurring in the upper extremity 29, 75 and back 40, 75 in modern or contemporary dance compared to ballet as a result of the former's dependence on floor-based and partner maneuvers that require substantial weightbearing involvement by the upper extremities. For dance injuries occurring in children and adolescents aged 19 years and younger, increasing age has been associated with increasing likelihood of injury to the lower extremity versus the upper extremity. 82

Roberts et al 82 reviewed 17 years of National Electronic Injury Surveillance System (United States) data for individuals aged 3 to 19. They identified a total of 113,084 dance-related injuries in this age group during the span of the study, with the number of cases and the annual age-adjusted rate of injury both increasing substantially during the span of years studied. Investigations that include injuries to dancers across their careers report that 84% to 95% of dancers are affected. 68, 87, 91

In a 1-year prospective study of professional ballet dancers, Allen et al 83 tabulated 355 injuries in 52 dancers, or a mean of nearly seven injuries per dancer in that single year. The researchers' injury definition was any condition that prevented a dancer from participating fully in normally scheduled dance activities for at least 24 hours from the time the injury occurred. The incidence was 4.4 injuries per 1,000 hours of dance exposure, and overuse injuries were the most commonly reported type in this sample (64% of injuries in females and 68% in males). Females had a mean time-loss from dance due to injury of 4 days, while males' mean time-loss was 9 days. This study is exemplary in that the high injury rate spurred the authors to implement an injury reduction program in their ballet company.

All of the literature taken together indicates, then, that the reduction of injury incidence in dancers is a worthwhile, if elusive, target. The task is multi-faceted, and certainly replete with opportunities for additional high-quality research engagement. For further insight into systematically approaching dance injury research, the reader is referred to Liederbach et al's technical report. 61

Challenges in caring for dancers versus traditional athletes

While highly tuned physical capacities are as important for dancers as they are for athletes, there are important differences between these two types of participants and between their activities. These factors impact the application of both preventive and treatment measures within the dance community.

Sports, in most cultures, are widely played, as well as followed by an enormous fan base. Interest extends from the highest professional ranks to the remotest of children's playgrounds. Dance, on the other hand, does not enjoy such cultural pervasiveness (nor do any of the performing or visual arts, for that matter) even though the art form is taught in many schools and universities, and worldwide there are immensely talented and popular dance companies. Overall, most dancers, dance teachers, choreographers, and dance funding patrons describe feeling a lack of appreciation and respect by society at large for their extraordinarily physical and aesthetic craft. Despite this, they are never dissuaded from pursuing its creation, rehearsal, and performance, as the very nature of dance as athletic artistry engenders a high degree of dedication in its participants. This motivation informs virtually every aspect of their participation and presents some unique challenges to clinicians.

In contrast to most athletes who engage in daily practice sessions that are of comparatively short duration, dancers may routinely participate in technique classes during most of any given day, followed by rehearsals through the late afternoons and evenings. Weekends may be similarly filled. They feel an obligation to participate in and perfect their art, and conversations with and observations of dancers corroborate for the health care professional the intense psyche these athletic artists possess. Ballet dancers, in particular, exhibit a consuming passion for dance that makes a decision to stop dancing for injury or other reasons exceedingly difficult, a frame of mind Wainwright et al 92 liken to an addiction.

One difficulty in assessing and monitoring dance injuries is dancers' extraordinary processing of pain. They exhibit both a higher pain threshold (the amount of pain required for them to acknowledge it) and a higher pain tolerance (their ability to disregard pain while participating in physical activity) than non-dancers. 93 This also may play a role in dancers' minimalist reports of pain that do not seem to correlate with the presence of imaging findings. 94, 95 In addition, Anderson and Hanrahan 96 noted that ballet dancers tended to distinguish poorly between pain that is customary in dance performance and pain associated with injury. Pain is typically seen by dancers as an accompanying facet of dance practice, and dancers are prone to "dance through" pain, even when doing so may be detrimental. 97 Moreover, their pain coping skills are not as developed as those seen in many types of sports participants. 98 These points should be helpful to anyone caring for injured dancers.

Psychosocial and technical factors related to dance injuries

Injuries are considered by dancers to be a natural, even necessary, part of participating in dance. 92 Toledo et al 99 suggest several contributors to dance injuries (). These should serve only as a general baseline, however, as research into dance injuries becomes more sophisticated with concomitant access to an ever wider cross-section of dancers, including increasingly popular genres like hip-hop 41 and breaking, 2, 4 as well as young dancers. 82, 89, 100 Note that most of the factors in are modifiable or treatable, thus making prevention more realistic. This and other references 101, 102 suggest that improved health care for dancers may result from a psychosocial approach wherein health care providers become conversant with the nature of dance practice and performance in order to effectively assist dancers in preventing and recovering from injuries.

