biopsychosocial factors in injury: from an artist's perspective

Biopsychosocial Factors in Injury:

From an Artist’s Perspective

Brittany N. Keefe

LEAP Senior Study

Biopsychosocial Factors in Dance Injury

Table of Contents

Abstract…………………………………………….3Preface……………………………………………...3Introduction………………………………………...4

Methods…………………………………………….5Results……………………………………………...7Discussion…………………………………………18References…………………………………………20

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Abstract

A study was created using a survey and interviews to discern the impact of

biopsychosocial factors on the incidence and rehabilitation of dance injuries. The survey

had ninety-two, respondents reporting an injury affecting their participation in class or

rehearsal for ten days or more. Of those, representing multiple dance genres from a

national scope, the foot/ankle was the most prevalent site of injury. Using questions from

established work-stress questionnaires, only 62% of the respondents reported feeling

motivated at work, while 43% reported the need to hide their feelings while working. The

results of the study pointed to perfectionist tendencies, lack of or underinsured healthcare

access, and economic struggles being the primary sources of negative stress. When asked

about income, 75% of the respondents reported wages low enough to qualify them at or

below poverty level. The most conclusive finding from the survey was 73.4% of

respondents stated troubles coping with their injury. Even with support, education, and

assistance going through the process of injury, the majority of dancers struggle coping

with being sidelined. Dance at an elite level is an all-encompassing experience; it is more

than a job. As such, the entire institution of dance needs to support the role of the artist

both physically and psychologically.

Preface

I am fortunate to have a limited history of injury from my 13 years as a

professional dancer, but the first injury that prevented me from performing definitely had

contributing psychological factors. This injury occurred when I joined a new ballet

company, and was dealing with a new environment, colleagues, and direction. We were

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building up to a performance and after the morning rehearsals, my right calf felt tight and

stringy. The afternoon rehearsal brought an opportunity to dance the lead role in front of

the entire company. I desired to prove that, although I was new, I deserved this role. At

the end of the first dance, I felt my calf cramp. I still finished the dance, but I couldn’t

flex my foot. There were three more dances to do, so thinking it was just a cramp, I

continued. I survived the run of the ballet, but couldn’t stand or walk after. The next

morning, I still couldn’t walk and went to the doctor to discover that I had torn my calf. I

was afraid to tell anyone important, fearing it would prove that I wasn’t capable of the

role or would be replaced. In addition to the physical demands of the form, dancers

commonly put many psychological stresses on their bodies, which contribute to the

prominence of injuries.

As I have continued in the field, I have been privy to witnessing many dance

injuries. I have also personally known the people to whom these injuries happen, and, in

many cases, have thought there must be some correlation between the stresses imposed

by the job on the individual and the occurrence of the injury.

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Introduction

There are many epidemiological studies and research on the cost, occurrence, and

contributing factors to sports and performing arts injuries (Garrick & Requa, 2005;

Liederbach & Compagno, 2001; Thomas & Tarr, 2009). Unfortunately, the point where

athleticism and art meet, that being dance, has a sparse database of research. Dance has

fewer financial resources, but to keep the art form moving forward, there is a great need

to support the study of psychological stresses on injuries. This research would serve to

support better training and treatment for dancers and could potentially extend an artist’s

career.

Injury is an inevitable factor of a career in dance. Dance injuries stem from both

intrinsic and extrinsic factors, such as: over training, repetition of similar movements,

poor anatomical technique, fatigue, costumes, and slippery or hard surfaces. Injury can

result in the loss of performances, career ascendance and income. Being injured can

cause the dancer to feel worthless, depressed, or isolated (Hamilton, 2008; Mainwaring,

Kerr, & Krasnow, 1993). Conversely, what if being sidelined from injury brings relief

from competition? Perhaps the artist may desire an interruption in the constant

perfectionist tendencies or a physical break from the rigors of training and performing.

