Recurrent Musculoskeletal Pain in Professional Ballet Dancers in

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reported musculoskeletal pain in profes- sional ballet dancers was investigated. Fifty-one (72%) dancers, working in professional companies on both occasions.
Original Article

Recurrent Musculoskeletal Pain in Professional Ballet Dancers in Sweden A Six-Year Follow-up Eva M. Ramel, R.P.T., Ph.D., Ulrich Moritz, M.D., Ph.D., and Gun-Britt Jarnlo, R.P.T., Ph.D.

Abstract In a six-year follow-up study, the selfreported musculoskeletal pain in professional ballet dancers was investigated. Fifty-one (72%) dancers, working in professional companies on both occasions participated in the study. The high prevalence of pain among the dancers was on both occasions dominated by problems in the back (69% and 82% respectively) and feet (73% and 82%). Pain reported some time during the preceding 12 months increased significantly only in the upper back region, while incapacitating pain decreased for the same region (p < 0.05). Recurrent pain was reported by 90% of dancers. Our results indicate that about every third dancer experiences recurrent incapacitating pain, with 75% set off by a previous major injury. In spite of an increased workload, and getting older, ballet dancers are not necessarily more prone to incapacitating pain, rather the opposite seems true. It is speculated that the right training facilities within the theater seem to be important to keep the dancers dancing.

I

njuries in ballet as well as sports injuries or work-related injuries are often referred to as either “acute” or “overuse” injuries. The term acute implies a sudden onset of pain or inhibition of activity as opposed

to gradual onset pain, which occurs over time and is generally a result of “overuse.”1 Although this is a common way of describing injuries (and the reasons for pain) in dancers,2-6 the etiology of a specific injury is likely to be multifactorial2,7-9 and not always easily defined. In recent years the awareness of the “overuse” problems as the most prominent cause of pain in dancers has grown3,10 and has been reported as five times more common than acute injuries.5 “Over use” has also been the main reason for musculoskeletal pain reported by the dancers themselves.11‑12 Another term sometimes used as the opposition for “acute” is “chronic” injuries. “Chronic” injuries can be caused by incorrect weight distribution and overburdening 13 where “overuse” in a sense is the cause and “chronic” is the result, similar to “overuse injury.” An acute injury can also become “chronic” if the dancer does not recognize the possible cause of the injury and take rehabilitative and preventive action, in which case the “acute” problem turns into an “overuse” or “misuse” problem resulting in a “chronic” problem.6

Eva M. Ramel, R.P.T., Ph.D., Ulrich Moritz, M.D., Ph.D., and Gun-Britt Jarnlo, R.P.T., Ph.D. are in the Department of Physical Therapy, at Lund University, Lund, Sweden. Correspondence and reprint requests: Eva Ramel, Department of Physical Therapy, Box 5134, Lund University, S-220 05 Lund, Sweden.

Of the 1,432 injuries in dancers and dance students seen by an orthopaedic surgeon during 17 years, 58.5% were classified as “overuse” injuries, while 29% were considered “acute,” and 12.5% “chronic” (more than one month old).6 The incidence of “chronic” injuries, defined in questionnaires as “giving them [the dancers] continuing problems” was reported in Great Britain in 47%14 and in Australia in 65% of professional dancers.15 A majority (52%) of the Australian dancers suffered from chronic injuries by the time they were 18 years old.15 For both acute and chronic injuries, soft tissue injuries are the most common, and the back the location for most chronic injuries.14 Other “chronic” soft tissue problems are tendonitis and myositis in the hip,4 and bursitis in the foot.3 If pain persists over the years it is likely to be categorized as “chronic.” In follow-up studies of self-reported musculoskeletal pain in different working populations, pain prevalence often does not change over the years.16-18 In a study of sewing machine operators the prevalence of neck and shoulder symptoms also remained unchanged after six years, but when analyzed it was found that between 31% to 50% of the operators had changed their responses; some no longer had any symptoms, and others had developed new symptoms (i.e., the prevalence figures in longitudinal studies, although unchanged, do not reflect “truly” chronic symptoms).19 93

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1989 1995 147 144 84 F, 63 M



89 F, 55 M

85

55 F, 30 M

employed both occassions

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Table 1 Background Factors for the 51 Dancers (34 Women and 17 Men) in the Follow-Up Group Present age, yrs Debut age, yrs Weight, kg Height, cm





71



- 20

non-participants in 1995 8 F, 12 M



1989 missing 1995 missing 26 (22-31) 32 (28-37) 10 (8-11) 10 (8-11) 54 (49-67) 2 56 (51-70) 7 170 (166-175) 170 (167-176) 4

Median values (quartile range, q1-q3)

- 14

leave of absence 9 F, 5 M



1999

51

actual study group 34 F, 17 M

Figure 1 Flow chart for participating dancers in 1989 and 1995 (F = Female, M = Male).