Table 1

General cause

Specific cause

Alterable with conservative management?

Improper training

Lack of warm-up exercise routine

Yes

Repetitive jumping

Yes

Poor alignment of body weight

Yes

Faulty technique

"Sickling" (forefoot/hindfoot varus in demi-pointe or en pointe)

Yes

"Rolling in" (foot hyperpronation)

Yes

Poor turnout (inadequate hip external rotation)

Somewhat

Environmental hazard

Hard floors Ill-fitting shoes

Depends on facility Yes

Barefoot dancing

Depends on genre* and instructor

Structural deformity of the foot

Hallux rigidus

Somewhat

Pes cavus (high arch)

No, but treatable

Biomechanical imbalance

Poor core strength

Yes

Weak eccentric strength of leg muscles

Yes

Tight Achilles' tendon

Somewhat

Adam et al, 103 Patterson et al, 104 and Hamilton et al 105 all found that negative stressors in ballet dancers' lives predicted an increased injury rate. However, they also found that this effect could be mediated by the presence of positive social support in the dancers' lives. Two examples of stressors suggested by Noh et al 106 that are associated with a heightened risk of injury in ballet dancers are worry and negative confidence in one's dance abilities. In another study, these researchers determined that ballet dancers who are taught general psychological coping skills experienced fewer injuries and less time injured. 107 Among professional ballet dancers, females tend to be more disciplined than males. Women portray a tougher personality than their male colleagues in the face of the demands of a professional dance career, along with generally having fewer negative psychological traits. 105 In addition, data from this study present a difficult enigma in suggesting that the same personality characteristics that promote success in ballet also place a dancer at increased risk of injury.

Technical intricacies required for success in particular dance genres may predispose dancers to injury. That is, aesthetic demands that are part of any given style of dance are typically not alterable. For example, "turnout" - externally rotating the hips and lower extremities to place the feet as close as possible to an ideal angle of 180° with each other - is a fundamental component of ballet. But, many dancers force this position beyond their normal limits, a practice that may result in conditions such as foot pronation, 35 low back pain associated with anterior pelvic tilt, 108, 109 and pain and injury in joints of the lower extremity. 35, 109 Younger dancers or dancers who are less well trained are especially susceptible because they strive for a technical performance level for which their bodies may not be suited or properly instructed. 110

In keeping the technical demands of dance from increasing the chance of injury, ensuring that dancers receive appropriately qualified instruction is paramount. However, poor teaching may be a difficult factor for health care providers to assuage unless they have both a dance background and unusually good access to the teachers of dancers under their care or in their community. Organizations such as the International Association for Dance Medicine and Science (IADMS, www.iadms.org) are important assets; IADMS holds a yearly educational day for dance teachers in conjunction with its annual conference, as well as produces resources designed specifically to foster healthy dance instruction.

Injury prevention factors in dance

Physical training

As previously described in light of a substantial body of research, dancers sustain many injuries. Research about preventive strategies to mitigate the incidence of dance injuries is less voluminous. Malkogeorgos et al 111 offer five main areas of attention for preventing dance injuries: warm-up, training (including muscular strength, power, and endurance; plyometrics; agility; balance; joint stability; and dance-specific technique), equipment (including footwear and surfaces); regulatory aspects (rules and regulations governing dance); and self-care prevention and treatment methods. Of these, training is the most expansive area, and one that perhaps holds the most promise for success in reducing the incidence of dance injuries.

An investigation of ballet dancers suggested that inadequate physical training was a primary contributor to dance injuries. 78 However, a 6-year follow-up of the same dancers revealed that, while they still were frequently injured, their increased age and dance workload did not result in more pain or injuries; rather, improved physical training facilities were identified as a helpful adjunct to their dance activity. 116 Furthermore, professional ballet dancers who participated in a fitness program apart from their dance technical training showed an increase in maximum oxygen uptake, as well as decreased psychological stress, in comparison to a control group of dancers who did not pursue a fitness program. 117

A study suggesting that decreased injury incidence in professional ballet dancers results from implementing physical training was performed by Allen et al. 84 Over 3 years of prospective injury recording, male dancers' injury incidence dropped from 4.76 per 1,000 hours of dance exposure to 2.22 per 1,000 hours. Injury incidence for females declined from 4.14 to 1.81 per 1,000 hours in the same 3-year period. Based on their first year's data, these researchers incorporated individualized conditioning programs based on each dancer's injury history and physical screening data and subsequently showed the value of such programs in reducing ballet injuries. As one possibility, physical regimens already popular with dancers, such as Pilates, 30 should be encouraged and greater intensity and training volume across a general fitness program are advisable.