Some of the stresses and life circumstances present in a dancer’s life are unique to

the field. These specific demands include the pressure of success for an upcoming

performance, the attainment of better roles, the relationship to a teacher or choreographer,

economic uncertainties in a fragile arts industry potentially leading to job loss, and

maintaining an ideal aesthetic. The current study was created in an effort to deduce what

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biopsychosocial factors may be present for a dancer, and if those factors could influence

their potential for injury. Biopsychosocial is defined as the social, biological, and

psychological aspects of illness in contrast with the biomedical aspects (Liederbach,

2010; Waddell, 2006). This study is administered from an artist’s perspective, versus a

clinical one, in hopes that the artists would be more forthcoming in their response.

Methods

A nationwide survey was distributed to discern whether or not stresses of

perfectionism, economic pressure, relationship troubles, and other psychological stresses

contributed to injury. In conjunction, a study from the Harkness Center for Dance Injuries

(Liederbach & Compagno, 2001) theorizes that stressors affect the preponderance of

injury by disrupting attention, increasing muscular tension, and reducing motor

coordination. The present study was retrospective, and relied on the participant’s memory

of a particular injury over an undetermined time frame. The working definition of injury

was any affliction keeping the dancer from full participation in class or rehearsal for ten

days or more.

The survey was administered through the Survey Monkey website for a period of

two-and-a-half weeks. The link to the survey was marketed through: personal email

contacts, personal healthcare relationships, a dance community newsletter based in

Minneapolis, MN, a link on the DanceNYC website, word of mouth, and the social

networking tool Facebook.

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Results

Of the 113 completed responses, ninety-two respondents were determined to have

an injury fitting the working definition. Of those ninety-two completed responses, 85.9%

considered themselves professional dancers, 6.5% were college students, 3.3% were

student dancers 18 years or younger, and 4.3% had another affiliation with dance.

The participants were asked what were their primary genres of dance and 76.1%

responded ballet, 32.6% responded modern, 9.8% responded musical theater and jazz,

2.2% responded folk/ethnic, and 9.8% responded with other forms (see figure 1).

Although the diversity of forms in the survey was not broad, the demographics

demonstrated a response coast-to-coast and represented over 27 states.

Figure 1- Primary dance genres.

In accordance with other studies (Liederbach, 2010), the foot/ankle was reported

in the survey to be the highest occurring injury. A total of 75 % of the dancers reported

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having a significant injury to this region. Subsequently, the back at 47.8%, the knee at

38%, the shoulder and the lower leg received 17.4%, and the neck totaled 16.3% of

reported injuries (see figure 2). Respondents submitted other injuries, not in the multiple-

choice options: broken rib, strained intercostals muscle, pulled hamstring, groin, hand,

and concussion.

Figure 2- Site of Injuries by Occurrence.

Numerous questions were created to determine the level of trust and

empowerment the dancer felt over his/her career at the time of injury. The employment

questions were adapted from the General Nordic (Kristensen, Hannerz, Hogh, & Borg,

2005) and Copenhagen PSychOsocial (Lindstrom et al., 2000) standard questionnaires

for work-related stresses. The former aimed at assessing psychosocial risks, and the latter

determined areas of work-related stresses. These questions discerned whether or not the

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dancers felt they had control over their working/dancing environment. Ergonomic

researcher Deeney & O’Sullivan (2009) observed, “There is growing evidence that

psychological risk factors exacerbate the effects of physical risk factors thereby

increasing the risk and severity of musculoskeletal disorders ” (p. 245). Questioning the

dancers’ feelings about their work could provide insight into their psychological state,

which potentially affects physical injury risk.

When asked to reflect about their working environment at the time of injury, only

62% of the dancers reported feeling motivated in their work. For such a short-lived, yet,

time and energy-consuming career, one would hope the degree of motivation would be

higher. Young dancers rarely consider the option of pursuing activities other than

dancing. Often this becomes a sacrifice of growing up without normal developmental

milestones such as graduation ceremonies, prom, football games, and parties with friends.

While these sacrifices for training may be true of any elite athlete, dance provides little

monetary compensation, so the trade-off is imbalanced.

When asked about emotional involvement in their place of work, 81.5% reported

positively stating they were emotionally involved. However, it seems that this

involvement is not completely transparent, because 43.5% of the dancers reported the

need to hide their feelings at work. This shows a majority of the dancers have an

emotional connection to their work, but are not always able to express themselves.

