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Assessing and reporting dancer capacities, risk factors, and injuries: recommendations from the IADMS standard measures consensus initiative.

From the Editors

We want to alert you to the fact that what you see below and on following pages is not just another article. It is an IADMS sponsored and sanctioned "White Paper," the intention of which is to provide guidance for how future research in our field is conducted and managed. Those of you who anticipate contributing to that research will want to keep this paper and its companion piece mentioned in the Abstract and Introduction close at hand as you develop your studies and implement the practices they recommend. Thus, you will be helping to build a coherent and integrated body of knowledge that will speed us on our mission to improve the health and wellbeing of dancers. Also, we invite you to join us in thanking the paper's authors for their outstanding dedication over many years to bringing this project to fruition.

Recognition of the need for standardized testing and reporting methodology in dance medicine and science research began to emerge within the IADMS community shortly after the organization's inception in 1991. In 1995 an injury surveillance system and reporting method which was specific to the dance environment was presented at the annual conference in Tel Aviv, Israel, and published in the meeting's Proceedings. (1,2) In 1998 and 2001 panel discussions focused on standardized testing methods were highlighted at the conferences in Hartford, CT, and Madrid, Spain, and again published in the Proceedings. (3,4) From 1997 to 2003 the Journal of Dance Medicine and Science published three special issues on topics related to standardized screening and measurement of dancer capacities, (5-7) and in 2006 and 2007 it carried two articles specifically addressing the need to standardize injury surveillance practices. (2,8) As a result of an ever-increasing awareness that the absence of generally agreed upon operational definitions was confounding efforts to integrate results across studies and to provide clear estimates of injury incidence and risk in dancers, (2,8-11) IADMS launched a multi-year consensus-building project at its 2004 conference in San Francisco, CA. The purpose of the project was to undertake a review of the literature and of current practices, and from the results of that review, to develop evidence-based recommendations for the standardization of testing and reporting methods. This project became the Standard Measures Consensus Initiative (SMCI).

This technical report is intended primarily for dance medicine and science researchers and those in clinical, administrative, and leadership positions whose roles involve responsibility for dancers' health. It provides an in depth summary of the background, literature, and rationale behind each of the report's recommendations. A shorter version of this Technical Report will be available as an Executive Summary on the IADMS website. The Executive Summary serves as a brief "how to" manual for implementing the recommendations of this Technical Report.

Purpose of the SMCI

The primary function of the SMCI was to create a set of recommendations to:

1. Establish uniform methodology for tests and measures used to assess dancer capacities and intrinsic and extrinsic risk factors for injury;

2. Establish common protocols for reporting injuries; and

3. Assist the dance medicine community in applying these recommendations through the use of all applicable technologies.

The ultimate goal of these recommendations is to standardize the measurement of intrinsic and extrinsic risk factors and injury reporting methodology for researchers in dance medicine and science, thus allowing for more robust comparison of results across research efforts. Standardization will also enhance the ability of the dance community to identify the most meaningful ways to reduce risk and prevent injury across dance genres.

Methods of the SMCI

The processes undertaken by the SMCI were as follows:

1. Reviewed existing literature to identify generalized models of health, injury prevention, and the causative factors of injury;

2. Reviewed existing literature and conducted surveys to determine how the dance medicine community was currently identifying, quantifying, and describing the occurrence of injury or illness and the mechanisms related to injury;

3. Compared and contrasted practices currently used by the dance medicine community with those models described as best practices in the literature;

4. Developed recommendations for best definition and measurement practices within the dance medicine and science community;

5. Developed recommendations for a model data management system;

6. Presented the following platform reports to the IADMS community at its annual conferences, inviting audience feedback and providing roundtable discussions: a. Statement of need: launch of SMCI (San Francisco, 2004);

b. Standardized measurement of function (Sweden, 2005);

c. Screening, merits and limits: what and why to measure; overarching aim to reduce injury risks; review of field survey results (West Palm Beach, 2006);

d. Injury reporting: epidemiologic content; review of field survey results; expert panel discussion (Canberra, 2007);

e. World Health Organization-based biopsychosocial predictive modeling (Cleveland, 2008);

f. Summary of SMCI work: whole context sequence of prevention model (downloadable video of this presentation available on the IADMS website), (The Hague, 2009); and

g. Best practices for collaborative research and secure data management of personal health information (Washington, DC, 2011).

Elements of the Present Technical Report

This Technical Report was built upon the SMCI's basic mission to facilitate ways for the dance community to reduce dancers' risk of injury. Central to this work is the understanding that dance injuries result from a complex interplay between human (intrinsic), environmental (extrinsic), and situational factors (which will be discussed in the Risk Reduction Strategies section below), and that these factors must be measured in a robust and standardized fashion if they are to be controlled. (12) There are six recommendations for achieving an adequate measuring process, derived in part from the SMCI's field survey results, which reflect a sample of the dance community's injury surveillance and screening behaviors and a comparison of those behaviors with published information about best practices from the health sciences literature. The report also includes current best practice models for managing injury data.

