Acessibilidade / Reportar erro

INJURIES IN PROFESSIONAL DANCERS: A SYSTEMATIC REVIEW

LESÕES EM BAILARINOS PROFISSIONAIS: UMA REVISÃO SISTEMÁTICA

LESIONES EN LOS BAILARINES PROFESIONALES: UNA REVISIÓN SISTEMÁTICA

ABSTRACT

Movement is a fundamental element of dance, and the dancer’s body is the raw material through which the art of dance is expressed; for this, it demands the utmost discipline in the pursuit of technical and artistic excellence. To meet the professional demands, dancers are subjected to strenuous training routines, which can lead to the development of injuries in this environment. The objective was to examine the etiology, main affected segments, prevalence, and instruments used to evaluate the lesions in studies with professional dancers and/or in comparison with similar populations. We selected articles published in the last decade in the databases BIREME, LILACS, MEDLINE EBSCO, WEB OF SCIENCE, SCOPUS (Elsevier), and PubMed, with cross-sectional, observational cohort and case control design published in Portuguese, English, or Spanish. Systematic reviews, case studies, dissertations, theses, book chapters, cross-referenced articles, and studies published outside of the last decade were not included. The search used combinations of the terms “dancing* and athletic injuries* and musculoskeletal* and pain*”. A principal investigator and two reviewers conducted the survey and analyzed all the potentially relevant articles, initially by the abstract and title. Twelve articles were included, with 1,149 participants (965 professional dancers of classical ballet, modern dance, contemporary dance, and breakdance, 104 amateur dancers, and 80 elite athletes). Nine studies found simultaneous lesions with emphasis on the foot and ankle (n=4), upper and lower limbs lesions (n=4) and lower and upper limb joints (n=1). Other studies have found lesions in the anterior cruciate ligament (n=3). There was no agreement regarding the instruments for detecting lesions in professional, pre-professional, and amateur dancers. There was a prevalence of studies aimed at classical ballet modality, evidencing a higher frequency of lower limb involvement in professional dancers.

Keywords:
dancing; athletes/injuries; movement

RESUMO

A dança tem o movimento como elemento fundamental e o corpo do bailarino como matéria-prima para expressar sua arte; para isso, exige a máxima disciplina na busca da excelência técnica e artística. Para atender às demandas profissionais, os bailarinos são submetidos a extenuantes rotinas de treinamento, que favorecem o desenvolvimento de lesões nesse meio. Objetivou-se examinar etiologia, principais segmentos acometidos, prevalência e instrumentos usados para avaliar as lesões em estudos com dançarinos profissionais e/ou em comparação com populações similares. Foram selecionados artigos completos publicados na última década nas bases de dados BIREME, LILACS, MEDLINE EBSCO, WEB OF SCIENCE, SCOPUS (Elsevier) e PubMed, com desenho de coorte observacional, transversal e controle de casos, publicados em português, inglês ou espanhol. Não foram incluídas revisões sistemáticas, estudos de caso, dissertações, teses, capítulos de livros, artigos com referências cruzadas e estudos publicados fora da última década. A busca usou combinações dos termos “dancing* and athletic injuries* and musculoskeletal* and pain*”. Um pesquisador principal e dois revisores realizaram a pesquisa e analisaram todos os artigos com relevância em potencial, inicialmente por resumo e título. Um total de 12 artigos foi incluído, com 1.149 participantes (965 dançarinos profissionais de balé clássico, dança moderna, dança contemporânea e breakdance, 104 dançarinos amadores e 80 atletas de elite). Nove estudos encontraram lesões simultâneas com ênfase no pé e tornozelo (n = 4), lesões dos membros superiores e inferiores (n = 4) e nas articulações de membros inferiores e superiores (n = 1). Outros estudos encontraram lesões no ligamento cruzado anterior (n = 3). Não houve consenso quanto aos instrumentos para identificação de lesões em bailarinos profissionais, pré-profissionais e amadores. Houve prevalência de estudos destinados à modalidade de balé clássico, evidenciando maior frequência de acometimento dos membros inferiores em bailarinos profissionais.

Descritores:
dança; atletas/lesões; movimento

RESUMEN

La danza tiene el movimiento como elemento fundamental y el cuerpo del bailarín como materia prima para expresar su arte; para ello, exige la máxima disciplina en la búsqueda de la excelencia técnica y artística. Para atender las demandas profesionales, los bailarines son sometidos a extenuantes rutinas de entrenamiento, que favorecen el desarrollo de lesiones en ese medio. El objetivo fue examinar etiología, principales segmentos acometidos, prevalencia e instrumentos usados para evaluar las lesiones en estudios con bailarines profesionales y/o en comparación con poblaciones similares. Se seleccionaron artículos completos publicados en la última década en las bases de datos BIREME, LILACS, MEDLINE EBSCO, WEB OF SCIENCE, SCOPUS (Elsevier) y PubMed, con diseño de cohorte observacional, transversal y control de casos, publicados en portugués, inglés o español. No se incluyeron revisiones sistemáticas, estudios de caso, disertaciones, tesis, capítulos de libros, artículos con referencias cruzadas y estudios publicados fuera de la última década. La búsqueda utilizó combinaciones de los términos “dancing* and athletic injuries* and musculoskeletal* and pain*”. Un investigador principal y dos revisores realizaron la investigación y analizaron todos los artículos con relevancia potencial, inicialmente por resumen y título. Un total de 12 artículos fueron incluidos, con 1.149 participantes (965 bailarines profesionales de ballet clásico, danza moderna, danza contemporánea y breakdance, 104 bailarines aficionados y 80 atletas de elite). Nueve estudios encontraron lesiones simultáneas con énfasis en el pie y el tobillo (n = 4), lesiones de las extremidades superiores e inferiores (n = 4) y en las articulaciones de extremidades inferiores y superiores (n = 1). Otros estudios encontraron lesiones en el ligamento cruzado anterior (n = 3). No hubo consenso en cuanto a los instrumentos para identificación de lesiones en bailarines profesionales, pre-profesionales y aficionados. Se observó una prevalencia de estudios destinados a la modalidad de ballet clásico, evidenciando mayor frecuencia de afectación de las extremidades inferiores en bailarines profesionales.

