Ballet dancing requires a high level of technical skill which involves pushing human body’s to the limit of strength and flexibility. Interestingly very few acute injuries are reported by dancers whereas there is a much higher rate of chronic injuries associated with over-load. This makes sense considering the unique repetitive nature of the sport and acute injuries being associated with loss of balance.
It has been found that ballet dancers may be at risk of some injuries independent of age, gender or level of mastery with important risk factors being intensity of training, poor control of lumbosacral complex motion, lower limb weakness and poor aerobic fitness. Even though we know about these risk factors and injuries there remains a lack of consensus about which physiotherapy treatments are best to use for ballet dancers.
Investigation into treatment effects in ballet dancers is usually reported in small cohort or case studies focussing on one joint rather than the ballet dancer as a whole – this is important considering the extreme multi-planar multi-joint range of movements the ballet dancers perform. Generally though the evidence as a whole points to physiotherapy reducing pain and increasing range of movement in ballet dancers.
A new systematic review published in PLoS ONE aimed to clarify this by assessing the effectiveness of physiotherapy interventions in the treatment of injuries in ballet dancers.
This sytematic review adhered to PRISMA guidance but was not pre-registered on PROSPERO which means there is opportunity for reporting bias as it will be difficult for future replication and direct comparison of this review.
The databses used were PubMed, OVID Embase, Cochrane, Medline, PEDro and Google Scholar and were searched by two reviewers and discussion was used to reach consensus. Again this should have been an independent third reviewer to reduce potential bias.
((((dance therapy[MeSH Terms]) AND (ballet[MeSH Terms])) OR (ballet dancer)) OR (classical dancer)) AND (pain)
All types of quantitative studies were included within the review including cohort and quasi-experimental designs. Studies were included if they were investigating ballet dancers with acute or chronic injuries and persistent pain and recieved physiotherapy interventions. There were no restrictions applied to the search and physio intervention was nonspecific.
The outcome measures of interest were multidimensional nature of pain, injury / pain site, non-specific treatments recieved and pain, ROM, quality of lide and function. In essence there was no limit to specific outcomes. Studies were excluded if they included surgery or pharamological interventions.
Quality of studies included was assessed using the NHMRC hierarchy of evidence and qualitative studies using the Modified McMaster Critical Review Form. Each study was rated independently by each reviewer and disputes resolved by discussion.
Results & Clinical Take Home
Ten articles were included within the review totalling 83 participants with age ranging from 11-29 and sample sizes of the studies ranged from 1 to 62. The overall quality of the included studies was poor (D rated) which limit the applicability of the results of the review.
That being said there are lessons to be learned from the review. There is significant variation in the treatments used to treat ballet dancers. Shockwave, manual therapy, stability training for lumbosacral spine, home exercise programmes, heat therapy, acupuncture and dry needling were all intervention used. Even within some studies multiple treatments were used making causality difficult to establish.
The effectiveness of interventions was assessed using a multitude of different outcome measures (OMS) making it hard to compare outcomes between studies. OMS used included VAS, muscle length tests, special tests, Beighton scale, MRI, CT scans, PedsQL as well as dance specific questionnaires such as DFOS. On the whole all studies indicated positive changes in outcomes across all treatments.
The results of the ten studies can be summarized across six domains;pain, ROM, phsical assessment, posture & gait, quality of life and structural status. Across all six of these domains the results suggest that physio interventions exerted a positive influence in all six domains.
Pain was assessed in all studies included within the review and all demonstrated an improvement in pain levels after physio intervention. Range of movements was assessed in six of the studies and again a positive effect was seen across the dancers. A smiliar pattern was seen in the quality of life and functional status questionnaires.
The question is though – how many of these injuries would have fully recovered without specific physiotherapy interventions? It is possible that specific interventions would have improved injuries quicker but the quality of study is poor meaning not a lot can be discerned from the results other than general physio approaches used for any sports person apply to ballet dancers.