Straight Talk.

An estimated 60 to 80 percent of ballet and modern dancers have some history of a back injury. Here are some indicators of spinal problems that can be recognized in the classroom and suggestions on tailoring an individual student's technique to avoid exacerbating the condition.

The spine--that complex, curvaceous, and flexible support that keeps the human body upright--is a part of the dancer's anatomy that requires careful alignment during early study if it is to remain healthy and centered.

The spinal column consists of thirty-three vertebrae (irregular bones)--seven cervical; twelve thoracic; five lumbar; five sacral; and four coccygeal--enclosing a cord of nerves, connected by discs and surrounded by various muscle groups that maintain its delicate balance. (See sketch at right.)

LUMBAR CURVATURE

Most deviations occur in the L5-S1 (lumbar 5 to sacral 1) joint, which experiences the most stress of any of the lumbar segments. An imbalance in the alignment can result in a hyperlordotic (hyperextended or very much hollowed) lumbar spine, a factor in a majority of dance-related injuries. Lordosis, a greatly exaggerated curve, can be caused by a forward pelvic: tilt due to tightness of the structure in the front of the hips; weakness of the abdominal muscles; weakness of the buttock muscles; overly turned-out feet in relation to the hips; weakness of the inner thigh muscles that produces a failure to hold the turn-out; swaybacked knees that produce a compensatory pelvic tilt; a bow in the shinbone that causes the weight to be pushed back, making it difficult to get hold of the inner thighs; weakness of the forefeet; working with the arms too far back, causing the upper trunk to tilt backward (often accompanied by a forward poking chin); and tight hamstrings.

Anatomically, weak abdominal or tight psoas muscles are indirect contributors; faults in technique, such as extending the pelvis to improve hip turn-out, executing arabesques through the extension of the lumbar spine, and poor lifting technique in male dancers, may also contribute. These conditions can become severe and eventually lead to an injury that may result in the end of a career.

TEACHER ALERT

Because it is postural, lordosis can theoretically be greatly corrected in the younger years before maturity, although in practice it is almost impossible to fully correct.

Proper placement and alignment are vital. The teacher should be watchful from the moment the young student stands facing the barre for the first time that the hips are square (not tilted) and the spine is in a neutral position. In demi-plie, the knees must always be on a line over the toes and the spine maintained in its neutral position.

A clear indication of lumbar distortion can be seen in arabesques. They should be executed with the hips kept square and the working leg raised without placing undue strain on the lower back or by twisting the hips. Unfortunately, many dancers find that an appearance of greater external rotation can be achieved by raising the hip of the working leg in arabesque and in extension a la seconde, thereby placing a greater strain on the lumbar area. These exaggeratedy turned-out positions can lead to pain, spondylolisthesis (stress fracture and forward slippage of the spine), hyperlordosis, and more serious injuries. While there is a current choreographic style and aesthetic preference for these placements, they cannot be safely accepted as a methodology during the early training years.

If fight muscles are restricting motion, a simple daily exercise can help to strengthen the muscles surrounding the spine: Have the student lie face down on the floor or on a low surface, hands behind the head, elbows out. Hold down the student's ankles while he or she arches the back by raising the head and upper torso slowly toward the ceiling while keeping the hands in place and the hips on the surface. The student inhales gently through the nose on the rise and exhales slowly through the mouth during the slow return to the flat position. Find a medium speed for the rising and lowering. Begin with ten repetitions; increase the number as strength builds and the student is able to arch higher.

As a rest position for strained lumbar muscles, have the student lie on his or her back, lumbar area pressed to the floor, knees bent and raised. Gently press the bent knees toward the shoulders with the hands. Hold for a few seconds, then release. Repeat as often as needed until some relief is felt. With serious defects, this exercise will not relieve the condition.

SCOLIOSIS 

A mild degree of scoliosis, a spinal curvature, may not be immediately apparent on initial observation. The area affected by the curvature is very much stiffer than normal and is mostly located in the dorsal (posterior) spine. This is not a major problem if the scoliosis is mild; however, since it is located in the lumbar region, the accompanying inflexibility can make the back too rigid to allow the movements required for ballet. Most of the movements of flexion and extension and lateral flexion and rotation take place in the lumbar region.