Descriptores:
baile; atletas/lesiones; movimiento

INTRODUCTION

Dance has the movement as fundamental element of its art, and the body as raw material, requiring discipline, develops and enhances it, in order to reach all the magnificence, line purity and possible expressions of the worked technics11. Simões RD, Anjos AFP. O ballet clássico e as implicações anatômicas e biomecânicas de sua prática para os pés e tornozelos. Conexões. 2010;8(2):117-32.. Dancers in different dance categories, are considered as much athletes as artists, because, their routine needs either an excellent physical condition and high efficiency, as the visual beauty assigned to the choreography movements22. Gamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns in elite preprofessional ballet dancers and the utility of screening programs to identify risk characteristics. J Orthop Sports Phys Ther. 2008;38(3):126-36.,33. Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M. Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther. 2012;42(9):781-90..

To fill all the athletic demands that dance as professional activity requires, these dancers are submitted to stressful charges in order to reach an excellent physical aptitude, and for that they need great levels of aerobic resistance, neuromuscular coordination, power, based muscular resistance, agility also flexibility and stretching44. Ojofeitimi S, Bronner S. Injuries in a modern dance company effect of comprehensive management on injury incidence and cost. J Dance Med Sci. 2011;15(3):116-22.

5. Lin CF, Lee IJ, Liao JH, Wu HW, Su FC. Comparison of postural stability between injured and uninjured ballet dancers. Am J Sports Med. 2011;39(6):1324-31.

6. Miyamoto RG, Dhotar HS, Rose DJ, Egol K. Surgical treatment of refractory tibial stress fractures in elite dancers: a case series. Am J Sports Med. 2009;37(6):1150-4.
-77. Ekegren CL, Quested R, Brodrick A. Injuries in pre-professional ballet dancers: Incidence, characteristics and consequences. J Sci Med Sport. 2014;17(3):271-5..

As much as athletes, professional dancers are susceptible to a constant injury risk. Factor often justified, by the exhausting training routine and the mistakes made due this routine77. Ekegren CL, Quested R, Brodrick A. Injuries in pre-professional ballet dancers: Incidence, characteristics and consequences. J Sci Med Sport. 2014;17(3):271-5.. The athletic life routine of these dancers starts from an early age, enabling them to become professionals near 15 years old88. Smith TO, Davies L, de Medici A, Hakim A, Haddad F, Macgregor A. Prevalence and profile of musculoskeletal injuries in ballet dancers: A systematic review and meta-analysis. Phys Ther Sport. 2016;19:50-6.. Since then these dancers are subjected to heavy loads of training, regardless their musculoskeletal structures be ready, raising the occurrence of acute injuries and granting the occurrence of chronicle injuries77. Ekegren CL, Quested R, Brodrick A. Injuries in pre-professional ballet dancers: Incidence, characteristics and consequences. J Sci Med Sport. 2014;17(3):271-5.,99. Roussel NA, Nijs J, Mottram S, Van Moorsel A, Truijen S, Stassijns G. Altered lumbopelvic movement control but not generalized joint hypermobility is associated with increased injury in dancers: A prospective study. Man Ther. 2009;14(6):630-5..

The incidence of injuries in dancers varies from 40% to 84% according Jacobs, Hincapie, and Cassidy1010. Jacobs CL, Hincapié CA, Cassidy JD. Musculoskeletal injuries and pain in dancers: a systematic review update. J Dance Med Sci. 2012;16(2):74-84., these being mostly caused by low cardiovascular conditioning, articular hyper mobility, postural deviation, alteration in the body’s center of balance, among thers22. Gamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns in elite preprofessional ballet dancers and the utility of screening programs to identify risk characteristics. J Orthop Sports Phys Ther. 2008;38(3):126-36.,99. Roussel NA, Nijs J, Mottram S, Van Moorsel A, Truijen S, Stassijns G. Altered lumbopelvic movement control but not generalized joint hypermobility is associated with increased injury in dancers: A prospective study. Man Ther. 2009;14(6):630-5.

