dance performance research paper

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Preventing dance injuries: current perspectives

Jeffrey a russell.

Division of Athletic Training, School of Applied Health Sciences and Wellness, Ohio University, Athens, OH, USA

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.

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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:

• Establish uniform methodology for tests and measures used to assess dancer capacities and intrinsic and extrinsic risk factors for injury;
• Establish common protocols for reporting injuries;
• 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 ( Table 1 ). 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 Table 1 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.

Contributors to dance injury

Adapted from Arch Phys Med Rehabil , 85(3 Suppl 1), Sports and performing arts medicine. 6. Issues relating to dancers, S75–S78, Copyright 2004, with permission from Elsevier. 99 The table has been reconfigured for clarity. Items in italics are additions to Toledo et al’s list, as are the commentaries in the rightmost column.

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.

Participation in dance is not sufficiently intense across long durations to substantially improve aerobic capacity, 31 , 112 , 113 and low cardiorespiratory endurance has been associated with dance injuries. 114 In adolescent female dance students, O’Neill et al 115 found that moderate-to-vigorous physical activity was lowest in the highest level dance classes, though students with more dance training generally tended to be more active in their classes than students with less training. Further, they noted that ballet classes offered less time for physical activity than did jazz and tap classes. Overall, the dance students they studied were moderately to vigorously active for only 10 minutes per hour of dance classes. In a study of modern dancers, Wyon et al 31 found, not surprisingly, that participating in dance performances resulted in significantly higher heart rates and greater mean oxygen uptakes than either dance classes or rehearsals. Activity heart rates in their cohort of dancers were only rarely at a level consistent with that needed for aerobic improvement.

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.

Whereas poor core stability has been identified as a risk factor for upper 118 and lower 119 extremity injury, and inadequate neuromuscular control in the trunk has been specifically associated with increased athletic knee injuries in females, 120 dancers’ attention to these components of fitness is warranted. In elite professional ballet dancers, smaller cross-sectional area of the multifidus muscles have been correlated with lower back pain. 121 The trunk muscles appear to fire in anticipation of lower extremity muscle contraction; 122 this suggests the importance of optimal core function as the aesthetics of dance are intimately dependent on precise control of both the trunk and extremities. Therefore, attention to core stability and strength should be considered foundational to the remainder of a dancer’s training with the caveat that further research on core function in dancers is needed in light of Rickman et al’s 123 findings that the research literature on this topic is relatively scant.

Low levels of muscular strength and power also have been suggested as predictive of dance injuries. 22 , 124 , 125 Specifically, thigh torque in a cohort of male and female ballet and contemporary dancers was correlated with severity of injury as measured in days lost from dancing. 124 Angioi et al 22 similarly found leg power measured by vertical jump height to be positively correlated with days lost from dancing. In support of the need for physical training by dancers, a 6-week program of circuit and vibration training of contemporary dancers led to improvement in lower body muscular power, upper body muscular endurance, aerobic fitness, and aesthetic competence. 34

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

Suboptimal nutrition has been associated with injury in dancers. 127 , 128 Disordered eating and eating disorders – a discussion of which is beyond the scope of this review – are well known to affect many dancers. 129 – 132 In addition, physiques generally associated with female ballet dancers, ie, high ectomorphy, low mesomorphy, and low percent body fat, have been linked to increased injury. 133 Ballet dancers are particularly prone to control their physiques, especially via restricted dietary practices, because of the aesthetic requirements of their genre, as well as the related issue of the pressure to manage every detail of their existence as a means to maintain their place in a dance company. Many dancers may not follow sound research-based nutritional practices; thus, health care practitioners should utilize well-documented advice in encouraging dancers toward a healthy energy and fluid intake. Excellent resources for this purpose include the joint position statement on nutrition for sports performance developed by the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine. 134

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.

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.

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 ( Figure 1 ). 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

A ballet dancer standing en pointe. Note the extreme talocrural plantar flexion and the architecture of the midfoot, the combination of which is required for the dancer to attain this position.

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.

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.

• 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.
• 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).
• Proper nutrition and rest (reduction of fatigue) are essential factors in maintaining a dancer’s body that is as resistant to injury as possible.
• The provision of specialized health care services to dancers is important to risk assessment, injury management, and injury reduction.
• 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.