Ambegaonkar et al 33 studied upper body muscular endurance in university modern dancers, finding no difference between dancers and non-dancers in spite of modern dance requiring more consistent work with the upper body than ballet, especially in females. They surmised that their dancers' lack of engagement in upper body physical training outside of dance classes, rehearsals, and performances was the primary contributor, thereby suggesting that participation in modern dance, in and of itself, does not lead to upper body muscular training effects.

In a sample of female professional ballet dancers compared to a control group, Koutedakis and Sharp 126 reported significant improvements in quadriceps and hamstring torque output, as well as improvement in thigh muscle fatigability during dance, as a result of 12 weeks of strength training for these muscles. The improvements were particularly noteworthy in dancers who were weaker at the beginning of the study. As the control group dancers did not exhibit strength increases, the authors suggested that dance technical training alone is incapable of eliciting strength gains. Undesirable increases in muscle bulk are a concern for many female dancers because of the importance of anatomical aesthetic contours in dance. However, importantly for females, the increases in thigh strength seen in this study occurred without a concomitant alteration of thigh circumference, a finding the researchers offer as an indicator that the aesthetic characteristics of the lower extremities can be preserved when female ballet dancers participate in weight training. 126

In view of the research evidence, it seems wise to recommend that dancers take part in general fitness training, not only as a helpful supplement to their technical training and performance, but as a means to reduce their chance of injury.

Nutrition and rest

Fatigue has been proposed as a risk factor for injuries in physical activity. 135- 139 In addition, fatigue manifest as "burnout" was shown to have a negative effect on several physical performance variables in professional female classical ballet dancers. 140, 141 Typical schedules of dancers that include dance classes and rehearsals throughout much of any given day may not be conducive to rest unless dancers purposely ensure they find time for adequate breaks and leisure. Also, dance seasons may not incorporate as much off-season recovery time as most sports seasons do. University dance students especially might be at risk of not receiving necessary rest because of the combination of their dance practice, the requirements of their non-dance academic work, and, often, their need to maintain employment to cover their personal expenses.

While research about fatigue and rest in dancers appears scarce, Twitchett et al 142 mapped female professional ballet dancers' activity across a typical workday. Ninety percent of the dancers took less than 60 consecutive minutes of rest, and one-third took less than 20 minutes rest during the day. In a 5-year prospective study of both ballet and modern dancers, more injuries tended to occur in the evening, toward the end of the season, and during performances; these all suggest fatigue as a contributing factor. 75 Thus, dancers must be encouraged to schedule appropriate "down time" in support of both their physical and emotional health.

Flooring

Most dancers prefer to dance on a "sprung" floor rather than on an unyielding surface such as concrete. Sprung floors are typically manufactured from wood and are set on a subfloor by means of a framework of dense foam blocks or other resilient material that effectively suspends the wood floor above the hard subfloor. In many genres of dance that utilize studios and stages, the wood is covered with a 1-2 mm thick vinyl sheet called "marley" in the dance vernacular. The suspended, or sprung, nature of the floor allows it to disperse some of the forces associated with dance, particularly in jumping and landing. 143, 144 Unfortunately, in many instances dancer preference must give way to the necessity of dancing on whatever surface is installed in a given school, studio, or theater. Hopper et al 145 found great variability in force reduction capability amongst different professional ballet venues, concluding that none of the floors met suggested standards for force reduction and that the floor with the greatest intra-surface variability in force reduction was the floor on which the most injuries occurred.

The shock absorptive quality of the surface may not be the only floor-related hazard associated with dance injuries, however. Wanke et al 146 attributed 12.7% of all accidents (291 of 2,281 reported injuries spanning 17 years) in professional and student dancers to a fault with flooring. The most common complaint from the injured dancers was a slippery floor, with the second most common being too much friction in the interface between the foot/shoe and the floor. The majority of the injuries to the professionals occurred on a stage surface, and about half of the professionals' injuries occurred during performances. In response to these data, optimal maintenance practices are essential to ensuring a surface properly prepared for the type of dance to be performed on the floor and the footwear to be worn (or the lack of footwear for some genres). However, this responsibility rests with the dance facility and, therefore, hazardous conditions may be outside the influence of a health care provider unless he or she is employed by the responsible dance company or university.