10. Jacobs CL, Hincapié CA, Cassidy JD. Musculoskeletal injuries and pain in dancers: a systematic review update. J Dance Med Sci. 2012;16(2):74-84.
-1111. Russell JA. Preventing dance injuries: current perspectives. Open Access J Sports Med. 2013;4:199-210.. A Study realized with amateurs dancers, shows that for each 1000 hours of training, the injuries incidence diagnosed was from 0.62 to 5.6 injuries per dancers22. Gamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns in elite preprofessional ballet dancers and the utility of screening programs to identify risk characteristics. J Orthop Sports Phys Ther. 2008;38(3):126-36.. Bearing in mind that the technical demand for a professional dancers is even higher, is considered that this number increases drastically into the professional contest.

Despite having a training as intense as the elite athletes, the professional dancers do not get the same assistance concerning to the injuries prevention, technical preparation and physiotherapeutic of others modalities, especially in the appearance and treatment of lesions99. Roussel NA, Nijs J, Mottram S, Van Moorsel A, Truijen S, Stassijns G. Altered lumbopelvic movement control but not generalized joint hypermobility is associated with increased injury in dancers: A prospective study. Man Ther. 2009;14(6):630-5.. The lack of national and international researches having the dance as object of study is evident in different areas, mainly with the injuries, once that one is yet very discussed in classical ballet, leaving others dance styles aside; and sometimes it makes impossible the relation between the lack produced material with more precise conclusions, in order to expose these to the scientific society77. Ekegren CL, Quested R, Brodrick A. Injuries in pre-professional ballet dancers: Incidence, characteristics and consequences. J Sci Med Sport. 2014;17(3):271-5.,1010. Jacobs CL, Hincapié CA, Cassidy JD. Musculoskeletal injuries and pain in dancers: a systematic review update. J Dance Med Sci. 2012;16(2):74-84.. The International Association for Dance Medicine and Science (IADMS) has been trying to organize some methodologic and scientific questions of the research involving the dance, suggesting some directives, and, allowing that future studies can be done with bigger background and credibility1212. International Association for Dance Medicine and Science. Presentation Proposal Guidelines. IADMS; 2009 [acesso em 2016 jul 06]. Disponível em: <Disponível em: http://c.ymcdn.com/sites/www.iadms.org/resource/resmgr/imported/guidelines.pdf >.
http://c.ymcdn.com/sites/www.iadms.org/r...
,1313. Liederbach M, Hagins M, Gamboa JM, Welsh TM. Assessing and Reporting Dancer Capacities, Risk Factors, and Injuries: Recommendations from the IADMS Standard Measures Consensus Initiative. J Dance Med Sci. 2012;16(4):139-53..

Above all this study seeks alerting the dancers involved of the possible risks involved in inadequate practices, stimulating preventative and conscious attitudes in the professional dance context. For that, just few researches were made in way to investigate the epidemiology of the injuries in professional dancers, demystifying cause, places, occurrence and most frequent injuries in that group88. Smith TO, Davies L, de Medici A, Hakim A, Haddad F, Macgregor A. Prevalence and profile of musculoskeletal injuries in ballet dancers: A systematic review and meta-analysis. Phys Ther Sport. 2016;19:50-6.. In face of that, the objective of this systematic review was to examine the etiology, main affected segments, prevalence and instruments used to evaluate the lesions in studies with professional dancers and/or compared to similar populations.

MATERIAL AND METHODS

Article selection and identification

This systematic review was registered at PROSPERO (International Prospective Register Of Systematic Reviews) under the number CRD42016036529, and follows the recommendations of PRISMA (Preferred Reporting Items for Systematic Review and Meta-analyses)1414. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. PLoS Med. 2009;6(7):e1000100.. For that were added complete articles, observational cohort type, transversal and control-case, that investigate injuries in professional dancers, published in Portuguese, English or Spanish in the last decade.

Search strategy

To search strategy were used the database BIREME, LILACS, MEDLINE EBSCO, WEB OF SCIENCE, SCOPUS (Elsevier) and PubMed. The used descriptors were “dancing* and athletic injuries* and musculoskeletal* and pain*”. The search was made in February 2016. Articles that brought the cited descriptors and evaluated professional dancers comparing them with similar populations as pre-professional dancers, amateur dancers and athletes were also included in the search.

Study selection and data extraction

To study selection and data extraction, one main researcher and two reviewers realized the search and analyzed all the potentially relevant articles, initially by the abstract and title. In cases of divergences between the articles selected by the reviewers, all repeated the procedures until the divergences were corrected.

The articles were accessed integrally on-line, available in Portuguese, English or Spanish, published in the last 10 years. Were also part, articles identified by the way of manual search of references of the included articles. Were not included systematic reviews, case studies, dissertations, theses, book chapters, identified articles as crossed reference and published studies out time and languages established previously.

Methodology evaluation

The quality of the data was evaluated independently by the reviewers based in the criteria of Downs e Black1515. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84., which consist in 27 questions that cover communication methodological aspects, inner and outer validity and statistic power. To the appreciation of the studies that do not included interventions, were considered just 15 questions, excluding 4, 8, 13-15, 17, 19, 21- 24 e 26 questions. To each question was applied the score zero (0), if the article wasn’t pertinent to what was being evaluated, e the score one (1) when observed positive answer to the requisite, observing that only the question 5 has maximum score 2. With that the maximum score to each article was 16 points. To analyze the quality of the data of the included studies, descriptive statistic was used (mean score).