The author reports no conflict of interest in this work.

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Review: Moscow City Ballet’s The Nutcracker at The Regent Theatre*

Last night, we went to see the magical story of The Nutcracker by the Moscow City Ballet at The Regent Theatre . Traditionally a Christmas tale, however, the Moscow City Ballet are currently just starting their UK 2020 Tour, which is due to last the next couple of months. On their roster, is Swan Lake, Sleeping Beauty and of course the Nutcracker, all being played in various cities around the UK and also three special performances (of each story) in Dublin.

Moscow City Ballet was started back in 1988 by the acclaimed choreographer Victor Smirnov-Golovanov, who sadly passed away in 2013. The company was taken over by his wife Ludmila Nerubashenko as Artistic Director. She had been Principle Ballet Mistress since 1993, therefore, was well equipped to take over his role. Smirnov-Golovanov’s concept was to allow artist licence to his dancers, with certain aspects of the choreography, allowing them the freedom to add in parts to the dance as long as they didn’t sway too far from the original choreographic concept.

What we thought of the Nutcracker

The Nutcracker, originally a story by Prussian writer E.T.A. Hoffman, written in 1814, and then adapted by the famous French writer Alexandre Dumas in 1844. This adaptation, then went onto be the inspiration for  Pyotr Ilyich Tchaikovsky Ballet of the same name which was completed in 1892.

Tchaikovsky iconic score of this Ballet is recognisable by all ages through all generations. I am sure you will remember as a child seeing or opening the classic children’s jewellery boxes that contained a dancing ballerina playing the music from this beautiful ballet? You will have heard the music on TV adverts, films and even weaved within nursery rhymes.

The Ballet begins with the Christmas Eve Party, where Clara first sees the Nutcracker. During this time the dancers are introducing you to the characters of the Nutcracker, the doll and the Mouse King. After the loosely choreographed first scene the dancers awoke to their centre stage performance that became a total delight. In scene two you are taken to the enchanted Forest where the blue tutus of the Ballerinas bounce, as their synchronised toes float across the stage.

The orchestra, although quiet at times, played beautifully and perfectly matched the pitter-patter of the ballet dancers movements across the boards of the theatre. As previously mentioned its such an iconic score and so delightful to hear live, however, it was a shame that it did at times lack a bit of oompf you would expect. I am not sure if this was down to the size of the orchestra or the dynamics of The Regent Theatre. That being said – my feet were still tapping at the most recognisable parts.

The second act makes for a truly magical performance, where the dancing flowers and fairies decorate the stage. We see how skilled some of the ballet dancers are as they jump and drift across the floor. It is with this combination of elegant movement and classical music, that makes the Nutcracker the perfect Ballet for those young and old who want to hold onto the magic of Christmas whatever the season.

Each ending in many different productions of this classic tale over the years have been different, and this also includes aspects of the narrative in the middle too. But Each one means that if you have seen this Ballet several times over the years, it means that you more than likely won’t have seen the same one!

Clara – Ksenya Basnet

Nutcracker Prince – Dzimitry Lazovik

Drosselmeier – Daniil Orlov

Flower Fairy – Liliya Orekhova

Mouse King – Mikhailo Tkachuk

Doll – Rachel Hernon

Nutcracker Doll – Sanzhar Omurbaev

Mouse King Doll – Daniyar Dosimbek

Fritz – Anastasiya Krutina

Spanish dance – Polina Tokareva

Russian – Rachel Hernon

Eastern dance – Taisiya Sukhorukova

Chinese dance – Mao Sakai 

Ballet Mistress – Lyudmila Poladkhanova 

With Artists of the Corps de Ballet 

With the Moscow City Ballet Orchestra conducted by Igor Shavruk 

Artistic Director Lyudmila Nerubashchenko 

How much do the tickets cost?

Tickets are priced from £13 to £56.90.

How do I book tickets to watch The Nutcracker?

Tickets are now on sale and available from the Box Office, by calling 0844 871 7649 or by visiting ATG’s website here .

How long is the show for and what are the timings?