I. Injury Surveillance

Injury surveillance is "the continuing scrutiny of all aspects of occurrence and spread of a disease or injury that are pertinent to effective control." (13) Dance injury surveillance refers to an ongoing and systematic collection, analysis, and interpretation of data related to occupational exposures in a dance environment, and to adverse health outcomes associated with exposure to work as a dancer.

In 2006 email blasts and newsletter announcements were made available by SMCI to all IADMS members, requesting participation in a survey of injury reporting methods being used in the field. Survey responses were received by the IADMS Research Committee. The de-identified data underwent an item-by-item analysis, and the results were shared with the public through a panel of injury surveillance experts during the 2007 IADMS Annual Meeting in Canberra, Australia. Institutional Review Board approval to publish these data was granted.

Ninety-eight surveys were received from 930 potential participants, the results of which are presented in Figures 1A and 1B. Fifty-nine percent of the respondents identified themselves as licensed healthcare practitioners, 38% as dance educators, and 3% as artists. Fifty-three percent reported that they were conducting injury surveillance at their worksite, whereas 47% were not. Of those who did have a surveillance system in place, 71% said participation in it was optional (not mandatory). Sixty percent noted that dancers reported their injuries to a healthcare practitioner and 40% to a dance teacher or company manager. When asked how "injury" was defined in the reporting system, 67% of respondents stated it was by tissue pathology or complaint of pain, 21% by need for medical attention, 4% by time lost from activity, and another 4% by the need to open a worker's compensation claim. Lastly, when asked if the injury reporting system measured "exposure," in 75% of cases it did not, in 15% of cases injury was measured per exposure-episode, in 6% per dancer-hours, and in 4% of cases it was measured per contracted work hours.

[FIGURE 1 OMITTED]

The findings of the survey revealed that adequate injury surveillance systems (i.e., active and mandatory) were only available in approximately 15% of all facilities covered by the returned questionnaires (Fig. 1). Further, the results indicated that the methods for defining and measuring injuries were highly variable, corroborating findings in the dance medicine literature. (2,8,9-11,14-23) In 75% of cases, exposure was not being measured, and by-and-large the reporting of injuries was not mandatory. Additionally, in many cases the reporting was not being documented by a healthcare professional trained in the recognition of injury and in the nomenclature of diagnosis and injury-mechanism.

From this information the SMCI concluded that a model for defining standard injury measures was indeed needed. Subsequently, an iterative model that describes the overall sequence of injury prevention was adopted (Fig. 2). (24,25) This model begins with identification of the magnitude of injury rates (Step 1), followed by definition of the factor(s) and mechanism(s) that play a role in the onset of injury (Step 2). Step 3 introduces measurable interventions that are likely to counter the variables identified in Step 2. Lastly, in Step 4, the effectiveness of the interventions is evaluated, and then Step 1 is repeated to determine if a reduction in injury rates indeed occurred.

[FIGURE 2 OMITTED]

For an injury reporting system to be robust, it is essential that the system capture the "right information," (26) as shown in Table 1. Injury surveillance systems fail when definitions of injury vary among users and when reporting is optional rather than mandatory. (27,28) It is not possible to determine incidence rates within a denominator group when reporting is optional because in that case a uniform and complete picture of all injury events for all people at risk within that group does not exist. Valid incident rates are an essential requirement for an accurate understanding of injury occurrence, and must be known in order to progress through the injury prevention model (Van Mechelen's model, Fig. 2). (24,25)

Without standard methods and complete reporting it is difficult to achieve a true understanding of injuries. We can look to sports for examples of the difficulty that lack of standardization imposes on comparisons across participating groups. In one sports-based report the incidence of concussion in rugby players ranged from 0.1 per 100 player-seasons to nearly 10 per 100 player-seasons. (29) Differences of this magnitude (100-fold) cannot reasonably be attributed to underlying variations in the incidence of concussion among the groups that formed the study population. More likely this magnitude was due to differences in sensitivity to concussion, counting time-at-risk, and computing measures of incidence. (30) Similar difficulties are present in the dance medicine literature. For example, incapacitating knee injuries self-reported by dancers in one company over a 1 year period occurred 45% of the time, (31,32) whereas knee injuries captured by healthcare professionals at two other companies showed incidences of 9% and 15%. (12,33)

Organized sports have long had several voluntary surveillance systems that are similar to communicable disease reporting systems. These include:

* The National Athletic Injury Reporting System (NAIRS), (34)

* The National Head and Neck Injury Registry, (35)

* The National Collegiate Athletic Association's Injury Surveillance System (ISS), (36)

* The National Electronic Injury Surveillance System (NEISS), (37)

* The American Football Coaches Association Annual Fatality Study, (38) and

* The National Center for Catastrophic Injury Research. (39)

All of these monitoring systems rely on local reporting to a central database of injury events by healthcare professionals who have implemented mandatory reporting systems within relevant groups. The SMCI believes that the sports model of injury surveillance can be used as a model for the dance medicine community.