RESULTS

Initially 174 articles were identified. After the withdraw of the duplicate and executed the title triage phase, abstracts and complete texts, was reach the number of 16 articles, among these, 8 satisfied the eligibility criteria. After the manual evaluation of these articles bibliography references, 4 more were added, totaling 12 potentially relevant articles to the qualitative evaluation (Figure 1).

Figure 1. Review included studies fluxogram.

As the obtained score by the way of the Downs and Black1515. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84. methodological Scale, the articles achieve 11.61 of average considering maximum score of 16 points. Among the methodological criteria that presented more failures are: the non-description of the individuals lost during the study characteristics; the lack of result basis definition (non-detailing of the main confusion factors) and the related aspects to the internal studies validity. The studies with best evaluation obtained score 14 of 161313. Liederbach M, Hagins M, Gamboa JM, Welsh TM. Assessing and Reporting Dancer Capacities, Risk Factors, and Injuries: Recommendations from the IADMS Standard Measures Consensus Initiative. J Dance Med Sci. 2012;16(4):139-53.,1616. Orishimo KF, Liederbach M, Kremenic IJ, Hagins M, Pappas E. Comparison of landing biomechanics between male and female dancers and athletes, part 1: Influence of sex on risk of anterior cruciate ligament injury. Am J Sports Med. 2014;42(5):1082-8.

17. Kauther MD, Wedemeyer C, Wegner A, Kauther KM, von Knoch M. Breakdance injuries and overuse syndromes in amateurs and professionals. Am J Sports Med. 2009;37(4):797-802.
-1818. Liederbach M, Dilgen FE, Rose DJ. Incidence of anterior cruciate ligament injuries among elite ballet and modern dancers: a 5-year prospective study. Am J Sports Med. 2008;36(9):1779-88.. And the studies with worst evaluation get 11 points44. Ojofeitimi S, Bronner S. Injuries in a modern dance company effect of comprehensive management on injury incidence and cost. J Dance Med Sci. 2011;15(3):116-22.,1919. Hopper LS, Allen N, Wyon M, Alderson JA, Elliott BC, Ackland TR. Dance floor mechanical properties and dancer injuries in a touring professional ballet company. J Sci Med Sport. 2014;17(1):29-33.

20. Elias I, Zoga AC, Raikin SM, Peterson JR, Besser MP, Morrison WB, et al. Bone stress injury of the ankle in professional ballet dancers seen on MRI. BMC Musculoskelet Disord. 2008;9:39.
-2121. Lo SL, Zoga AC, Elias I, Peterson JR, Chao W, Green J, et al. Stress fracture of the distal phalanx of the great toe in a professional ballet dancer: a case report. Am J Sports Med. 2007;35(9):1564-6..

The methodological evaluation shows that any article reach maximum values, making clear that some methodological failures in the execution of these researches. However, none of them got values under 11, what may determine the sample as “good” according to the qualitative rating of Downs e Black1515. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-84..

The main characteristics of the studies included in the review are presented in Table 1. The presented review is formed by 12 articles, 11 published in English between 2007 and 2014, where the year of 2008 obtained the greater number of publications, totaling 4 articles, presented in the supplements. The total sample of this review was composed by 1149 participants, where 325 men and 427 women, which 965 professional dancers of the classical ballet, modern dance, contemporary dance and break dance modalities, 104 amateur dancers and 80 elite athletes. As the etiology of the related lesions, stand out the floor surface, the inappropriate technic and the lack of stability in some moves the overload of activities, the excessive effort in the training routine, the muscular fatigue, the biomechanical stress and the lack of proper equipment.

Table 1
Main characteristics of the studies included in the review.

The selected studies main objectives description, as the main discoveries and the classification of the methodological evaluation are presented in Table 2. Is observed that the studies have characteristics, objectives and different forms; where the most common objectives the etiology survey, incidence and lesions characteristics, as well the comparison between the biomechanical execution of movement in dancers and other modalities athletes.

Table 2
Study objectives, main results and evaluation Downs & Black.

As the used instruments to the lesions evaluation in professional dancers, pre-professionals and amateurs, was verified the absence of an agreement about the use of these. For evaluation of the lesions were used ways of direct evaluation, as magnetic resonance, X-Ray and electromyography2020. Elias I, Zoga AC, Raikin SM, Peterson JR, Besser MP, Morrison WB, et al. Bone stress injury of the ankle in professional ballet dancers seen on MRI. BMC Musculoskelet Disord. 2008;9:39.