In professional dancers the prevalence of musculoskeletal pain is high. Dancers have a prevalence rate of low back pain similar to that of construction workers (72%) and larger than that of gymnastics teachers (65%).11 However, no long-term follow-up of pain, discussing the recurrence of pain as perhaps an indicator of chronic problems in professional dancers, has to our knowledge been described. The aims of the present study were therefore to follow self-reported musculoskeletal pain and its impact on working ability (incapacitating pain) in professional dancers, and to compare pain locations with reported major injuries during the dance career. We also wanted to make comparisons between companies as well as between soloists and corps dancers. Associations between workload and pain, as well as between individual development and pain, were also of interest.

Subjects and Methods The Royal Ballet in Stockholm, The Gothenburg Opera Ballet, and The Malmo Ballet met the inclusion criteria: each company had more than 10

Table 2 Comparison of Follow-Up Group with the Group that did not Answer the Second Time, in 1995; Prevalence of Answers from the First Survey, in 1989 Follow-up % (n = 51) Men 33 Debut: < 10 years 69 Age: < 27 years 53 Corps dancers 77 No pain (12 month prevalence) 4 No pain (7 days prevalence) 35 No incapacitating pain 31

No second answer % (n = 20) 60* 55 70 90 5 40 25

* = p < 0.05

dancers and had a permanent “home” stage. These companies combined had 147 dancers in 1989 and 144 in 1995 and represented about 90% of all professional ballet dancers employed by theaters in Sweden. Seventy-two percent of these dancers participated in the study (Fig. 1) (Stockholm 66%, Gothenburg 69%, and Malmo 100%). In 1995 the median number of years of employment by the dancers’ present employer was 10 years (interquartile range: 7 to 16 years). The first investigation took place in the middle of the fall season in 1989 and the second in the middle of the spring season in 1995, initiated by the fact that all three directors announced their resignations; two of them leaving after the spring season. The organization and type of work (repertoire and styles) were similar in these companies during the six years between investigations; with a mixture of classical and modern work and with traditional daily training (class). The company in Stockholm, however, worked in a theater with a stage floor and the floor in one of the two training studios with a 4% tilt. The company in Gothenburg

moved into a new Opera house with better training facilities in 1994. One company had the same director while the other two changed directors once during the investigated six years. The general characteristics of the subjects in the study are shown in Table 1. For calculations premiere dancers and soloists were combined in one group called “soloists” to make a larger group for both statistical reasons and to ensure better anonymity. The follow-up group (51 persons) did not differ significantly from the rest (77 persons) of the original group in 1989; neither for age, debut age, and percentage of men in the population or reported musculoskeletal pain. Of the twenty dancers who choose not to participate in the second survey more were men (p = 0.04), but they did not otherwise differ significantly from the follow-up group (Table 2). Pain was assessed through selfadministered questionnaires that consisted of the Nordic Musculoskeletal Questionnaire about pain, ache, and discomfort from the musculoskeletal system,20 which in this study was called “pain,” and additional questions

Journal of Dance Medicine & Science

Table 3 Number of Dancers (soloists n = 20; corps dancers n = 31) with Low, Medium, and High Individual Demand, Based on Median Hours of Work during the Preceding Two Months (n = 51) Individual Demand High Medium Low No answer

Total 7 15 18 11

concerning background and working conditions. Questions were asked about: 1. Pain any time during the preceding 12 months; 2. Pain in the preceding seven days; and 3. Incapacitating pain any time during the preceding 12 months, for nine body regions: neck, shoulders, elbows, wrists/ hands, upper back, lower back, hips, knees, and ankles/feet. If the same pain location (body region) was reported on both occasions this was called “recurrent” pain. The additional questions in the original questionnaire were created in close cooperation with a “research circle”21 and is more extensively described elsewhere.11,22 In the second study, questions were added concerning major injuries during the career (which body regions, cause of injury, and time off work). A major injury was defined as one which stopped participation in

Dancers

dance for at least one month and the cause of injury was what the dancer recalled as the reason for the injury. Other questions concerned individual development (any extra education provided by the present employer and an open question about matters of importance for the professional role during the preceding five years), and individual work load during the preceding two months (number of performances and also division of working time between daily class, rehearsals, and performances). An index called “individual demand,” based on the median values for division of working time was created. If a dancer scored equal or greater than the median value on all three subgroups (daily class, rehearsal, and performances) the dancer was given a “high” score; if the dancer scored equal to or greater than the median on two of the sub scores, they were give a “medium” score; all others were given a “low” score (Table 3).