Certainly, in any group endeavor, there is some degree of compromise. But, this finding

suggests a need for greater empowerment of the artists through open communication

channels and strong leadership. In accordance, the survey also showed the majority of the

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respondents (46.7%) felt that “only sometimes” they had a large degree of influence over

their work.

The lack of influence dancers feel over their work may be based in the

hierarchical and dogmatic approach with which dance is taught. Students are first taught

the basic positions and movements of dance through emulation. Eventually, as the student

becomes more skilled, the dancer moves and is ‘corrected’ in their experience. This

correction is a criticism and carries the expectation that the movement will then be

‘fixed’. In a sort of reverse psychology, the dancer anticipates and craves the attention of

the correction. This criticism becomes an important aim in assessing progress. In an

interview with professional dancer Michelle deFemery, she supposes, “Dance can be so

negative….we see corrections/criticisms as compliments and spend so much time picking

things apart in a mirror” (M. deFemery, personal communication, December 29, 2010). If

the instructing and leading of dance work instilled a higher degree of empowerment in its

dancers, the dancers could see their degree of influence over the artistic product more

clearly.

The dancer’s quest to maintain peak physical condition and performance is a

given stress of the art, but obviously dancers experience other daily struggles, which may

influence their susceptibility of injury. A study through the Stanford University (Adam,

Brassington, Steiner, & Matheson, 2004) assessed stress and self-esteem over an eight-

month period in thirty-nine female university students. At the end of the study, there was

a strong correlation between the psychological stresses and total injury duration. There

was also a distinction found between the influences of positive stress and negative stress.

Negative events connected with longer injury duration, whereas positive events shortened

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the length of rehabilitation. These results paralleled other sports studies on the influence

of psychological factors on injury. Specifically, Astrid Junge (2000) reported, “it can be

supposed that psychological stressors modify the emotional state, especially

characteristics such as vigor, concentration, or attention” (p. S-14). Dance requires all of

these attributes for peak performance.

Performance-decreasing external stressors can stem from both unique job

demands and struggles for survival. Some of the sources reported in the present dancer

survey included low income, feelings of inadequacy, lack of insurance, new job, and

struggles with a boss. The American College of Sports Medicine recently made a public

statement to various coaches and trainers stating stressed-out athletes are at least twice as

susceptible to injury than their non-stressed peers (Hamilton, 2008, p 138.).

Low income is a known issue for those pursuing a career in dance. Income is

rarely steady and may include periods of unemployment. In the current survey the

primary average monthly income was between $1000-$2000 for 28.3% of the dancers.

The next highest percentage from respondents was 25% reported earnings in excess of

$2000 per month; the next total being 22.8% of dancers earning $0-$250 per month (see

figure 3). While the survey was limited in its ability to decipher earnings in excess of

$2000 per month, even without the highest category, it demonstrated 75% of the

respondents are living at or below the poverty level. The survey was conducted in the

fall, a typically more lucrative season, so it should be noted that the results might be

affected. The summer and late winter are times of more unemployment or fewer jobs.

Still, these statistics demonstrate the reality of low income when considering that 85.9%

of the respondents considered themselves professional dancers.

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Figure 3- Average monthly income.

The economic circumstances affect both the organizations and individuals

contributing to dance. It is often difficult for small organizations to afford insurance for

their dancers, let alone prevention or treatment programs. A study of 100 dance

companies in the bay area (Garrick & Requa, 2005) of San Francisco, California, found

that less than half of the 192 dancers included were covered by workers compensation.

When the largest ballet company was excluded from the study, less than 10.2% of the

dancers had any access to regular health insurance coverage (p. 81). The costs of

healthcare then fall onto the individual dancer, most of who are already living and

working just above the poverty level. In this study, 25% of the respondents reported that

not having insurance or being under-insured, was a stress in their lifestyle.