21. Lo SL, Zoga AC, Elias I, Peterson JR, Chao W, Green J, et al. Stress fracture of the distal phalanx of the great toe in a professional ballet dancer: a case report. Am J Sports Med. 2007;35(9):1564-6.
-2222. Rein S, Fabian T, Zwipp H, Rammelt S, Weindel S. Postural control and functional ankle stability in professional and amateur dancers. Clin Neurophysiol. 2011;122(8):1602-10.; multisensorial platforms to biomechanical analysis of the activity1616. Orishimo KF, Liederbach M, Kremenic IJ, Hagins M, Pappas E. Comparison of landing biomechanics between male and female dancers and athletes, part 1: Influence of sex on risk of anterior cruciate ligament injury. Am J Sports Med. 2014;42(5):1082-8.,2222. Rein S, Fabian T, Zwipp H, Rammelt S, Weindel S. Postural control and functional ankle stability in professional and amateur dancers. Clin Neurophysiol. 2011;122(8):1602-10.; physics tests2222. Rein S, Fabian T, Zwipp H, Rammelt S, Weindel S. Postural control and functional ankle stability in professional and amateur dancers. Clin Neurophysiol. 2011;122(8):1602-10.,2323. Meuffels DE, Verhaar JA. Anterior cruciate ligament injury in professional dancers. Acta Orthop. 2008;79(4):515-8. and clinical4. Besides the indirect measures, as the questionnaires33. Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M. Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther. 2012;42(9):781-90.,44. Ojofeitimi S, Bronner S. Injuries in a modern dance company effect of comprehensive management on injury incidence and cost. J Dance Med Sci. 2011;15(3):116-22.,1717. Kauther MD, Wedemeyer C, Wegner A, Kauther KM, von Knoch M. Breakdance injuries and overuse syndromes in amateurs and professionals. Am J Sports Med. 2009;37(4):797-802.,2222. Rein S, Fabian T, Zwipp H, Rammelt S, Weindel S. Postural control and functional ankle stability in professional and amateur dancers. Clin Neurophysiol. 2011;122(8):1602-10.,2424. Dore BF, Guerra RO. Sintomatologia dolorosa e fatores associados em bailarinos profissionais. Rev Bras Med Esporte. 2007;13(2):77-80.. Just two of the used questionnaires were pointed specifically to dancers, among them one non-validated questionnaire to personal identification, dance experience and lesion history1717. Kauther MD, Wedemeyer C, Wegner A, Kauther KM, von Knoch M. Breakdance injuries and overuse syndromes in amateurs and professionals. Am J Sports Med. 2009;37(4):797-802. and the Dance Functional Outcome System Questionnaire44. Ojofeitimi S, Bronner S. Injuries in a modern dance company effect of comprehensive management on injury incidence and cost. J Dance Med Sci. 2011;15(3):116-22..

Nine studies found simultaneous lesions with emphasis in foot and ankle (n=4)44. Ojofeitimi S, Bronner S. Injuries in a modern dance company effect of comprehensive management on injury incidence and cost. J Dance Med Sci. 2011;15(3):116-22.,2020. Elias I, Zoga AC, Raikin SM, Peterson JR, Besser MP, Morrison WB, et al. Bone stress injury of the ankle in professional ballet dancers seen on MRI. BMC Musculoskelet Disord. 2008;9:39.

21. Lo SL, Zoga AC, Elias I, Peterson JR, Chao W, Green J, et al. Stress fracture of the distal phalanx of the great toe in a professional ballet dancer: a case report. Am J Sports Med. 2007;35(9):1564-6.
-2222. Rein S, Fabian T, Zwipp H, Rammelt S, Weindel S. Postural control and functional ankle stability in professional and amateur dancers. Clin Neurophysiol. 2011;122(8):1602-10., upper and lower limbs lesions (n=4)33. Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M. Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther. 2012;42(9):781-90.,1919. Hopper LS, Allen N, Wyon M, Alderson JA, Elliott BC, Ackland TR. Dance floor mechanical properties and dancer injuries in a touring professional ballet company. J Sci Med Sport. 2014;17(1):29-33.,2424. Dore BF, Guerra RO. Sintomatologia dolorosa e fatores associados em bailarinos profissionais. Rev Bras Med Esporte. 2007;13(2):77-80.,2525. Liederbach M, Kremenic IJ, Orishimo KF, Pappas E, Hagins M. Comparison of landing biomechanics between male and female dancers and athletes, part 2: Influence of fatigue and implications for anterior cruciate ligament injury. Am J Sports Med. 2014;42(5):1089-95.and together lower and upper limbs (n=1)1818. Liederbach M, Dilgen FE, Rose DJ. Incidence of anterior cruciate ligament injuries among elite ballet and modern dancers: a 5-year prospective study. Am J Sports Med. 2008;36(9):1779-88.. Other studies found lesions in the anterior cruciate ligament (n=3)1616. Orishimo KF, Liederbach M, Kremenic IJ, Hagins M, Pappas E. Comparison of landing biomechanics between male and female dancers and athletes, part 1: Influence of sex on risk of anterior cruciate ligament injury. Am J Sports Med. 2014;42(5):1082-8.,2323. Meuffels DE, Verhaar JA. Anterior cruciate ligament injury in professional dancers. Acta Orthop. 2008;79(4):515-8.,2626. Briggs J, McCormack M, Hakim AJ, Grahame R. Injury and joint hypermobility syndrome in ballet dancers--a 5-year follow-up. Rheumatology (Oxford). 2009;48(12):1613-4..

