Ballet dance requires a high level of technical ability, which brings the human body to the limits of its strength and flexibility. Interestingly, very few acute injuries are reported by dancers, whereas there is a much higher rate of chronic injuries related to overuse. This makes sense when you consider that sport is uniquely repetitive and acute injuries are associated with loss of balance.
It was found that ballet dancers can be at risk of injury regardless of age, gender or level of skill, with important risk factors being exercise intensity, poor control of lumbosacral complex movement, weakness of the lower limbs and poor aerobic fitness. Although we know about these risk factors and injuries, there is still no consensus as to which physiotherapeutic treatment methods are most suitable for ballet dancers.
A detailed examination of sports physiotherapy
The study of treatment effects in ballet dancers is usually reported in small cohorts or case studies that focus on one joint rather than the ballet dancer as a whole – this is important given the extreme multi-planar multi-joint range of motion the ballet dancers perform. In general, however, the overall evidence indicates that physiotherapy reduces pain and increases the range of motion in ballet dancers.
A new systematic review article published in PLoS ONE was intended to clarify this by evaluating the effectiveness of physiotherapeutic interventions in the treatment of injuries in ballet dancers.
Methods
This systematic review followed the PRISMA guidelines, but was not pre-registered on PROSPERO, which means that there is an opportunity to report bias as it will be difficult for future replication and direct comparison of this review.
The databases used were PubMed, OVID Embase, Cochrane, Medline, PEDro and Google Scholar and were searched and discussed by two reviewers in order to reach a consensus. This in turn should have been an independent third reviewer in order to reduce possible distortions.
((((dance therapy [MeSH Terms]) AND (ballet [MeSH Terms])) OR (ballet dancer)) OR (classical dancer)) AND (pain)
All types of quantitative studies were included in the review, including cohort and quasi-experimental designs. Studies were included when examining ballet dancers with acute or chronic injuries and persistent pain and receiving physical therapy interventions. The search was not restricted and the physiotherapeutic intervention was unspecific.
The outcome measures of interest were the multidimensional nature of pain, injury / pain site, unspecific treatments received and pain, ROM, quality of the eyelid and function. In essence there was no restriction to specific results . Studies were excluded if they included surgical or pharmacological interventions.
The quality of the included studies was assessed using the NHMRC hierarchy of evidence and qualitative studies using the modified McMaster Critical Review Form. Each study was assessed independently by each reviewer and disputes were settled through discussion.
Results and clinical takeaway
Ten articles were included in the review with a total of 83 participants aged 11 to 29 years and a sample size of the studies from 1 to 62. The overall quality of the included studies was poor (D rating), which limits the applicability of the results of the review.
That being said, there are lessons to be learned from the review. There are significant differences in the treatments used to treat ballet dancers. Shock waves, manual therapy, stability training for the lumbosacral spine, home exercise programs, heat therapy, acupuncture and dry needling were used as interventions. Several treatments were even used in some studies, which made it difficult to establish causality.
The effectiveness of interventions was assessed using a large number of different outcome measures (OMS), which made it difficult to compare results between studies. The OMS used included VAS, muscle length tests, special tests, Beighton's scale, MRI, CT scans, PedsQL and dance-specific questionnaires such as DFOS. Overall, all studies showed positive changes in results across all treatments.
Brief summary of the effectiveness of physio interventions in ballet dancers
There is a lack of high-quality studies examining a physiotherapeutic treatment specifically for ballet dancers
VAS score improved in all studies
Rome improved in six of the studies
Some improvement was noted when using modalities such as shock wave for dancers with metatarsal fractures
In general, the same treatments should be used for ballet dancers as for athletes
The results of the ten studies can be summarized over six domains: pain, ROM, physical assessment, posture & gait, quality of life and structural condition. Across all six of these domains, the results suggest that physiotherapeutic interventions had a positive influence in all six domains.
Pain was assessed in all studies included in the review and all of them showed an improvement in the pain level after physiotherapeutic intervention. The range of motion was assessed in six of the studies and again a positive effect was observed in the dancers. A similar pattern was found in the questionnaires on quality of life and functional status.
The question, however, is – how many of these injuries would have completely recovered without specific physiotherapeutic interventions? It is possible that specific interventions would have improved the injuries faster, but the quality of the study is poor so that little else can be seen from the results than general physiotherapeutic approaches for every athlete apply to ballet dancers.
