Follow-up links on concussion

Following last month's blog on concussion (which can be found here) there have been a few interesting articles popping up over the internet:

Controlling body composition - nutrition

From the results of last week's survey (thank you for participating in it!) one issue was raised several times - nutrition and weight control.  So here's a guide on how to begin addressing your nutritional needs while maintaining control over body composition.

Concussion in dance and aesthetic sports

Concussion, also referred to as minor traumatic brain injury (mTBI), is an injury more commonly associated with contact sports than with dancing. There has however been an increase in recent years in the number of reported concussions in dancers, and it is necessary for the dance teacher, director, choreographer and dancers themselves to be able to recognise and react to a concussion when it occurs.

In aesthetic sports such as gymnastics and cheerleading, and in dance related genres such as physical theatre, the reported instances of concussion are significantly higher than in dance, largely due to moves performed while elevated and in performing tricks and stunts. In cheerleading, stunts are responsible for 90% of the concussions suffered by athletes, with the majority of these affecting the bases, rather than the athlete in the air. Across various genres of dance, from street to ballroom to contemporary to lindy-hop, numerous aspects of choreography can pose a risk to dancers if not executed properly. With dance choreography constantly pushing new limits of dancers' physical abilities, and increasingly incorporating tricks and stunts in pieces, it is useful to now consider dance alongside gymnastics and cheerleading as an activity carrying the potential for concussion. 

In a wide variety of sports, it has been found that concussion is under-reported, and that athletes go on to perform or compete after sustaining a head injury. It is imperative for the safety of the dancer or athlete that all concussions are recognised and appropriately addressed. Self-reporting of symptoms has been proven to be ineffective at identifying concussion, and so standardised testing procedures should be in place to ensure concussions are identified and appropriately addressed.

Anterior Pelvic Tilt in Dancers

Correct alignment is crucial to dance technique. A common alignment issue in dancers is an exaggerated anterior pelvic tilt - tilting the the pelvis forward. No two individuals will have identical spinal and pelvic alignment, and so it is perhaps useful to think of there being an  range that can be considered optimal rather than one set alignment that is perfect. The anterior pelvic tilt pulls the body out of correct alignment (outwith the optimal range), resulting in flawed technique and impaired performance. Your lower abdomen will protrude and your backside will stick out. Over and above the artistic flaw, anterior pelvic tilt impairs turnout and prevents proper muscle recruitment, can cause hip pain, back pain, knee pain and flat feet.

The hip flexors connect the femur to the hip and lower back; tight, short hip flexors cause the hip to pull forward. Any misalignment of the hips will effect the back, and anterior pelvic tilt will give a pronounced curvature of the thoracic spine. This in turn may then produce upper back pain, shoulder and neck pain, headaches and migraine.

Healthy hips are essential in dance, the turnout and all subsequent movement of the lower body originates here. While pelvic motion is central to many of the basic movements of dance (for example the battement de vant, a la seconde and derrière all display differing degrees of pelvic motion), the body should have a neutral home alignment. The internal rotation of the hip displayed with APT goes on to effect the lower limbs, producing subsequent internal rotation of both the femur and tibia, reducing turnout. This can cause or exaggerate existing over-pronation of the feet, causing foot, ankle and knee pain. Incorrect alignment further predisposes the dancer to injury.

Flexibility training - is it necessary?

Flexibility training can be divisive issue. Even I'm divided on it. On the one hand, you can improve your flexibility levels to a degree through appropriate training (stretching) methods. On the other, the gains you can make are somewhat limited, and I'll often argue largely outweighed by the likelihood of injury (up to 80% of dance injuries are sustained during flexibility exercises. That's an awful lot.).

Having spent the better portion of my life in dance training and surrounded by other dancers, I can honestly say I've seen a LOT of time wasted on flexibility training for next to no gains. 85% of your flexibility is down to your skeletal structure, 5% is down to environmental circumstances, leaving only 10% down to muscular elasticity.  10%. All those hours spent trying to push that little bit further, and the best you can hope for is 10%.

Fitness for dance...not dance fitness

For sedentary individuals, taking up dance as a hobby or a past time can undoubtably have a positive effect on their overall health, fitness and well being, just as taking up any physical discipline can have a positive effect. Movements such as Zumba, aerobics, Jazzercise etc are all forms of dance fitness; as well as the plethora of community dance classes across a range of disciplines. While great at getting otherwise sedentary individuals into physical exercise, dance fitness has no relevance to the dance professional.

As far as physical fitness goes, for the professional (or preprofessional) dancer, dance training alone is not enough. If you are serious about your dance performance you should get fit in order to dance, not dance to get fit. This means training outwith your technique and performance classes, to prepare the body for the demands you throw at it. Strength, aerobic, interval, plyometric and flexibility training are all necessary in order to condition your body to perform at the highest level.

Every professional athlete and sportsman/woman will train not only in their discipline, but for their discipline. A sprinter does not only sprint in their training sessions, a golfer does not spend all their time swinging clubs and a dancer should not spend all their time working on repetoire and syllabus.