In the studies that took part of this systematic review, five related systematic train of 5 to 6 time per week33. Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M. Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther. 2012;42(9):781-90.,1717. Kauther MD, Wedemeyer C, Wegner A, Kauther KM, von Knoch M. Breakdance injuries and overuse syndromes in amateurs and professionals. Am J Sports Med. 2009;37(4):797-802.,1919. Hopper LS, Allen N, Wyon M, Alderson JA, Elliott BC, Ackland TR. Dance floor mechanical properties and dancer injuries in a touring professional ballet company. J Sci Med Sport. 2014;17(1):29-33.,2323. Meuffels DE, Verhaar JA. Anterior cruciate ligament injury in professional dancers. Acta Orthop. 2008;79(4):515-8.,2424. Dore BF, Guerra RO. Sintomatologia dolorosa e fatores associados em bailarinos profissionais. Rev Bras Med Esporte. 2007;13(2):77-80., but just four of these informed the amount of rehearsed hours, what results in a 23.17 average of dedicated hours between classes, rehearsals and training33. Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M. Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther. 2012;42(9):781-90.,1717. Kauther MD, Wedemeyer C, Wegner A, Kauther KM, von Knoch M. Breakdance injuries and overuse syndromes in amateurs and professionals. Am J Sports Med. 2009;37(4):797-802.,1919. Hopper LS, Allen N, Wyon M, Alderson JA, Elliott BC, Ackland TR. Dance floor mechanical properties and dancer injuries in a touring professional ballet company. J Sci Med Sport. 2014;17(1):29-33.,2424. Dore BF, Guerra RO. Sintomatologia dolorosa e fatores associados em bailarinos profissionais. Rev Bras Med Esporte. 2007;13(2):77-80., the other studies (n=7) do not informed the amount of rehearsed hours.

DISCUSSION

According to the results of the 12 included studies in this systematic review, lower limbs, specially foot, ankle and knee seem to be the main affected segment in the dancers population, and the anterior cruciate ligament are the most found lesion. Among the investigated dance modalities, the classical ballet presented a higher prevalence in the lesion occurrence33. Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M. Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther. 2012;42(9):781-90.,1818. Liederbach M, Dilgen FE, Rose DJ. Incidence of anterior cruciate ligament injuries among elite ballet and modern dancers: a 5-year prospective study. Am J Sports Med. 2008;36(9):1779-88.

19. Hopper LS, Allen N, Wyon M, Alderson JA, Elliott BC, Ackland TR. Dance floor mechanical properties and dancer injuries in a touring professional ballet company. J Sci Med Sport. 2014;17(1):29-33.

20. Elias I, Zoga AC, Raikin SM, Peterson JR, Besser MP, Morrison WB, et al. Bone stress injury of the ankle in professional ballet dancers seen on MRI. BMC Musculoskelet Disord. 2008;9:39.
-2121. Lo SL, Zoga AC, Elias I, Peterson JR, Chao W, Green J, et al. Stress fracture of the distal phalanx of the great toe in a professional ballet dancer: a case report. Am J Sports Med. 2007;35(9):1564-6.,2323. Meuffels DE, Verhaar JA. Anterior cruciate ligament injury in professional dancers. Acta Orthop. 2008;79(4):515-8.. Results confirmed by Smith et al.88. Smith TO, Davies L, de Medici A, Hakim A, Haddad F, Macgregor A. Prevalence and profile of musculoskeletal injuries in ballet dancers: A systematic review and meta-analysis. Phys Ther Sport. 2016;19:50-6. that when investigated the prevalence and the profile of musculoskeletal lesions in professional dancers, pre-professionals and amateurs, reinforced in his discoveries a higher prevalence of lesions in lower limbs of professional dancers and pre-professionals dancers.

These data can be explained observing that the dance, regardless the modality, when practiced in a professional level, charges from the dancer an excellence and technical perfection that only can be achieved through straining physical train2727. Rodrigues dos Santos JA, Amorim T, Marques F. Dança: A parte imersa do iceberg. Acta Farmacêutica Portuguesa. 2015;4(1):67-9.. The constant repetition of positions and choreographic postures demand too much straining physical charges that sometimes exceed these dancers’ physical capacities, facts that, together with the absence of adequate recovery breaks between training, support to the occurrence of lesions2727. Rodrigues dos Santos JA, Amorim T, Marques F. Dança: A parte imersa do iceberg. Acta Farmacêutica Portuguesa. 2015;4(1):67-9.. Other support factor with the increase of lesions in professional dancers is the methodological training model. That many times does not respect the principles of sportive training, especially in the matter of preparation and previous conditioning specified to the body and charges that it is submitted. When lesser is the time of this preparation, higher tends to be the lesion rate of these dancers2828. Twitchett E, Brodrick A, Nevill AM, Koutedakis Y, Angioi M, Wyon M. Does physical fitness affect injury occurrence and time loss due to injury in elite vocational ballet students? J Dance Med Sci. 2010;14(1):26-31..

The higher incidence of lower limbs lesion is high related with the biomechanical that dance most common postures demand, causing the musculoskeletal system lesions. One of these common biomechanical alterations is the geno recurvatum, which is characterized by the hyperextension and sometimes by hypermobility of the knee. This specific change happens by the posture maintenance that dancers have to adopt during the training and concerts, promoting an over activation of the quadriceps in a way to maintain lower limbs super stretched. This posture is demanded from dancers, for draw a straight line in their lower limbs, mostly achieved when the positions are realized on ballet pointe shoes2929. Pappas E, Kremenic I, Liederbach M, Orishimo KF, Hagins M. Time to stability differences between male and female dancers after landing from a jump on flat and inclined floors. Clin J Sport Med. 2011;21(4):325-9..