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One of the dancers from the survey reported their struggle with insurance and

how it directly related to the condition of their body. In an open-ended question the

participant responded, “I am currently still dealing with this injury. It has been very

frustrating and I have not had the extra money or health care benefits to really take care

of it. I have been dancing with pain for two months now. If I had insurance or savings I

would be making an appointment with a doctor.” While conventional wisdom would

suggest the dancer should rest to help to heal an injury, it is possible this dancer cannot

afford to stop dancing. Additionally, rest alone may not restore his/her function. In the

present study, inadequate healthcare affects 33.3% of respondents in their delay of

treatment paired with another 36% who saw money as an obstacle to seeking help.

Worker’s Compensation is another avenue for treatment of injuries for the

dancers contracted with larger dance companies. However, this is not without stress

either for the organization or the individual. The premiums of insurance are often

unrealistically high. Over the course of a five-year period the Boston Ballet generated a

study (Solomon, Solomon, Lyle, & McGray,1999) on its insurance premiums and the

potential savings that could be attained from supplementing care through other avenues.

The impetus of the study was a proposed Workers Compensation Insurance premium of

over $792,000. Through time and additional services, the premium was reduced to an

average of $389,262 per season for the 60+ dancers (p. 168). If they can even afford to

offer insurance, smaller organizations do not always have the resources to provide

alternative treatment nor can they afford to have an increase in their premiums. In this

survey, one dancer mentioned fighting with his/her employer to get Worker’s

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Compensation Insurance coverage for a ruptured ACL. It is likely this fight for care both

delayed treatment and prolonged the rehabilitation.

Fortunately, results from the survey demonstrated an expeditious path to

treatment and diagnosis. In fact, only 2.2% of respondents did not seek help. Half the

respondents did find medical assistance within the day of injury. Again this is in the

context of injuries, which are defined as something keeping a dancer from full

participation in class, rehearsal or performance. Additionally, 65% of injuries in dance

result from repetitive overuse, or micro trauma, that can eventually progress to chronic

injury (Liederbach, 2010). These types of injuries can often be prevented if caught early

on, if the dancer has access to treatment and is willing to seek help.

Physical Therapy Assistant Shannon Casati reports in her work with dancers there

are still many injuries dancers are afraid to acknowledge or treat. Mrs. Casati supposes,

“There is often fear associated with stopping and taking care of an injury in the first

place. Dancers don’t want to seem vulnerable to a colleague or a boss… Sometimes a

dancer will decide that their injury is healed because it is more convenient…” (S. Casati,

personal communication, December 28, 2010). It can be assumed these injuries are not

yet the type to fulfill the working definition of injury, but it is possible they can develop

into a more serious or chronic injury. The dancer’s dependency on how others view them

creates a plethora of psychosocial issues.

Perfectionism dominates the field of dance, which contributes constructively to a

dancer’s drive toward constant work and technical growth. But more often, perfectionism

may lead to a dancer’s decreased sense of self –worth or control over his/her abilities.

This can lead to eating disorders in an attempt to regain control over a career and the

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primary tool- the body (Hamilton, 2008). Especially within the path of classical ballet,

the ideal aesthetic is already prescribed. Dr. Linda Hamilton, the renowned dance

psychologist has done significant research on eating disorders. She asserts that some of

the stress stems from the reality that only 4% of the population naturally achieves the

ideal ballet body type, the rest need to work at it (L. Hamilton, personal communication,

November 13, 2010). That does not mean a stressful nor unhealthy end, but often the

dancer takes it upon his/herself to meet the perceived aesthetic body type without

knowing how to do so, or to whom to turn for help. From a study of a group of South

African ballet dancers (van Staden, Myburgh, & Poggenpoel, 2009), one professional

reported, “When I was younger, when I just came into the company, there were times that

I didn’t allow myself to eat anymore. I wanted to look like the others” (p. 22). It is not

wrong for a dancer to want to fit in, but the safe and healthy means must be established

for dancers to attain longevity and a life beyond dance.

Another maladaptive sense of perfectionism can result in a feeling of inadequacy

in their dancing. From the study of South African classical ballet dancers (van Staden,

Myburgh, & Poggenpoel, 2009), one of the principal dancers commented, “…Dancers

are their [own] worst enemies, because you get off stage and you could never be perfect.