140

°

130 120

°

110 100 90 80 70

x

°

° x

60

x

50 40 30 20

Solo/Corps (2/5) (9/6) (5/13) (4/7)

*

*

x

°x

°

* *

x

*

*

89/90 90/91 91/92 92/93 94/95 95/96

°

*

Stockholm x Gothenburg Malmo Figure 2 Number of performances during the six years.

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On both occasions the questionnaires were distributed after the daily class by one of the authors. Dancers on leave of absence (seven persons in 1989 and another seven in 1995) were excluded but dancers who for other reasons were not present at the time, had the form mailed to them with a return envelope. A reminder was mailed three weeks later to those who had not answered the first time. The exact number of performances for each of the six years (Fig. 2) was provided by the theater offices. Statistics The median values were chosen for background variables. Differences in reported pain between the two occasions were tested on the individual level with McNemar’s test.23 Differences on the group level were tested with Chi square test or Fisher’s exact test. Correlations were tested with Spearmans rank correlation (R s). Analysis was performed with The Statistical Package for the Social Sciences (SPSS).24 A probability level of p < 0.05 was accepted as statistically significant.

Results

Comparisons of Pain Prevalence between 1989 and 1995 Pain some time during the preceding 12 months was on both occasions mostly reported in the low back and the feet. The statistical comparison was performed so that every dancer was compared with himself or herself for each body region and the changes were significant for pain from one region; the upper back (p = 0.02) (Table 4). Pain reported in the preceding seven days showed somewhat the same distribution as for the 12 month prevalence (Table 4). Fewer dancers reported incapacitating pain in the upper back (p = 0.04) on the latter occasion. Incapacitating pain from the feet had also dropped, but not significantly (p = 0.3). Whereas 60% of those with pain from the feet in 1989 had been incapacitated, 41% had been so in 1995 (Table 4). The total number of dancers who

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Table 4 Dancers’ Self-Reported Prevalence of Musculoskeletal Pain (n = 51) Incapacitating Some Time Last 12 mos Last 12 mos Last 7 Days (% of total) -89 -95 -89 -95 -89 95 Neck 67 63 24 24 12 8 Shoulders 51 33 12 10 12 8 Elbows 0b 10 0 6 2 2 Hands 22 16 6 6 8a 8 Upper back 35 55* 16 24 16 2* Low back 69 82 26 37 28a 33 a Hips 43 59 22 24 22 22a Knees 43 43 12 20a 18 16a Feet 73 82 35 51 43 33a

Incapacitating Last 12 mos (% of those with such pain) -89 -95 18 13 23 23 0c 20 36a 50 44 4 40a 41 50 37a 41 36a 60 41a

* = differences between 1989 and 1995, p < 0.05; a = 1 missing answer; b = 3 missing answers; c = calculation not performed due to missing answers

reported incapacitating pain is shown in Figure 3. Four dancers were on both occasions without such problems. In Gothenburg fewer dancers (p = 0.04) were incapacitated in 1995 (six persons) than in 1989 (13 persons). A comparison between companies in 1995 showed that fewer dancers in Gothenburg (compared with Stockholm, p = 0.005, and Malmo, p = 0.046) were incapacitated because of pain. There were no differences between the companies in the 12 month or seven day pain prevalence between the two occasions. The consistency of responses between the two occasions is shown in Table 5. Forty-six persons (90%) experienced recurrent pain some time during the preceding 12 months (one or several locations). The percentage of dancers with such recurrent pain from one particular body region, ranged from 4% (elbows and/or wrist/ hands) to 31% (feet). The variation in pain/no pain or vice versa showed that nine dancers with hip pain in 1989 no longer had such pain six years later, but 18 new cases had emerged. Three dancers reported healthy backs over the preceding 12 months on both occasions and the same number of dancers reported no foot pain (Table 5). On both the 1989 and 1995 questionnaires the most frequently reported pain occurring in the preceding seven days was foot pain (26% of respondents). Foot pain was reported