Footwear

Most genres of dance employ specific types of shoes, although modern/contemporary dancers and certain ethnic style dancers do not wear shoes. Unshod dancers are especially challenging when foot orthotics are indicated for treatment or prevention of injury. Dance shoes in genres that require them (eg, ballet, jazz, tap, flamenco, Irish) are minimally force dispersive by nature of their construction. Ballet slippers, jazz shoes, and Irish dance shoes are little more than a layer or two of leather or microfiber material. Flamenco shoes have high heels suggested to be a cause of injuries to the feet and lower back. 42, 43 Despite the possibility that cushioned shoes help dissipate energy when landing on a floor 57, 147 and provide shock absorption to reduce the chance of lower limb pathology, 148 dancers are unlikely to incorporate these into their rehearsals because they need to precisely replicate their performance conditions and because the specific "feel" of the floor by their feet is essential to their success in dancing.

Pointe shoes in ballet are supportive of the foot, having been shown to provide stiffness with compromise of the midfoot ligaments. 149 They are a necessity for en pointe technique, but have been associated with foot pain and injuries. 150, 151 Their ability to dissipate force through the sole appears to be better than ballet slippers. 152 Some evidence suggests that a soft, partial pointe (ie, demi-pointe) shoe is helpful in reducing leg, ankle, and foot injuries in adolescent dancers when these shoes are worn as a prelude to initiating pointe training. 153

Certainly, research on footwear in dance is insufficient at present. 154 In short, health care providers must work within the constraints of the footwear - or lack of footwear - customary within the dance genres practiced by their dancer-patients.

Dancing en pointe

Dancing en pointe is a specific type of ballet that can give rise to numerous injuries in young dancers if proper care is not exercised in deciding when a dancer is ready to begin pointe training. 155, 156 It requires an extreme amount of plantar flexion 157- 159 that includes motion among the bones of the feet 160 in order to stand on the toe tips in pointe shoes (). The physical test - among several evaluated - found to be most associated with appropriate readiness for pointe work is the "Airplane test," 161 an assessment substantially related to core stability. The dancer stands on one leg while bending over at the waist and extending the other leg backward such that it and the trunk are parallel to the floor. In this position, then, the dancer is facing downward at the floor. The upper extremities are extended outward from the shoulders, also parallel to the floor. The dancer then lowers herself by flexing the knee of the support leg, simultaneously keeping the trunk and nonsupport leg parallel to the floor and bringing the fingertips of both hands downward, while maintaining extended elbows, to touch the floor in front of the face. The dancer then extends the knee and upper extremities to return to the starting position. Four out of five consecutive trials performed with good balance and without valgus or varus motion of the support knee are required to pass the test. 161

Other factors related to success in moving to ballet en pointe include foot strength, ankle range of motion, stability and control during rising to the toes and lowering, and seriousness of ballet training as evidenced by the number of days and hours per week the student attends ballet classes. 155, 156 Implementing solely an age-based criterion for advancement to pointe is not appropriate. 88, 156 Health care providers who have occasion to consult with young dancers and their parents about dancing en pointe should become conversant with the demands of this activity.

Specialized health care access for dancers

Most dancers do not enjoy access to specialized health care that is equivalent to their counterparts in traditional sports. 30, 162- 164 Moreover, when they do approach the health care profession, the response they receive is often unconstructive or, even, discouraging. 40, 165- 167 Russell and Wang 167 found that 80% of university dancers surveyed reported that they felt their health care providers did not understand dancers and 43% indicated that their health care providers gave unhelpful advice. Empirically, most dancers will report at least one - and often several - instances of being told by a practitioner to "stop dancing" as a method to manage their injuries. While this advice is sound under certain injury circumstances that require complete rest (eg, a tibial stress fracture), dancers loathe receiving it as a carelessly offered, supposed panacea. From the perspective of artists, health care workers could better serve them by purposefully learning about performing arts medicine 168 and by attending dance performances as a method for understanding the physical demands of dance. 165 If reduction or discontinuance of dancing is warranted for an injury, one method of improving the relationship between providers and dancers, and better serving the physical nature of dance, is for those in health care to prescribe rehabilitative regimens that either moderate dancers' dancing or define suitable activity alternatives during recuperative periods (rather than suggest they "stop dancing").