Staying active during injury recovery

First up before I say anything else - speak to your doctor/physio/surgeon before you go hell for leather into any training routine while you're injured. The last thing you want to do it prolong your recovery or worsen your existing injury. Also, there are times when giving your body a break for at least a couple of weeks might actually be the best thing for it. Speak to your doctor, assess your situation and make your decision.

Training when you're injured can have a lot of benefits if you do it safely; it can slow muscle atrophy if you have limb immobilied, maintain your existing fitness levels, or at least prevent them from dropping too far, and can lessen the psychological impacts of injury. Unfortunately if you're injured and want to stay active, you may have to accept that you won't be dancing for a while. This doesn't mean you can't work on specific aspects of technique or fitness, just be smart about it. Any time I've injured myself I've found boredom and frustration can be one of the worst aspects so finding a way to stay motivated and at least maintain a basic level of activity feels better than nothing.

Hypermobility in dancers

Despite hypermobility being a topic that is frequently discussed in both dance and dance science circles, it was not an area I've ever had a great interest in. My focus has generally been on supplemental strength training and endocrinology, and anything that falls outside of that I've been reluctant to delve into too deeply. That is until I was diagnosed with hypermobility syndrome after my most recent injury. Being the type of person I am, I can't be told something is affecting my body without then poring over every piece of information on the subject that I can get my hands on. I've never considered myself to have above average flexibility compared with both my dancer and non-dancer colleagues, in fact, my lack of hip flexibility and subsequent limited turnout had been a bone of contention for most of my performing life. Sure I had to resort to my knees rotating and sneakily compensating for what my hips lacked (terrible idea by the way), but the rest of my flexibility levels were pretty good so I accepted you can't win them all and figured I was working from a pretty typical physical start-point. I therefore assumed hypermobility wasn't going to be a problem that affected me. Turns out I was wrong - I was blessed with both average flexibility and sub-par joints. Hypermobility syndrome affects the stability and range of motion of several of, although not necessarily all the body's joints and subsequently can have a substantial impact on posture, joint pain, physical performance and proprioception. 

An overview of injury in dance

Dance medicine and science practitioners focus predominantly on three interlinked areas - injury prevention, healthier dance practice and the development of peak performance. When working towards these goals, it can be useful to take a step back and consider the extent of the healthcare issues facing dancers that must be addressed. Injury is the key factor in this, as neither healthy dance practice and peak performance cannot be achieved without addressing the significant problem of injury occurence in the dance profession.

Instances of injury are excessively high in the dancers. Across all disciplines of dance musculoskeletal injury is common in both student and professional dancers. Pushing the body to it's limits and the evolution of evermore demanding choreography means that dance will always be a risky profession; this does not mean however that steps cannot be taken to reduce the risk.
Collecting data on dance injury can be problematic due to dancers often being reluctant to report physical problems to directors or company doctors out of fear of losing professional position or opportunity. Therefore in many studies on dance injury, anonymous self-reporting has proven more useful than company medical records, as is the case with the studies discussed below. The extent of the problem, when providing the security of anonymity to dancers, is shown to be much wider than official company records state. What follows is a brief overview of the issue according to published research.

Nutrition - Protein

It is essential when following a low calorie diet, as many dancers are, that nutrient intake is monitored and you ensure you are providing your body with adequate provision of carbs, protein and fat. Protein is an essential macronutrient that contributes to the formation and repair of muscle and other tissues. It is also required for metabolic processes, formation of antibodies making it crucial to the immune system, hormone synthesis, and even functioning as an energy source when carbohydrate and fat stores are depleted (i.e. in cases of starvation, exhaustion or extreme endurance exercise).

Dietary protein has additional benefits including increased feelings of satiety (making you feel fuller), higher thermic effect during metabolism than fats or carbs (meaning consumption of dietary protein may increase your metabolic rate) and increased protein turnover (regeneration of body tissue). Protein contains nitrogen, enabling it to form amino acids. There are 20 amino acids that the adult body needs, classified as either essential or non-essential amino acids. The 9 essential amino acids cannot be made in the body and therefore must be provided for through protein sources in our diet. So protein does one hell of a lot for us, and we need to ensure that even when controlling energy intake in low calorie diets, we are meeting our bodies' requirements.

Timetabling in full-time training

Dance schools, conservatoires and companies have a responsibility to care for the overall health and well-being of the dancers they work with. This means on top of technical training providing measures for injury prevention, fitness training, nutritional support, psychological support and a measured approach to workload. Training frequency and scheduling is often waylaid due to other concerns; timetabling tends to be based on what is convenient for studio space or teacher availability, rather than what makes the most sense for the dancers. Scheduling of training can have a significant effect on the dancer's performance and well-being and it is important that companies and schools recognise the implications of their timetabling.

Nutrition and Injury Recovery

I'm currently typing this one-handed, sitting banged up at home with my first serious injury in about 4 years. I dislocated my elbow at the start of the week and will be spending the foreseeable future in the world's least stylish full-arm cast and not lifting anything heavier than a teacup. Awesome. So it seems as good a time as any to discuss options for injury rehab, recovery nutrition and finding some way to not just bow down and give up for several weeks.