You will never ever be satisfied…never”, (p.21). This dissatisfaction with oneself can

create a negative psychological stress, which has been linked to affecting the onset of

injury (Mainwaring, Kerr, & Krasnow, 1993).

Perfectionism can also make a dancer fear showing vulnerability, or they often

perceive there is no time for injury. It can lead a dancer to continue pushing in rehearsal

or performance when their body is giving clear indications for the need of rest. A study

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published in the Journal of Dance Medicine (Liederbach & Compagno, 2001) detailed

how fatigue related to injury. In the study, 79% of injured dancers reported having

danced in excess of 5 hours prior to injury, (p. 118). Similarly, all of the qualified

healthcare professionals interviewed in this study cited stubborn dancers pushing beyond

their bodies’ warnings. Dr. Hamilton mentioned that sometimes teachers are also

responsible for forcing students to work beyond the body’s limits. She stressed the

importance of the student/teacher (or student/parent) relationship. She hypothesized

sometimes pleasing the teacher or parent is so strong that the early warning signs of

injury go unnoticed in pursuing the dream job or role. The dancer feels pressured to work

through pain and abuse, which is ultimately sabotaging (L. Hamilton, personal

communication, November 13, 2010).

While perfectionism is a known psychological stress for dancers, it is also a key

factor in the success of a dancer. However, an important determining factor of how likely

an injury will occur because of stress or perfectionism lies in how a dancer responds, or

what mechanisms they have to help cope. The most conclusive finding from the survey

was that 73.4% of respondents stated troubles coping with their injury. Even with

support, education, and assistance going through the process of injury, the majority of

dancers struggle coping with being sidelined. Assistance during rehabilitation was

primarily sought from family and friends, with 92% of the respondents citing outside aid.

Other sources included spirituality and meditation. Additionally, 62% of the dancers

reported that the injury negatively affected other aspects of their lives. Clearly,

preventative measures would be well warranted for helping dancers to deal with injury,

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but more pressing is the need for resources to aid an injured dancer to deal with the

implications of being injured.

During the interviews, it was repeatedly mentioned that subsequent injuries are

often easier psychologically than the first. Michelle deFemery utilized the knowledge she

had gained from her first injury as a coping mechanism to ease the fear and frustration of

the second injury. Senior Physical Therapist Faye Dilgen, PT, DPT of the Harkness

Center for Dance Injuries correlates, “Unfortunately, I think the dancers who deal best

with an injury have been injured before. They know what to expect, they know how to

rehab their injury and respect the time frame of healing. Dancers who have never been

injured may have expectations that are not realistic - the learning curve is much steeper”

(F. Dilgen, personal communication, December 13, 2010).

A pointed question was asked in all of the interviews about the creation of injury,

which couldn’t be shown through the survey. The question read: “Have you ever

considered that injury might be self-created or even an opportunity for psychological

healing?” None of the respondents thought that a dancer would knowingly injure

him/herself but they all noted the possibility of self-created injury. Things mentioned

included the opportunity for release from a stressful lifestyle, time-away from a negative

environment, an opportunity to focus on other aspects of life, and even physical time off.

Faye Dilgen replied, “There are dancers who prefer to have an injury – especially if they

are looking for attention and want to keep coming to PT as this is a person who listens to

them, touches them, and gives them undivided attention for a treatment session. This can

facilitate psychological healing, but I have rarely seen an instance when there was not

true injury…” (F. Dilgen, personal communication, December 13, 2010). One dancer

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agreed that while there may be some need for attention, not unlike an eating disorder, the

injury was probably already a potential; a chicken before the egg scenario (M. deFemery,

personal communication, December 29, 2010). The question leads back to the need for

attention and a high degree of care for a dancer to consistently achieve an elite level of

performance.

Discussion

Given that the study relied on the respondents recall, it can be questioned whether

the results are affected by the dancer’s current physical condition or state of mind. In

recording the artists psyche by recollection, this study may have positive bias. However,

the data correlates to existing research about types of injury sustained in the field, and it

further exposed the need for care of the artists. Perhaps also the results would prove

different if the format was more personal, such as an interview type format, versus an

online survey.