In the majority of cases, the cause of scoliosis is unknown. Many professional dancers have a mild form, which can be improved by electrical muscle stimulators worn at night, mechanical braces, or exercises. In mild scoliosis cases, difficulty can be experienced in centralizing the line of weight-bearing--usually when favoring the shorter side. As a result, low-back strains are common. Frequently, hamstrings on one side are much tighter than on the other, which can lead to hamstring injuries. Tightness arises because of the presence of a pelvic tilt associated with scoliosis and, on the looser hamstring side, a close-legged, knock-kneed configuration known as jarrete, or hyperextension, causing its own particular difficulties. In addition, a relationship between scoliosis and stress fractures, secondary amenorrhea (the absence of a menstrual cycle after it has once appeared), and delayed menarche (delayed onset of the cycle) has been demonstrated. Screenings, therefore, are essential since scoliotic spines may have a lateral curvature but exist without measurable rotation--however, measurable rotation does not always indicate scoliosis.

EVALUATION AND REHABILITATION

Robert S. Gotlin, D.O., says, "I deal with nonprofessional as well as professional patients, and in each category I have to get to know the personality--especially to determine who is holding back on rehabilitation because they don't want to stop performing. It's a one-on-one process.

"Scoliosis is preprogrammed and the issue is early intervention. In a child, if a curvature, located at any part of the spine, measures a deviation of 0 to 20 degrees, simple exercises may help. On a scale of 20 to 40 degrees, bracing is considered. After 40 degrees, surgical intervention may be needed. The tricky thing with scoliosis is to decide whether to use exercise, a brace, or pressure in the opposite direction of the curve--a common sense approach. Growth-spurt periods are also factored into the rehabilitation program. A functional brace will permit the patient to perform without the discomfort that may be the result of irritating a bone, causing nerve and muscle pressure.

"A female child is usually more self-conscious about wearing a spinal brace for many hours, but the newer models are custom designed and more discreet.

"If the curvature does not progress beyond that 40-degree point, the body can compensate. In medicine, we can step back a bit more now than we could before and let the body compensate during the rehabilitation. In musculoskeletonal medicine, 80 percent of the time we can expect self-healing with exercise and watchful waiting.

"The essential ingredient in any therapy, however, is not to be closed-minded and focus only on that one. The body is one instrument. It moves in sync, and while there are exercise books out there that you can follow for scoliosis and that are not harmful, those exercises may not be enough. Just to look at the back is insufficient; you have to assess the entire body. For that reason, it is important to get a professional evaluation."

The rehabilitation center at Beth Israel Medical Center, under the direction of Gotlin, is extensive and multifaceted for each patient. An individual therapy program is constantly adjusted and enhanced as the sources of discomfort are tamed and gradually disappear.

RELATED ARTICLE: TEACHER ALERT: WHAT TO WATCH FOR

On a less scientific level, the teacher can observe the spinal column of a dancer as he or she bends forward at a fight angle or executes a head-to-knee bend from Fifth or First Position. Notice that the spine is not perfectly straight in all individuals, and that some normal range of lateral curvature is allowed. If the curve seems pronounced, however, suggest professional evaluation.

According to Gotlin, there are a few clues that can indicate a number of different sources of a spinal problem at any age:

1. Pronation. The arches touch the floor or the feet don't match--one arch is on the floor; the other is up. The harmful effect from this condition can be seen in the knees, hips, and back.

2. Leg Length. This difference can sometimes be seen visually; often it is more easily observed in the uneven hemline of pant legs or of a skirt.

3 Weakness or preference for one leg. Is there a tendency to use the stronger leg even going up or down stairs? A decided preference for doing turns or jumps only on one side?

4. Shoulder discomfort. Hanging your dance bag on one shoulder is not always the source of shoulder pain, Check a male dancer's lifting technique while partnering.

Robert S. Gotlin, D.O., is director of Orthopaedic and Sports Rehabilitation in the Department of Orthopaedic Surgery at Beth Israel Medical Center, Singer Division, in New York City.