Appropriate, specialized health care for dancers is necessary not only for proper care of injuries, but for prevention of new injuries or worsening of current injuries. For example, anterior leg pain that a dancer considers as "shin splints" - and a corollary of participating in dance - may have disastrous sequelae. As one dramatic illustration of this, Martinez and Murphy 169 described their experience with a male professional ballet dancer exhibiting a radiologically confirmed tibial stress fracture in the anterior cortex that did not respond to conventional treatment. To address this, intramedullary nailing was performed. However, the dancer did not seek consistent follow-up care, and 4 months post-surgery he landed from a jump, re-fractured the tibia, and bent the nail, thus necessitating revision surgery.

Notably, Bronner et al 24 reported a substantial decrease in time-loss injury incidence and a concomitant decrease in medical expenditures following implementation of a health care program in a professional modern dance company. They compared injury records for 2 years without health care intervention against the records for 3 years with provision of comprehensive care. Their definition of injury was "any musculoskeletal complaint resulting in financial outlay". Injury rates, measured by the quantity of new workers' compensation claims amongst the company's dancers, dropped markedly, declining from about 80% across the first 3 years of the study to 24% in the fourth year and 17% in the fifth year. The number of injuries per 1,000 hours of dance exposure also fell.

In a follow-up study, Ojofeitimi and Bronner 39 slightly refined their injury definition: "a physical insult that required financial outlay (WC [workers' compensation] or self insurance) or caused a dancer to cease dancing beyond the day of injury (time-loss injury)". They studied a further 3 years of data from their experience with the professional modern dance company and found overall that the company exhibited a 34% decrease in injury incidence, 66% fewer workers' compensation claims, and a 56% decline in days lost from dance. These two studies are highlighted because they imply that attentive health care for dancers, both preventive and restorative, is associated with amelioration of injury rates.

Conclusion

Dance is a rigorous physical activity accompanied by a large quantity of injuries in its participants. In spite of some similarities dance shares with sports, a number of differences and challenges present themselves to those charged with caring for dancers. Several elements related to how dancers approach their art form are worthy of consideration in determining how best to reduce their injuries. In summary, and in light of the literature review presented above, the following current perspectives are offered to professionals in dance, health, research, and health care to support reducing and preventing dance-related injuries.

1. Screening of dancers' physical and psychological attributes, prior injuries, and current and planned dance activity can identify areas that should be addressed to minimize the likelihood of injury.

2. Physical training of dancers, apart from their technical training in dance, should be encouraged, with special attention to the core and to the musculature specific to the demands of their genre(s).

3. Proper nutrition and rest (reduction of fatigue) are essential factors in maintaining a dancer's body that is as resistant to injury as possible.

4. The provision of specialized health care services to dancers is important to risk assessment, injury management, and injury reduction.

5. Health care practitioners not conversant with dance or the psyche of performing artists will become more appreciative of dance's physically rigorous nature, be better equipped to care for dance injuries, and gain favor with dancers by observing different varieties of dance and interacting with dancers about their art form.

Footnotes
Disclosure
The author reports no conflict of interest in this work.

References

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Preventing dance injuries: current perspectives

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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.

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16. Raising the barre: how science is saving ballet dancers

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16. Raising the barre: how science is saving ballet dancers

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an article from the guardian discussing the London royal ballet and its focus on dance medicine to hep prevent and treat injury

the Guardian. (2018). Raising the barre: how science is saving ballet dancers. [online] Available at: https://www.theguardian.com/stage/2018/jul/15/raising-the-barre-how-science-is-saving-ballet-dancers [Accessed 8 Dec. 2018].

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At the Royal Opera House in London, home of the Royal Ballet, art is fusing with science to revolutionise the way dancers prepare. In the glass-panelled healthcare suite, ballerinas are standing on high-tech force platforms which analyse their leg power, and gripping barbells fitted with linear encoders to track their lifting velocity. This is how modern dancers fortify their joints and boost the dazzling height of their grands jetés. With their hair in buns and pink pointe shoes poking out of their gym bags, the ballerinas shift weights with such power that staff have installed padding to spare the nerves of the costume department below.