Regardless to the survey’s imperfections, it is clear dance at an elite level is an

all-encompassing experience; it is more than a job. When a dancer can’t do their job, they

often have troubles dealing with the rest of their life psychologically and financially. The

results of the survey demonstrated a strong link to coping strategies and injury. There is a

need for future studies to discern what programs best serve dancers coping with injury

and how the dancers find such resources. The repeated mention of subsequent injuries

being easier to cope with also demonstrates an avenue for future studies.

Dancers do not enter the field anticipating financial stability. But how can schools

or companies aide their artists with managing finances and dealing with lost income

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during injury? Similarly, what resources can be made available to dancers to be able to

afford and utilize healthcare? Without these resources dancers are less able to deal with

injury.

The entire institution of dance needs to support the role of the artist both

physically and psychologically. This support comes in the form of readily available heath

care resources, sympathetic directors and teachers, healthy schedules that maximize

exertion when the dancer is warm and not fatigued, and appropriate spaces and surfaces

for the dancers to safely train and perform. Until we empower and support the “whole

dancer,” injuries will continue to plague the artists more than necessary.

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References

Adam, M., Brassington, G., Steiner, H., & Matheson, G. (2004). Psychological factors associated with performance- limiting injuries in professional dancers. Journal of Dance Medicine and Science, 8(2), 43-46.

Byhring, S., Bo, K. (2002). Musculoskeletal injuries in the Norwegian National Ballet: a prospective cohort study. Scandinavian Journal of Medicine and Science in Sports, 12, 365-370.

Deeney, C., & O'Sulivan, L. (2009). Work related psychosocial risks and musculoskeletal disorders: potential factors, causation and evaluation methods. Scandinavian Journal of Work, Environment and Health, 239-248.

Garrick, J., & Requa, R. (2005). Do professional dancers have medical insurance? company-provided medical insurance for professional dancers. Journal of Dance Medicine and Science, 9(3&4), 81-83.

Hamilton, L., Hamilton, W., Meltzer, J., Marshall, P., Molnar, M. (1989) Personality, stress and injuries in professional ballet dancers. The American Journal of Sports Medicine, 17:2, 263-267.

Hamilton, L. (2008) The Dancer’s Way: The New York City Ballet Guide to Mind, Body and Nutrition. New York: St Martin’s Griffin.

Junge, A. (2000). The influence of psychological factors on sports injuries: review of literature. The American Journal of Sports Medicine, 28(5), S10-S15.

Kristensen, T., Hannerz, H., Hogh, A., & Borg, V. (2005). The copenhagen psychosocial questionnaire- a tool for the assessment and improvement of the psychosocial work environment. Scandinavian Journal of Work, Environment and Health, 31(6), 438-449.

Liederbach, M. (2010). Injuries in dance: biopsychosocial considerations. Power point presentation at the Harkness Center for Dance Injuries principles of dance CME course. July 15, 2010.

Liederbach, M., & Compagno, J. (2001). Psychological aspects of fatigue-related injuries in dancers. Journal of Dance Medicine and Science, 5(4), 116-120.

Lindstrom, K., Elo, A., Skoggard, A., Dallnee, M., Hattinen, F., Knardahl, S., Orhede, E. & Gamberale, F. (2000). User guide to qps nordic: general nordic questionnaire for psychological and social factors at work. Nordic Council of Ministers, 8(2), 239-248.

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Mainwaring, L., Kerr, G., & Krasnow, D. (1993). Psychological correlates of dance injuries. Medical Problems of Performing Artists, 3-6.

Solomon, R., Solomon, J., Lyle, J., & McGray, E. (1999). The "cost" of injuries in a professional ballet company. Medical Problems of Performing Artists, 164-170.

Thomas, H., Tarr, J. (2009). Dancer’s perceptions of pain and injury - positive and negative effects. Journal of Dance Medicine and Science, 13(2), 51-59.

Waddell, G. (2006). Preventing incapacity in people with musculoskeletal disorders. British Medical Bulletin, 77 & 78, 56- 69.

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

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biopsychosocial factors in injury: from an artist's perspective

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