Although of 12 studies being fitted in the results, just one of them has, as objective, investigate the lesions etiology. Just the Allen et al33. Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M. Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther. 2012;42(9):781-90., that follow during a year season, 52 professional dancers, propose itself to relate the incidence, severity and etiology of the occurring lesions. Relating a frequency of 6.8 lesions per professional dancers in a period of a year, classified as temporary, even for men (87%) as for women (94%), happening mostly in the lower limbs, and with the occurrence prevalence of the same during the company rehearsals. Although not deeply discussed some risk factors were pointed in the studies included in the review, such as, the excessive repetition of movements, the overload of activities, the muscular fatigue and the biomechanical stress33. Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M. Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther. 2012;42(9):781-90.,1717. Kauther MD, Wedemeyer C, Wegner A, Kauther KM, von Knoch M. Breakdance injuries and overuse syndromes in amateurs and professionals. Am J Sports Med. 2009;37(4):797-802.,2020. Elias I, Zoga AC, Raikin SM, Peterson JR, Besser MP, Morrison WB, et al. Bone stress injury of the ankle in professional ballet dancers seen on MRI. BMC Musculoskelet Disord. 2008;9:39.,2323. Meuffels DE, Verhaar JA. Anterior cruciate ligament injury in professional dancers. Acta Orthop. 2008;79(4):515-8.

24. Dore BF, Guerra RO. Sintomatologia dolorosa e fatores associados em bailarinos profissionais. Rev Bras Med Esporte. 2007;13(2):77-80.
-2525. Liederbach M, Kremenic IJ, Orishimo KF, Pappas E, Hagins M. Comparison of landing biomechanics between male and female dancers and athletes, part 2: Influence of fatigue and implications for anterior cruciate ligament injury. Am J Sports Med. 2014;42(5):1089-95., the inappropriate technique of jumps landing1616. Orishimo KF, Liederbach M, Kremenic IJ, Hagins M, Pappas E. Comparison of landing biomechanics between male and female dancers and athletes, part 1: Influence of sex on risk of anterior cruciate ligament injury. Am J Sports Med. 2014;42(5):1082-8.,2222. Rein S, Fabian T, Zwipp H, Rammelt S, Weindel S. Postural control and functional ankle stability in professional and amateur dancers. Clin Neurophysiol. 2011;122(8):1602-10., and also the influence of the mechanical characteristics of the floor1919. Hopper LS, Allen N, Wyon M, Alderson JA, Elliott BC, Ackland TR. Dance floor mechanical properties and dancer injuries in a touring professional ballet company. J Sci Med Sport. 2014;17(1):29-33..

Supporting, some studies claim that aerial movements like jumps, its forms and landing time are risk factors to the development of lesions in dance11. Simões RD, Anjos AFP. O ballet clássico e as implicações anatômicas e biomecânicas de sua prática para os pés e tornozelos. Conexões. 2010;8(2):117-32.,3030. O'Halloran E, Vioreanu M, Padinjarathala B. "Between the jigs and the reels": bilateral metatarsal phalangeal stress fractures in a young Irish dancer. Clin J Sport Med. 2011;21(5):454-5.. The importance of prevention strategies of the lesions in dancers have becoming more important, as the growing number of practices and the exponential increase of the lesions arising from the training routine of these88. Smith TO, Davies L, de Medici A, Hakim A, Haddad F, Macgregor A. Prevalence and profile of musculoskeletal injuries in ballet dancers: A systematic review and meta-analysis. Phys Ther Sport. 2016;19:50-6.. Studies realized in pre-professional dancers and amateurs have suggested the importance in a lesion prevention work22. Gamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns in elite preprofessional ballet dancers and the utility of screening programs to identify risk characteristics. J Orthop Sports Phys Ther. 2008;38(3):126-36..

Works like the Gamboa et al.22. Gamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns in elite preprofessional ballet dancers and the utility of screening programs to identify risk characteristics. J Orthop Sports Phys Ther. 2008;38(3):126-36. and O’Halloran et al.3030. O'Halloran E, Vioreanu M, Padinjarathala B. "Between the jigs and the reels": bilateral metatarsal phalangeal stress fractures in a young Irish dancer. Clin J Sport Med. 2011;21(5):454-5., show that a proprioception training, associated to an improvement in the postural control and articular stability can potentially contribute to decrease the risk of lesions in semiprofessional dancers. In a way to minimize the lesions risk and improve the functional ankle stability, O’Halloran et al.3030. O'Halloran E, Vioreanu M, Padinjarathala B. "Between the jigs and the reels": bilateral metatarsal phalangeal stress fractures in a young Irish dancer. Clin J Sport Med. 2011;21(5):454-5. suggest the addition of proprioceptive activities focusing in the postural control, even for professional dancers as amateurs.