Our facilities are now similar to those of a Premier League club

Principal dancers Marianela Nuñez and Alexander Campbell glide past. More arrive in white tutus, fresh from rehearsals for Swan Lake; a graceful, giggling wave of youthful energy, chatting about barbecues and Instagram. Some complete bespoke cardio drills, calibrated using oxygen-uptake tests, to get fit for quick-tempo allegro routines. Others strengthen their soleus calf muscles, which on-site electromyography (EMG) analysis suggests can help stabilise their ankles. Every workout is uploaded to Smartabase, a data-analysis platform also used by the US military. Meanwhile, fatigued dancers apply Game Ready leg wraps, which harness Nasa space-suit technology to deliver tissue-repairing cold therapy, and learn how adding omega-3-rich anchovies to their salads can reduce muscle inflammation.

The Royal Ballet is rich in tradition, but the company's 97 dancers are now supported by a 17-strong team of sports science and healthcare experts. "Our facilities are now similar to those of a Premier League football club," explains Gregory Retter, clinical director of ballet healthcare. "Strength, jumping, force attenuation, cardiovascular fitness, psychological wellbeing and nutrition; all support the dancer to be free to create artistic excellence. This is a completely new concept in dance."

Many of the Royal Ballet's innovations are inspired by a wave of game-changing new research overseen by the National Institute of Dance Medicine and Science (NIDMS). Launched in 2012, this collaboration of UK dance institutions and universities examines everything from dancers' ankle mechanics to performance anxiety. Professor Emma Redding, head of dance science at Trinity Laban Conservatoire of Music & Dance in south-east London, is a founding partner of NIDMS. "Dance has always been based on tradition and anecdote, but we started using words like 'measure' and 'evaluate', which are frowned upon in the arts world," explains Redding, a former dancer. "People thought science might dilute the art. But we started asking, can't we get dancers' bodies and minds even stronger? Or even extend their capacities?"

Trinity Laban's Dance Science lab features wireless EMG equipment and face masks that can measure dancers' muscle activity and oxygen uptake; an Optojump system, which uses infrared LED lights to analyse jumps; and a Tekscan pressure sensor, which gauges postural sway during pliés and pirouettes. This is where many ballet innovations are tested. "We have worked with choreographers like Wayne McGregor, but if you are paying to watch a professional ballet, you don't want to see people with masks on," smiles Redding. However, her findings are disseminated through journals and conferences to companies such as the Royal Ballet, which joined NIDMS last year. Research by current guest lecturer Kim Hutt, supervised by Redding, has shown how eyes-closed training can boost a dancer's proprioception - a kind of "sixth sense" which helps them understand the relative position of their limbs on darkened stages.

Ballet's old regime didn't cater to the type of dancers we have become

"Our challenge is to apply these new insights into a busy company," says Retter, guiding me into a light-drenched rehearsal studio at the Royal Opera House where principals Sarah Lamb, Yasmine Naghdi and Federico Bonelli are painting elegant arcs with their bodies to the sound of a live piano. Dancers face relentless workloads, with a 75-minute class and five to six hours of rehearsals every day, six days a week, and typically three to four performances every week. That's why Retter's main priority is to reduce injuries. Dancers suffer an injury rate comparable to American football, with a mean of 6.8 injuries per year. "The guys suffer shoulder, patella [knee] and Achilles injuries from the lifts and jumps, and the females suffer foot injuries from pointe work, but generally 60-70% of injuries are below the knee. We're working to protect them from this huge workload."

To achieve this, Retter's team combines external insights from NIDMS with in-house research. Strength coach Adam Mattiussi opens his laptop to show me a series of charts. "We are starting to quantify ballet," he explains. "What are the dancers' physical requirements? How many jumps will they do? What are their rest intervals?" As well as force platforms, EMG units, oxygen-uptake masks and heart-rate monitors, extra tools are accessible through their partnership with St Mary's University, London, including a Vicon motion capture system used in Hollywood special effects studios. Data is allied to "difficulty scores" for each role, provided by the artistic staff.

The mission is to build a digital bible of the Royal Ballet's entire repertoire, enabling dancers to tailor their physical training for upcoming roles. The data has already yielded surprises. In The Nutcracker, Clara must complete 196 jumps, while Hans-Peter executes 18 lifts. Some male dancers land with 6,000N of force - the equivalent of eight times their body weight. These stats are now transforming the way dancers prepare. "The biggest change is the strength training," explains Royal Ballet sports scientist Gregor Rosenkranz, pointing out the barbells, kettlebells and heavy sandbags. "It helps dancers attenuate those landing forces and avoid muscle injuries. But squats also influence jump height and balance, which helps create buy-in from the dancers." A study by NIDMS confirmed that a year of conditioning can slash the injuries suffered by female dancers from 4.14 per 1,000 hours of dancing to 1.71.