The show opened on Monday,  20 January and will run until Wednesday, 22 January 2020. Shows will be at 7pm each night and will run for 1 hour and 50 minutes (including interval).

• Parking is ample either around the public car parks close to The Regent, but do check the rules. Some parking lots might need you to pay even at night. We parked up at intu Potteries and that cost us £1 (its fixed rate after 6pm).
• The Regent also provides binoculars (usually located at the back of each seat) for £1.
• Programme Booklets are usually on sale for £5, full details of the show and cast members are featured on it.
• The Regent is a beautiful theatre with ornate decor and traditional seating. It has plenty of performances out throughout the year and lots of variety.

About Regent Theatre

The Regent Theatre is a theatre in Stoke-on-Trent, England. Constructed in 1929 as a cinema, it is one of several theatres in the city centre and one of two owned by the Ambassador Theatre Group. The building was converted for full-time use as a theatre in 1999, and since then has hosted a number of shows and musicals. The theatre is also the northern base for the Glyndebourne Touring Opera.

About Moscow City Ballet

The Moscow City Ballet was founded in 1988 by the distinguished Russian choreographer Victor Smirnov-Golovanov, with the aim to promote the original ideas of the great 19th and 20th century Russian choreographers.  The birth of the company was a direct outcome of the sweeping changes in the Soviet Union in the late 1980s, where “Glastnost” and “Perestroyka” made the private enterprise legal again and Moscow City Ballet was the first privately owned ballet company in the USSR. It’s original name “The New Ballet of Moscow” was deemed too descriptive and the new name, “The Moscow City Ballet” was adopted in 1990.  The company remains true to its original ideals, showcasing some of the greatest works of the Russian and Soviet ballet heritage.  Its new aim is to preserve the legacy of late Victor Smirnov-Golovanov’s original choreography, with the ballets such as The Nutcracker, Cinderella and Romeo and Juliet having been exclusively choreographed by Victor for the Moscow City Ballet.

The company’s first appearance was in 1989 in Seoul, Korea. Its success outside of Russia makes it one of Russia’s most extensively touring ballet companies. Since 1988, Moscow City Ballet has appeared in Belgium, Brazil, Bulgaria, Cyprus, Czech Republic, Denmark, Egypt, Estonia, Germany, Hong-Kong, Hungary, Ireland, Israel, Italy, Japan, Jersey, Latvia, Lithuania, Luxemburg, Netherlands, People’s Republic of China, Philippines, Poland, Portugal, Republic Korea, R.O.C. Taiwan, Romania, Serbia, Singapore, Slovakia, Spain, United Arab Emirates, United Kingdom, United States of America and, naturally, in Russia itself.  The company’s greatest success has been in the United Kingdom where it has given more than 1000 performances since 1991, accompanied by the Moscow City Ballet Orchestra.

Moscow City Ballet is one of Russia’s most successful and popular touring ballet companies, highly admired for its distinctive style, dramatic story‐telling, exciting choreography and exceptionally gifted dancers. Under the artistic direction of Victor Smirnov-Golovanov’s widow, Ludmila Neroubashchenko, the company continues to be committed to promoting ballet in the Russian classical tradition to audiences all over the world.

About PMB Presentations

PMB Presentations has a reputation for excellence. The organisation represents ‘high end’ visiting companies of genuine repute and pedigree. PMB personnel have been associated with all genres of live shows especially Dance, Opera and Ballet since 1996, and participated in over 10,000 high-quality performances in the major UK regional theatres; international concert halls; Theatre Champs Elysees Paris, and in London at the Royal Festival Hall, the Royal Albert Hall, Cadogan Hall and London Coliseum. In the UK dance market where theatres and councils attempt to build audiences for dance, particularly contemporary dance, classical ballet touring under the PMB banner remains the most popular audience choice, maintaining consistently large attendance.

Review by: Lex Ward

You may also want to read this:

Review: Fame The Musical at The Regent Theatre in Stoke-on-Trent

Review: Matthew Bourne’s The Red Shoes at The Lowry in Salford, Manchester

Review: Birmingham Royal Ballet – Beauty and The Beast at The Lowry Theatre

Photo Credit:  Regent Theatre/Moscow City Ballet/PMB Presentations

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I bet this is absolutely incredible to get to see live – especially with the Moscow ballet! There is something magical about The Nutcracker and if I was to go and see a ballet it would definitely be this one.