by 16 new subjects on the second questionnaire, while four persons no longer reported such pain (Table 5). Recurrent incapacitating pain was reported by 16 dancers (31%) at a total of 20 body sites. There were eight reports of recurrent, incapacitating pain in the ankles/feet, seven reports included the low back, two reports of pain occurring in the hips, two reports of pain in the knees, and one report of recurrent pain located in the neck. About one fourth of the reported incapacitating pain locations (20 of 80 in 1989, and 20 of 74 in 1995) were “recurrent.” Ten new subjects had reported experiencing incapacitating foot problems on the second questionnaire, while 15 reported that they were no longer incapacitated for that reason (Table 5). Major Injuries Major injuries during their career were reported by 41 dancers (80%). They presented a sum of 58 major injuries; foot injuries were the most common, followed by injuries in the low back. Twenty-six persons reported only one injury area (of which 19 reported foot injuries) while the remaining dancers reported injuries to a combination of body areas. There were no differences either between companies, between men and women, or between soloists and corps dancers. Five dancers in each Gothenburg and Malmo had not experienced any major injuries (Table 6).

Incapacitated

1989

Not Incapacitated

14

34

21

13

4

10

1995

31

17

Figure 3 Number of dancers who had been incapacitated because of pain some time during the preceding 12 months in 1989 and/or 1995, (n = 51, 3 missing answers).

The recalled time off work because of injuries during their career was at the most 36 months (for problems with the feet solely) with a median of 6 months (interquartile range: 2 to 12 months). Believed causes for major injuries were “overuse,” “worn out,” “pushing the body,” and “tired” (23 dancers); “bad training” and “bad preparation” (12 dancers); and “accident” and “bad luck” (10 dancers). Other reasons were “difficult choreography” (4 dancers), “bad floor” (5 dancers), and bodily disadvantages such as “bad turn out” (not enough external rotation in the hips), “weak feet” and “worn cartilage” (4 dancers). “Stress” and “being unhappy” was mentioned by two dancers. The most commonly believed cause for the 28 foot injuries was “overuse” (14 dancers) followed by “bad luck” (8 dancers). The location for major injuries and recurrent pain some time during the preceding 12 months was the same for 26 of 46 dancers (57%), but most dancers reported more pain locations than major injury locations. For 12 of the 16 dancers (75%) with recurrent incapacitating pain the pain location was the same as for their major injury. Pain from the Upper or Lower Body Multiple locations of pain (12-month prevalence) were reported by about 90% of the dancers (46 dancers in 1989 and 47 in 1995). For such pain

Journal of Dance Medicine & Science

Table 5 Number of Dancers Reporting Pain Both Times Prevalence of Rid Incapacitating Got No of Missing Pain -95 Pain Pain Pain Pain Answer (P+GP) Neck 12 29 3 14 5 Neck 7 5 7 32 6 1 Neck incap 3 2 42 3 1 at least 5 Shoulder 12 12 6 22 11 Shoulder 7 0 6 39 6 Shoulder incap 0 4 41 6 - 4 Elbow 12 2 3 45 1 Elbow 7 0 3 48 0 Elbow incap 0 1 50 0 - 1 Hands 12 2 5 34 10 Hands 7 0 3 45 3 Hands incap 0 4 42 4 1 at least 4 Upper back 12 16 13 20 2 Upper back 7 3 9 33 5 1 Upper back incap 0 1 41 8 1 at least 1 Lower back 12 30 13 3 5 Lower back 7 8 11 26 5 1 Lower back incap 7 10 24 8 2 at least 17 Hips 12 12 18 11 9 1 Hips 7 3 9 30 7 2 Hips incap 2 9 30 9 1 at least 11 Knees 12 16 6 23 6 Knees 7 6 5 38 1 1 Knee incap 2 6 35 7 1 at least 8 Feet 12 31 11 3 6 Feet 7 13 16 16 4 2 Feet incap 7 10 17 15 2 at least 17

Table 6 Location of Self Reported Major Injuries in Dancers during their Career (more than one injury possible) Total (n = 51) Ankles/feet 28 Low back 10 Hips 7 Knees 7 Neck 4 Elbows 2 No major injury 10