Dancers' career longevity and post-retirement health are also factors. Research suggests 36% of professional dancers retire due to a musculoskeletal injury, with 91% suffering pain in later life. Dancers are also more prone to low bone-mineral density, which is linked to osteoporosis. The strength-training sessions help to boost bone-mineral density and reduce muscle injuries. But Redding speculates that dancers' growing scientific education may even influence choreography in the future: "The culture of ballet is that you don't ask many questions, but when a movement isn't good for them they may start to say something."

Retter had to "convince and cajole" dancers when the suite first opened in 2013. "Dancers see themselves as artists whose job is to perform complex choreography and convey emotion to the audience and I am trying to gently say, actually, you are athletic artists," he explains. "If we make dancers jump higher and land more softly, they should perform better aesthetically, too." One study published by NIDMS confirmed that strength, aerobic and power training can increase dancers' aesthetic performances by developing better timing and rhythmical accuracy.

First soloist Claire Calvert's knee surgery in 2013 was her catalyst for experimentation. "A year off can send you into a black hole, but I thought about how I wanted to come back even better," she says. "Suddenly, if I wanted to spend eight hours in the gym, I could." At the peak of her rehab her squat one-rep max was 100kg. "It is my claim to fame," she chuckles. That gives her a higher strength to weight ratio than 6ft 7in, 111kg England rugby star Courtney Lawes, whose one-rep max is 180kg.

"Ballet's old-school regime didn't cater for the type of dancers we have become," she explains, citing the relentless programme and high scrutiny. "Now we have higher demands of physicality, a more diverse repertoire, so many shows, and little recovery time. On stage, I now have the strength and confidence to keep pushing through and perform steps better. When productions return every few years I realise they feel easier."

First artist Gemma Pitchley-Gale once deadlifted 97.5kg. "I was shocked when the staff said, 'You know it is not normal to lift more than double your bodyweight.' But the squats and deadlifts have alleviated my back and hip pain and I find jumps much easier." During workouts between shows, the dancers lift lower weights but the maximal figures reveal their huge physical capacity: most can lift 2.5 times their bodyweight using just their calf muscles.

Dancers are artists, not gymnasts, and value emotional storytelling over raw athleticism, but science is supporting their aesthetic endeavours in surprising ways. Tests have shown how dancers can soften their landings by ironing out muscle imbalances. EMG analysis has even suggested technical improvements. "By priming their leg muscles in the 'flight phase', dancers can attenuate landing forces using tendons and muscles, instead of relying on bone and cartilage, which causes stress and injury," says Rosenkranz. Fitness tests also revealed that dancers' heart rates never got as high during rehearsals as in front of audiences, when adrenaline kicks in. "If you only dance, without extra fitness sessions, you can't perform at your best," insists Rosenkranz. Dancers now bolster their fitness with bespoke cardio drills on rowers and stationary bikes. "I am no longer afraid of running out of breath," says Campbell.

Finding the time is not so easy. "We have to be respectful of rehearsal because this is where the real artistic excellence is created," says Retter. His team uses strategic planning to avoid interfering with the sacrosanct work of the choreographers and artistic staff. "We map dancers' workloads and do tests throughout the year to identify how best to use our limited time," says Mattiussi. "We might say: let's use that six-week gap before The Nutcracker for some big training, then back off during the shows."

The relentless schedule also plays havoc with the work of dietitian Jacqueline Birtwisle. "For dancers, it's a constant battle between quality, bulk, availability and speed of digestion," she says, shaking her head in mock-horror at the challenges. "And, of course, aesthetics are important. They work in front of a mirror all day and in front of an audience at night."

Drawing on nutritional science, she encourages dancers to drip-feed their bodies with easily digestible fuel, such as softened bircher muesli with milk and berries for breakfast; a tuna salad for lunch, eaten at intervals between rehearsals and topped up with snacks of rice cakes, popcorn or malt loaf; and a light risotto before a show. Dancers eat oily fish to fight muscle inflammation and use flaxseed to take in fibre without the bloating caused by heavier foods like potatoes. They also supplement with vitamin D, which research by NIDMS has shown can boost jump performances by 7.1%. Nutritional science is proving popular. "Federico [Bonelli] quizzes me all the time and Yasmine, Frankie Hayward and Sarah Lamb are very diligent," says Birtwisle. Dancers can also download an app which enables her to give live feedback on their food choices.