In just 6 of the 12 articles, was verified the participation an involvement of a medical team in the professional companies33. Allen N, Nevill A, Brooks J, Koutedakis Y, Wyon M. Ballet injuries: injury incidence and severity over 1 year. J Orthop Sports Phys Ther. 2012;42(9):781-90.,44. Ojofeitimi S, Bronner S. Injuries in a modern dance company effect of comprehensive management on injury incidence and cost. J Dance Med Sci. 2011;15(3):116-22.,1717. Kauther MD, Wedemeyer C, Wegner A, Kauther KM, von Knoch M. Breakdance injuries and overuse syndromes in amateurs and professionals. Am J Sports Med. 2009;37(4):797-802.,1919. Hopper LS, Allen N, Wyon M, Alderson JA, Elliott BC, Ackland TR. Dance floor mechanical properties and dancer injuries in a touring professional ballet company. J Sci Med Sport. 2014;17(1):29-33.,2121. Lo SL, Zoga AC, Elias I, Peterson JR, Chao W, Green J, et al. Stress fracture of the distal phalanx of the great toe in a professional ballet dancer: a case report. Am J Sports Med. 2007;35(9):1564-6.,2323. Meuffels DE, Verhaar JA. Anterior cruciate ligament injury in professional dancers. Acta Orthop. 2008;79(4):515-8.. This deficiency can be related to the fact that many companies are afraid of the presence of a medical team interfering directly in the elaboration and execution of their work; what is shown that some characteristics of specific movements, as well the training intensity, the choreographic demands and even the patterns of the body constitution can result in acute traumas and/or chronical in theses dancers. Beside this, other complicating would be the high costs of maintaining a multidisciplinary work involving a medical team, as few companies have sponsors or investors3131. Fernandes TF, Lopez AD. Lesões musculoesqueléticas no ballet: revisão sistemática. Ter Man. 2011;9(43):304-10..

Other highlighted problem in one of the articles included in the review is the high pain resistance break point that dancers develop2424. Dore BF, Guerra RO. Sintomatologia dolorosa e fatores associados em bailarinos profissionais. Rev Bras Med Esporte. 2007;13(2):77-80.. This acquaintance with pain behavior, the not maintenance of physical and mental health harmful conducts goes against to the health precepts that health area professionals safeguard, reason that collaborate to the alienation of these professionals from the high performance companies3232. Bolling CS, Pinheiro TMM. Bailarinos profissionais e saúde: uma revisão da literatura. Rev Med Minas Gerais. 2010;20(2Supl2):S75-S83..

After the analysis of the selected studies is, clear the need of instruments with more specific prognostic characteristics focused in professional dancers lesions prevention. It is perceptible the absence of standardization of specific instruments to lesion evaluation in dancers, what hinders the comparison between studies. The development of criteria and reference values to different dance modalities and levels of action (professional, pre-professional and amateurs) would be more effective in the evaluation of these individuals, preventing the lesion progress in this meantime.

The presence of studies with longitudinal with cohorts was not verified, targeting these professional dancers career follow up. This type of study is highly relevant, according to the variety of relations that can be investigate in the long term, the influence of nutritional aspects, psychological and even physics in the incidence and characteristics of the lesions in the different age-groups, even not being object of this systematic review. This kind of information would allow the development of actions to avoid bad habits in the beginning of the career of theses dancers, avoiding damaging behavior during their professional life.

This review becomes effective, because, identify the most recurrent lesions and the main segments affected in professional dancers consists in a needy thematic in actual literature. As studies limitations is highlighted the difficulty of further development about the lesions etiology, this way suggesting that further investigations with a greater number of professional dancers of different dance modalities be developed. Also looking for the creation of prevention programs conducted by capable professionals linked to the health area focused in this population. In order to reduce the incidence and severity of lesions, looking to avoid especially the removal of the professional career by these dancers, and minimizing the psychological impact and the appearance of adverse events that could compromise the health and life qualities of a professional dancers77. Ekegren CL, Quested R, Brodrick A. Injuries in pre-professional ballet dancers: Incidence, characteristics and consequences. J Sci Med Sport. 2014;17(3):271-5..

CONCLUSION

After analyzed the studies included in this systematic review, it was evident that the most affected segment was the lower limbs, specially foot, ankle and knee. However, there was a difficulty in identify the etiology of these injuries, as well an appropriated instrument to detect lesions in professional dancers, pre-professionals and amateurs. As for as the modality classical ballet was the most prevalent in the studies.

The impact due these injuries caused by the training routine or the inappropriate execution of movements, influence not just the professional life of a professional dancers, but also its health, even after the conclusion of its professional career. However, these consequences remain without a proper investigation. In these terms is suggested that more studies be developed with the target population, investigating others modalities of dance in the professional acting context, with gender distinction, and focus in the incidence, severity and injuries etiology often in this in this group. Boosting preventive actions that favor a healthy and safe career to the professionals involved on its practice.

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  • CONTRIBUIÇÕES DOS AUTORES:

    Each author made significant individual contributions to this manuscript. AAC (0000-0002-0280-7567)*, NMR (0000-0002-3925-9357)* and APRM (0000-0001-7469-1092)*, contributed to the study conception/design, data collection, analysis and interpretation of the data and writing of the manuscript. MCSU (0000-0002-7861-7620), LB (0000-0003-4978-9703)* and ACAG (0000-0001-5167-2921)*, contributed to the design, analysis and interpretation of the data and writing of the manuscript. All authors approved the final version of the manuscript. *ORCID (Open Researcher and Contributor ID).

Publication Dates

  • Publication in this collection
    Nov-Dec 2017

History

  • Received
    19 Oct 2016
  • Accepted
    20 June 2017
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