Male/Female Soloists/Corps S/G/M (n = 17/34) (n = 20/31) (n = 23/18/10) 5/23 10/18 16/8/4 5/5 4/6 6/3/1 1/6 4/3 2/4/1 4/3 5/2 4/2/1 1/3 2/2 3/1/0 0/2 0/2 1/1/0 5/5 3/7 0/5/5

S = Stockholm, G = Gothenburg, M = Malmo.

from the upper half of the body (neck, shoulders, and upper back) the combination of all three areas was the most common (15 and 13 persons in 1989 and 1995, respectively). Although not significant, slightly more dancers had experienced pain from the upper body in 1995, but less had on that oc-

casion been incapacitated because of such pain. More dancers also reported pain (12 month prevalence) from the lower body (low back, hips, knees, and feet) and 20 persons in 1989 and 31 in 1995 reported the combination of three or more locations. The number of dancers with incapacitating pain

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from the lower body had also increased from 21 persons in 1989 to 29 in 1995 (Fig. 4). The low back was the location for most of this increase. If the low back is excluded, the number of persons with incapacitating pain from the lower extremities decrease between the administration of the two questionnaires; 12 in 1989 and 8 in 1995. Individual Development during the Years Between 1989 and 1995 Fourteen dancers (28%) had been provided with extra education (almost all in mental training or positive thinking) offered by the employer some time during the last five years; slightly more in Stockholm (30%) and Gothenburg (28%) than in Malmo (20%). There were no differences between those who had extra education and those who had none, in any of the pain categories. Important events for their careers were pointed out by 34 (65%) of the dancers with 25 persons giving 45 positive factors, five persons giving seven negative factors, and four persons giving both negative and positive factors. Good teachers as well as improved body awareness (kinesiology, mental training, Pilates training, yoga, and so forth), were indicated by 14 dancers in each company, while added professional status (such as becoming a soloist, a raise in salary, working in acting, choreographing, not dancing in operettas) was mentioned by nine dancers. Family events (getting married, having a baby, and so forth) were positive events for the careers of eight dancers. The negative factors were almost all related to teachers and training; being treated as too old for the work, not getting parts, or being generally ignored by the teacher and/ or director. No differences between gender or professional status were found. More dancers who reported only negative factors had experienced incapacitating pain from the upper half of the body than those with positive and/or both positive and negative experiences (p = 0.009). A comparison between companies showed that nine dancers of 18 in Gothenburg stated

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Journal of Dance Medicine & Science Upper Body

No such pain: 1 (4) Incapacitated: 29 (21)

Low Back

Neck

2 (2)

10 (9)

4 (2)

13 (15) 2 (0)

0 (9)

2 (2)

Hip(s) 1 (1)

2 (0)

2 (1)

0 (1)

10 (8)

1 (1)

0 (2)

Knee(s) 2 (2)

5 (2)

1 (4)

Foot (feet) 8 (10) 12 (8)

Upper Back

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Lower Body

No such pain: 11 (13) Incapacitated: 7 (11)

9 (1)

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3 (1)

1 (3)

Shoulder(s)

Figure 4 Number of dancers with pain in 1995 (1989) in the upper and lower part of the body, illustrating the combination of areas of pain some time during the preceding 12 months, n = 51.

generally better training and/or increased body awareness during the last years as compared to five of 23 in Stockholm and three of 10 in Malmo. Workload in 1995 Between 1989 and 1995, there was an increase in the number of performances in all three theaters (Fig. 4). Nine persons had been promoted; the ratio of soloists to corps dancers was in 1989, 11 of 40 and in 1995, 20 of 31. There was also an increase in dancers who reported working more than 40 hours per week: 9 in 1989 and 17 in 1995. The self-reported median number of performances during the preceding two months for the individual dancer in 1995 was 10 (interquartile range: 3 to 13). There were no significant correlations between the reported number of performances and any of the three pain categories in 1995. The median time per week spent in class was 9 hours (interquartile range: 7 to 10 hours), in rehearsals, 20 hours (interquartile range: 5 to 25 hours), and in performances, 9 hours (interquartile range: 5 to 10 hours). For 18 dancers the individual demand had been low, while seven dancers (three in Stockholm and four in Gothenburg) reported a high individual demand (Table 3). The seven day pain prevalence was positively correlated with the individual demand index (Rs = 0.3; p = 0.03). Eleven dancers chose not to estimate their working time.