Ballerinas have long been vulnerable to the "female athlete triad" of anorexia, amenorrhoea and osteoporosis - interrelated conditions caused by insufficient calorie intake - but Birtwisle says this is normally the result of "unintentional underfuelling", and improved awareness is reducing the threat. Retter has noticed a cultural shift: "When I arrived, the nutritionist was seen as the person you visited if you had a disordered eating issue. Now she is the person dancers ask about how best to fuel their day."

Professional ballet is riddled with pressures and anxieties, which is why occupational psychologist Britt Tajet-Foxell likens her work to The Princess and the Pea. "A psychological issue may be hidden under a hundred mattresses but it's my job to find it," she says. "I tell dancers, you get goblins in your mind that chew and get fat, but you can have warfare with them when you know how."

Injured dancers learn to create a mental video reel of positive associations - memories of good performances, safe places, or positive colours like red or yellow - to break negative reinforcement loops and boost self-esteem. "The subconscious says, 'I will miss that role in Swan Lake, people think I am unreliable.' Those dysfunctional thoughts wear you down. I collect those shattered fragments of confidence and create a positive framework to tap into." Nervous performers learn to change focus, like switching camera lenses: "You must focus on the here and now, not 'I hope I don't wobble on that pirouette.' Consequence-land is not a good place to be." Tajet-Foxell also rewires signs of perfectionism - a trait linked to disordered eating and anxiety. "A perfectionist's mindset is: 'I must do it perfectly.' That's not possible. But if you say: 'I am pursuing excellence,' you always have somewhere to go."

Other wellbeing services range from expert tuition in the pilates studio to massage therapy in the recovery suite. Science is making its mark here, too, with those Nasa-inspired leg wraps, as well as Recovery Boots, which use sequential pneumatic pressure to squeeze out metabolic waste after exercise. An advanced system of pulleys known as a Gyrotonic station helps develop flexibility through fluid, dance-specific movements. Thanks to this mix of expertise and innovation, performance time lost to injuries has fallen over the past four years. And skilled ballet rehab coaches are getting dancers back on stage quicker than ever. "One dancer is jumping in the gym four weeks post-op, whereas 10 years ago he would still be on the sofa," says Calvert.

Performance science is even quietly shaping how some dancers manage their bodies on stage. Pitchley-Gale now combines her intuitive ballet mind, honed over decades of disciplined training, with detailed anatomical thinking. "The lower-leg footwork in Swan Lake makes you fatigue rapidly but - thanks to the squats and deadlifts - when I am jumping I now use my more dominant glutes and hamstrings higher up the chain to alleviate the strain on my lower-leg muscles, so my feet last longer," she says. During pointe work, she consciously activates her core to optimise her posture and reduce the pressure on her foot bones. This example of aesthetic instinct underpinned by intelligent athleticism is, in many ways, the ultimate expression of Retter's project: "Gemma is an amazing dancer who absolutely gets that this is all about freeing her to produce a brilliant artistic performance."

Days later, I watch a performance of Swan Lake, attended by 2,256 spectators at the Royal Opera House and beamed to 1,084 cinemas in 29 countries worldwide. Memories of EMG graphs and pneumatic boots dissolve from my mind as the dancers enchant the audience with their ethereal talent, every gesture electrified with raw emotion, every limb flowing like shimmering silk. Science may be silently ushering ballet into the future, but dancers' centuries-old talent for conjuring movements of impossible beauty with such effortless grace will forever remain ballet's grand, unquantifiable mystery - and its greatest gift.

This article was ammended on 17 July to reflect the fact that Dr Redding was Kim Hutt's supervisor while researching training with eyes closed to improve balance. She currently works at London Contemporary Dance School.

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Raising the barre: how science is saving ballet dancers

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At the Royal Opera House in London, home of the Royal Ballet, art is fusing with science to revolutionise the way dancers prepare. In the glass-panelled healthcare suite, ballerinas are standing on high-tech force platforms which analyse their leg power, and gripping barbells fitted with linear encoders to track their lifting velocity.

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Sustaining healthy and long careers in dance performance 

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Sustaining healthy and long careers in dance performance 

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Store photos and docs online. Access them from any PC, Mac or phone. Create and work together on Word, Excel or PowerPoint documents.