Supplements use in dancers

Dietary supplements are taken by athletes to supplement their existing nutritional intakes and address any insufficiencies or deficiencies that may affect their health or performance. While some are taken for performance and others for health, others are completely pointless, occasionally dangerous, and all cost a considerable amount of money. Individuals with low caloric intakes may need to consider supplementation in order to ensure their nutrient intake is adequate. As many dancers use calorie restriction in an attempt to control weight and body composition, they are an at-risk group for nutrient insufficiencies/deficiencies and so it is worth considering where insufficiencies may arise.

Disordered Eating in Dance

When it comes to discussing eating disorders in dancers, I seem to spend all my time either trying to convince my non-dancing friends that the majority of dancers do not have an eating disorder, or trying to convince my colleagues who do work in dance that it is a serious problem that needs addressing. While to non-dancers the image of the anorexic ballet dancer is at least familiar if not cliched, to many dancers there is a denial regarding the degree to which disordered eating is a serious and wide-spread problem and there is a sense of many people and companies being in denial about the severity of the issue. In reality the scope of the problem sits somewhere between the two outlooks - disordered eating is a serious problem for a significant minority of dancers.

Research Update: Vitamin D status in ballet dancers

A new study carried out by Roger Wolman of the Royal National Orthopaedic Hospital in Stanmore, along with colleagues at the University of Wolverhampton, has looked at the vitamin D status of professional ballet dancers in winter vs summer months.

(c) Koji Aoki  

The 6 month cohort study contrasted high sunlight months (summer) against low sunlight months (winter). The study looked at 19 professional ballet dancers within the UK and considered their vitamin D status through serum 25-hydroxyvitamin D levels within the body, as well as recording parathyroid hormone (PTH) and blood serum bone turnover markers (CTX and PINP). The dancers all danced 6-8 hours a day, for 38 hours a week. The Company's doctors recorded injury instance over the 6 month period.

Significant differences were found in levels of serum 25-hydroxyvitamin D, PTH  and blood serum bone turnover markers between summer and winter months. Although levels of 25-hyrdoxyvitaminD were higher in summer months, only 3 of the 19 dancers achieved "sufficient" levels during the summer period, with the rest being considered either insufficient or deficient in vitamin D. All dancers' vitamin D levels were found to be insufficient or deficient in winter months.

The importance of dance-specific medical practitioners

If you're a dance student, working freelance, part-time or recreationally, or indeed if you're aligned to a company that does not have it's own physio, podiatrist or osteopath, you've probably had some mixed experiences going to see medical practitioners about dance related injuries. In the UK we're lucky enough to have the NHS, meaning we don't have to pay to see a specialist. The downside of this is we usually don't get to pick who we see.

Overtraining

Overtraining or burnout refer to a condition where athletes or dancers note a marked decrease in physical performance for no apparent physical or medical reason, suffer from prolonged fatigue and display behavioral and emotional changes. Symptoms of overtraining will vary from individual to individual, the most common symptoms include:

• Increased perception of effort during exercise
• Excessive sweating
• Frequent upper respiratory tract infections
• Breakdown of technique
• Muscle soreness
• Sleep disturbance
• Lack of concentration
• Loss of appetite
• Mood disturbances
• Signs of depression
• Decreased interest in training and performance
• Decreased self-confidence

Nutrition - Carbs

Nutritional needs get a whole lot easier to understand if you have a basic understanding of your energy systems and the fuels each energy system uses. Your body has 3 - the ATP-PCr, the Glycolytic and the Oxidative systems.

The ATP-PCr System produces immediate energy and so is able to assist in instantaneous muscle contraction for short periods of high exertion exercise.The Glycolytic System, producing ATP through the breakdown of glucose. The Glycolytic system resynthesises ATP at a faster rate than the Oxidative system, and produces energy for short bursts of activity lasting up to around 2 minutes. The Oxidative System takes longer to be activated through activity than the other energy systems, however it has a higher energy producing capacity and so is utilised in endurance activities. Dance utilises all three energy systems, depending on the specific activities being performed; all three systems use carbohydrate as their main, if not sole, source of fuel.

Working with recreational dancers

Working with recreational community dance groups poses a different set of considerations in class planning. Instead of working with a known quantity, you never know how many dancers you will have; what level of fitness they are at or what level of technique, if any, they have. It can make planning sessions and creating choreography tricky at best. You can have individuals brand new to exercise in with semi-professional dancers, or people who have trained to a high level alongside people with reasonable levels of fitness but absolutely no technical knowledge. Fitness and technical skill can vary wildly, and your job is to find a means of providing a diverse population with a useful, enjoyable and fulfilling class.

Physiological Considerations with Children

Most dancers work with children at some point, whether it's on a daily basis or once or twice a year; through teaching, outreach or company workshops almost all of us will work with young people on and off throughout our careers. In developing the skills of young dancers it's helpful to have an understanding of the implications of various growth stages on their physical performance.