Discussion Few dancers escape musculoskeletal pain, but in spite of an increased 12-month pain prevalence over the years, the incapacitating pain for the persons in this study did not increase. These dancers somehow lived and worked with their pain, in spite of an increased number of performances over the years. The dancers in this study represent a highly selected group and comparison with dancers in general or dance students should be made with caution. Even if professional ballet dancers use the same basic work technique all over the world, generalizations about the work should also be exercised with caution. After six years more persons were working more hours per week, there was an increased number of performances for all three theaters, and more dancers had been promoted to soloists; all which indicate a more strenuous working situation for the group in general in 1995 than in 1989. This should be kept in mind when comparing the pain outcome. Our results show that the high pain prevalence was similar on both occasions regardless of theater, but that incapacitating pain was significantly different between theaters according to the results of the second questionnaire in 1995. One reason for fewer dancers reporting incapacitating pain in Gothenburg may be the better training facilities in the new Opera

house, as was indicated by some of the answers these dancers provided about their individual development. To investigate dancers’ musculoskeletal problems a questionnaire was chosen because we wanted to reach all professional dancers in the major companies in different parts of Sweden. At the time of the first investigation we did not find any standardized questionnaire suitable for the theater or that specifically focused on the working conditions of dancers. Thus the instrument was created in a “research circle,” where two professional ballet dancers helped in wording and creating valid questions for ballet work. For the pain reports the standardized Nordic Musculoskeletal Questionnaire was included. Studies of reliability of the Nordic questionnaire by test-retest have shown that the percentage of identical answers varied from 77% to 100%.20,25 Validity tests against interviews about medical history have shown agreement varying from 80% to 100%.20 The sensitivity and the specificity of the Nordic questionnaire to detect musculoskeletal disorders revealed by clinical examination of the neck/ shoulder region were 77% and 78%, respectively.18 The reason that the follow-up questionnaires were administered in the 1995 spring season (and not in the fall season as originally planned) was that all three directors announced their resignations. New directors using new methods can affect the dancers in many ways, so for consistency we felt that it was important to perform the follow-up investigation before any such changes occurred and confounded the results. The lower response rate at the latter occasion may have been because some dancers felt uncomfortable to word opinions about their working situation in a questionnaire. Some dancers also expressed feelings such as “nothing will ever change for us anyway,” which made them indifferent to the investigation. However, it is not likely for the pain report to have been affected by the dropouts, and the prevalence shows no dramatic differences between the two occasions

Journal of Dance Medicine & Science

on which the questionnaires were administered. The impact on the musculoskeletal system from work in ballet may vary according to the production and the style of ballet being rehearsed and performed. Therefore, in the present study, an effort was made to estimate the workload preceding the dancers’ pain reports in 1995, by obtaining data about division of working time (Fig. 2 and Table 3). The internal drop-out (11 persons) for the questions suggests that it was difficult to do such an estimation retrospectively, and that a prospective dairy method would perhaps have been better. The correlation between the preceding two months’ work and the seven day pain prevalence, but not the other two pain variables, indicates that there is a distinction between present pain and the pain that is recalled. Since ballet work is very physical it can create a kind of muscular training soreness, but we were especially interested in the more persistent pain, which would be remembered from “some time during the preceding 12 months,” and incapacitating pain. The seven days pain prevalence is therefore not discussed further. Specific definitions for “overuse,” “underuse,” “misuse,” and “abuse” have been suggested by a Standards Committee in the Performing Arts Medicine Association, recognizing the confusion in terminology over the years.26 Also the term “chronic” needs to be discussed because definitions in dance medicine literature vary.6,14 In the medical literature perhaps the most widely used definition of chronic pain is: pain with a duration of greater than 3 or 6 months.27 Using this, the prevalence in a general population in Sweden has been found to be 55% (greater than 3 months duration) and 49% (greater than 6 months).28 However, much of the “chronic” pain in active dancers could be expected to go away with therapy, rest, or after retirement and should therefore not be regarded as truly “chronic.” “Persistent” pain may be a better label, and if the same pain is found at different occasions, without record of the pain