You are so right Sarah, there were parts in it which was so magical and the ballet dancers were so graceful and the choreography is so wonderful

I would love to see this, I bet it was amazing to watch I have always wanted to see this live, hopefully one day x

Hope you do get to watch it, they are touring around the UK at the moment

Oh that looks abaolutely wonderful. I love going to see the ballet and would really like to see this, what a treat!

Absolutely, we totally enjoyed last night’s show

My girls and I LOVE going to ballets! Having kids in ballet class, I find that going to these only inspire them, as well as entertain. I would love for us to see the Nutcracker!

Hope you all do get a chance to see it, we watched it with our girls and loved it!

I saw this 12 years ago and I still have such fond memories of it.

Despite being heavily pregnant and forced in to a tiny seat, it was just the most wonderful experience x

How wonderful to hear your story Claire, glad our post brought back those memories

I would love to go and see this ballet. Moscow City Ballet and the other similar theaters from Russia have such talented dancers who work a lot to be able to perform so perfectly.

Absolutely! The amount of practise they have put into it shows, it was amazing to watch them perform

I love going to the ballet, such beautiful performances to watch. I haven’t been in so long so would love to see the Moscow City Ballet!

They were so beautiful to watch and we especially our kids totally enjoyed the performance

I’d love to go to the ballet as I’d be mesmerized by the dancers, it’s so impressive what they do. Each Christmas I see the nutcracker on show so maybe next year I’ll need to go x

Hope you get a chance to see the nutcracker when it tours near your place.

The performance was sublime, the company are very accomplished. We thoroughly enjoyed the performance.

I have to agree with you there Kevin, we totally loved it as well. Preferred the second part more to the first

I must admit I am not a ballet fan, although this does look very interesting. My mum is though, so maybe I will have to treat her?! 🙂

You must do, lots of families were there, young and old, men and woman

Its not necessarily my thing however my family, especially the three girls, love performances, theatres and Ballet and would have found this very enjoyable, great Review!

Thank you Liam for taking the time to read our review and leave a comment

A friend of mine teaches ballet and she talked about meeting the Moscow city ballet and lamented on how talented they are, the nutcracker show must have been incredible to watch.

Yes it certainly was, it is a privilege watching them live

Oh wow what a beautiful show, the pictures look amazing! Its a show I would love to see, in fact any of the shows you mentioned above I am sure would be lovely to watch. I find the ballet so elegant to watch and the music is always so beautiful too!

The dancers are such professional and so flawless and graceful when they dance. Such joy to watch them

Oh wow, that looks simply incredible. I’ve never seen a ballet, but would love to watch one one day. What a great experience!

It was a lovely experience to see the show live, hope you get the chance too

Wow it sounds amazing, only ever been to one ballet and I loved it. I would love to be able to go to more.

Hope you get the chance to watch the Nutcracker by the Moscow City Ballet dancers

I would love to see this ballet but mistakenly thought it was being performed in March 2020. So disappointed to have missed it but hopefully it will return to the Regent Theatre sometime in the not too distant future!

They are touring around the UK Rota, so worth checking out their website to see where they are headed to next, not too sure if they will head back to The Regent Theatre this year.

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Title: phi-3 technical report: a highly capable language model locally on your phone.

Abstract: We introduce phi-3-mini, a 3.8 billion parameter language model trained on 3.3 trillion tokens, whose overall performance, as measured by both academic benchmarks and internal testing, rivals that of models such as Mixtral 8x7B and GPT-3.5 (e.g., phi-3-mini achieves 69% on MMLU and 8.38 on MT-bench), despite being small enough to be deployed on a phone. The innovation lies entirely in our dataset for training, a scaled-up version of the one used for phi-2, composed of heavily filtered web data and synthetic data. The model is also further aligned for robustness, safety, and chat format. We also provide some initial parameter-scaling results with a 7B and 14B models trained for 4.8T tokens, called phi-3-small and phi-3-medium, both significantly more capable than phi-3-mini (e.g., respectively 75% and 78% on MMLU, and 8.7 and 8.9 on MT-bench).

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