in between, we suggest “recurrent” as a more appropriate term. In the present study, recurrent pain from one or several body regions was reported by 90% of the dancers and this demonstrates the magnitude of dancers’ pain problem. The increase in upper back pain may be partly explained by the decrease in shoulder pain (Table 4) and that it is perhaps difficult to distinguish between body regions. A combination of painful body regions was common (about 90%) in this study and in accordance with that (85%) found also for persons with chronic pain.28 Recurrent incapacitating pain was reported by 31% of the dancers in this study, and the “stability” was greatest for the low back and the feet regions. This is perhaps an indicator of “chronic” pain, more so than the 12 month prevalence. Compared to earlier dance surveys, the “chronic” pain prevalence found in this study is smaller than that found in Great Britain (47%)14 or in Australia (65%),15 but at the same time twice that of the dancers and dance students with “chronic” problems (12.5%) seen as patients by an orthopaedic surgeon.6 The most common locations, low back and feet, are however in agreement with earlier surveys.6,14,15 The increased number of complaints from the hips after six years is in accordance with studies of chronic pain in the general population, which show an increased number of persons with pain from the lower extremities up to age 55 to 59 years.28 Also, extreme joint mobility decreases slightly with age29 and, because the outward rotation of the hip (turn out) is greatly stressed in ballet, the increased number of dancers with hip pain after six years may be due to the process of aging. The low back pain may also be a result of hip problems.30 Fewer dancers (although not statistically significant) had, however, been incapacitated by pain from the lower extremities, which was somewhat contradictory (Table 4). With increased age either the demands from the work decrease,

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because the dancer is not “used” by directors, or the dancer learns to live (and work) with the pain. For corps dancers it may be that older dancers get “easier” parts because of known incapacities, but also as dancers get older, increased maturity and awareness of their capabilities can make them “work smart” and learn how to stay working despite their problems. For soloists the demands (both the amount and the quality of work) are, however, not likely to decrease in the same way. But, a higher status usually means a little more personal freedom during training, so these dancers can use their own judgment more and take better care of themselves. Anatomical deficiencies as an explanation for the occurrence of pain, which is often discussed as a major cause for problems in dancers,7,10,30 was rarely mentioned by the dancers in this study. By the time a dancer becomes professional, the selection process may have “weeded out” persons with anatomical deficiencies so that injuries (and pain) are then mostly associated with overuse and poor training,12 which were also the two most mentioned explanations in this study. Major injuries in one body region (mostly the feet) had in many cases (75%) left the dancer with recurrent incapacitating pain. Dancers often return to work too quickly after an injury.9 Active rehabilitation, which has for example been shown to improve postural stability in dancers after ankle sprains,31 could perhaps be one way to prevent recurrence of injuries and pain. A reduction in both cost and the number of injuries as a result of better rehabilitation and injury prevention has been presented.32 Although special training programs have been developed to rehabilitate dancers with musculoskeletal problems,33 there is still a need for more research about the effectiveness of such programs. In summary our results indicate that about every third dancer experiences recurrent incapacitating pain, which is incurred by a previous major injury in 75% of cases. In spite of an increased workload and getting older

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the work as a ballet dancer does not necessarily make you more prone to incapacitating pain, rather the opposite. It is speculated that the right training facilities within the theater seem to be important to keep the dancers dancing. Acknowledgement We thank the Swedish Work Environment Fund for their kind funding of the project.

References 1. Bak K, Kalms SB, Olesen S, Jorgensen U: Epidemiology of injuries in gymnastics. Scand J Med Sci Sports 4:148-154, 1994. 2. Milan KR: Injury in ballet: A review of relevant topics for the physical therapist. JOSPT 19(2):121-129, 1994. 3. Weiker GG: Dance injuries: the knee, ankle, and foot. In: Clarkson PM, Skinar M (eds): Science of Dance Training. Champaign, IL: Human Kinetics Publishers, Inc., 1988, pp. 147-192. 4. Sammarco GJ: Diagnosis and treatment in dancers. Clin Orthop Rel Res 187:176-187, 1984. 5. Perrault M: Preventing injuries in theatrical dance: The Quebec dancers’ and producers’ viewpoints. Presented at International Conference on Medicine for Performing Arts. Jerusalem, Israel, 1989. 6. Garrick JG, Requea RK: The relationship between age and sex and ballet injuries. Med Probl Perform Art 12:79-82, 1997. 7. Hamilton WG: Physical prerequisites for ballet dancers. J Musculoskel Med 3(11):61-66, 1986. 8. Micheli LJ, Solomon R: Training the young dancer. In: Ryan AJ, Stephens RE (eds): Dance Medicine: A Comprehensive Guide. Chicago, IL: Pluribus Press, 1987, pp. 51-72. 9. Stephens RE. The etiology of injuries in ballet. In: Ryan AJ, Stephens RE (eds): Dance Medicine: A Comprehensive Guide. Chicago, IL: Pluribus Press, 1987, pp. 16-50. 10. Howse J, Hancock S: Dance Technique

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and Injury Prevention. London: A & C Black, 1988. 11. Ramel E, Moritz U: Self-reported musculoskeletal pain and discomfort in professional ballet dancers in Sweden. Scand J Rehab Med 26:1116, 1994. 12. Brinson P, Dick F: Fit to Dance? The Report of the National Inquiry into Dancers’ Health and Injury. London: Calouste Gulbenkian Foundation, 1996. 13. Larsen C: Causes and prevention of injury in dance. Ballet International 9:38, 1991. 14. Bowling A: Injuries to dancers: prevalence, treatment and perception of causes. BMJ 298:731-734, 1989. 15. Geeves T: Safe Dance Project. A Report on Dance Injury Prevention and Management in Australia. Jamison, Australia: The Australian Association for Dance Education in association with The National Arts Industry Training Council, 1990. 16. Rundcrantz B-L, Johnsson B, Moritz U: Pain and discomfort in the musculoskeletal system among dentists. A prospective study. Swed Dent J 15(5):219-298, 1991. 17. Stål M, Moritz U, Johnsson B, Pinzke S: The natural course of musculoskeletal symptoms and clinical findings in upper extremities of female milkers. Int J Occup Environ Health 3:190-197, 1997. 18. Ohlsson K, Hansson GÅ, Balogh I, Strömberg U, et al: Disorders of the neck and upper limbs in women in the fish processing industry. Occup Environ Med 51:826-832, 1994. 19. Schibye B, Skov T, Ekner D, Christiansen JU, Sjogaard G: Musculoskeletal symptoms among sewing machine operators: Scand J Work Environ Health 21:427-434, 1995. 20. Kourinka I, Jonsson B, Kilbom Å, Vinterberg H, et al: Standardized Nordic questionnaire for the analysis of musculoskeletal symptoms. Appl Ergon 18:233-237, 1987. 21. Lindström KG, Persson LI, Ruth W, Svenstam Å: A Study of the Theatre’s Working Environment and its Future Development. Lund, Sweden: The Di-

vision of Educational Planning and Development at Lund University, 1989. 22. Ramel EM, Moritz U: Psychosocial factors at work and their association with professional ballet dancers’ musculoskeletal disorders. Med Probl Perform Art 13:66-74, 1998. 23. Stat Xact 3 for windows, CYTEL Software Corporation, 1995. 24. SPSS, Chicago, Marketing Dept SPSS, 1992. 25. Dickinson CE, Campion K, Foster AF, Newman SJ, et al: Questionnaire development: An examination of the Nordic Musculoskeletal Questionnaire. Appl Ergon 23(3):197-201, 1992. 26. Dawson WJ, Charness M, Goode D J, Lederman RJ, Newmark J: What’s in a name? Terminologic issues in performing arts medicine. Med Probl Perform Art 13:45-50, 1998. 27. IASP Subcommittee on taxonomy: Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. Pain 3(Suppl):S1-S226, 1986. 28. Andersson HI: The epidemiology of chronic pain in a Swedish rural area. Quality of Life Research 3(Suppl 1):19-26, 1994. 29. Larsson L-G, Baum J, Mudholkar GS, Srivastava DK: Hypermobility: Prevalence and features in a Swedish population. Brit J Rheumatol 32:116-119, 1993. 30. Bachrach RM: The relationship of low back/pelvic somatic dysfunctions to dance injuries. Kinesiol Med Dance 9:11-14, 1986. 31. Leanderson J, Eriksson E, Nilsson C, Wykman A: Proprioception in classical ballet dancers: A prospective study of the influence of an ankle sprain on the proprioception in the ankle joint. Am J Sports Med 24(3):370-374, 1996. 32. Solomon R, Micheli LJ, Solomon J, Kelley T: The “cost” of injuries in a professional ballet company: A three year perspective. Med Probl Perform Art 11:67-74, 1996. 33. Bryan N, Smith BM: Back school programs: The ballet dancer. Occup Med 7(1):67-75, 1992.

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