Like the 1970s NAIRS model mentioned above, a dance injury reporting system needs to be continuous and allow for comparisons among participating groups, while creating a repository of information that can be used for systematic decision making. (34) Other features of strong surveillance systems are that they are cost-effective, simple, and unambiguous, offering broad coverage through local collection. As should be clear by now, it is essential that a surveillance system requires mandatory participation and universally accepted definitions of injury and exposure. (24,28)

Having advocated for an injury surveillance system, it is important to understand that such systems are only moderately successful at determining the actual effect of any given prevention effort on incidence rates (moving from Step 4 to Step 1 in Fig. 2). This is because it is not possible to rule out the effect of change due solely to the passage of time on the outcome variable. (25,27) Although some of the etiologic factors in injury are relatively stable over time (sex, age, height, hypermobility, etc.), others are ever changing (situational attention, effect of ambient light and temperature, venue, costume, etc.). The latter type of information would be useful only if it were collected on all of the non-injured dancers in the same denominator group at the same time. (25,40) Consequently, a randomized clinical trial incorporating standardized injury surveillance and the sequence of prevention model (Fig. 2) is the design of choice for evaluating the effect of a specific preventive measure.

Recommendation #1:

Injury Surveillance: A dance injury surveillance system should be mandatory, utilize licensed healthcare professionals trained in the diagnosis of injuries, and employ a standardized protocol for capturing injury per exposure for all dancers within a specified group.

II. Defining Injury

Injury surveillance systems must establish the determinants of when an injury has occurred, and quantify the extent of that injury in some manner. These purposes overlap. There is typically a threshold for the extent of the incapacity that determines if an injury has actually occurred, and whether a case must be reported. However, many operational definitions of injury exist. They can include: dancer complaint of pain, cost associated with the complaint, decreased activity measured by loss of function in a body part, decreased time engaged in activity (class, rehearsal, or performance), or the act of consulting with medical or training personnel. Typically, injury definitions include a severity rating and are often broadly categorized as "acute" (associated with macrotraumatic inciting events) or "overuse" (associated with insidious onset repetitive microtrauma). (25,27)

Classification of injury by diagnosis is inherently complex, and an otherwise well-designed injury reporting system can quickly be rendered invalid if diagnoses are not accurate. (27) For this reason, it is recommended that only licensed healthcare practitioners trained in the recognition and nomenclature of injury be the people to document injury information within the surveillance system. Sub-par identification of injuries is the bane of all injury reporting systems, and severely limits the conclusions that can be drawn from them. (40)

There are six conventional modes of defining injury:

1. By particular tissue pathology and nature of the injury (e.g., strain; sprain; infection or inflammation; concussion),

2. By duration and nature of treatment,

3. By time lost from a particular task (referred to as "activity" in the World Health Organization [WHO] model), (41)

4. By time lost from work (referred to as "participation" in the WHO model), (41)

5. By measure of permanent functional loss (wherein the WHO-defined ability to "participate" is altered permanently), (41) and

6. By cost of care. (42)

[FIGURE 3 OMITTED]

Time lost from work is the most widely accepted and generally used approach to defining injury in sports, but time loss grades are not without problems caused by differences in personal motivation, pain tolerance, peer influence, and coaching staff reluctance or encouragement. Many studies also distinguish between reportable injuries (time loss) and non-reportable (no time loss) injuries. Interestingly, non-time loss injuries, although not reportable, consume more time and services from college athletic department healthcare personnel than do time-loss injuries. (43)

In 2007 Orchard and Hoskins (44) published a paper that reviewed the reliability and functionality of the above described injury definitions among sports medicine practitioners. The investigators utilized the written image of an iceberg to illustrate the challenge of defining injury (Fig. 3). Essentially, the entire iceberg represents 100% of injuries experienced by athletes (or, in our case, dancers). The part of the iceberg above water represents those injuries that are most easily seen and thus more reliably measured. The part of the iceberg below water represents those injuries that are less visible and consequently less likely to be measured accurately. These "submerged" injuries could be, for example, ones that inhibit optimal performance but do not prohibit it altogether, or even injuries actually responsible for time lost from work but not reported as the causative factor (e.g., sick days).

Few, if any, injury surveillance systems will be able to capture data on all injuries. Therefore, it is important to estimate the direction and extent of bias present in under-reporting. Understanding the under-reporting bias is critical when attempting to achieve consensus on a definition of injury.

Injuries can be conceptualized along a spectrum based on severity. For example, injuries may be as minor as a blister or as severe as death. (40) Severity can also be related to time lost in participation. Degree of tissue damage is typically related to participation time lost, but not necessarily in a one-to-one correspondence. What is clear is that injuries that are less severe are often not visible (not measured, as they may be unreported or do not contribute to decreased participation), and that as injuries increase in severity they become more visible (more easily measured). Consequently, more severe injuries can be reliably measured by multiple types of observers. (44)

Definitions of injury are fraught with potential for error in applying them. Some dancers, for example, will continue dancing when they have substantial tissue damage that might sideline another dancer with the exact same injury. On the other hand, some dancers will skip a class or rehearsal because of an ache or pain, while another dancer with the same condition will work through the ache or pain in order to improve their technique and readiness for performance. These differences in behavior can have as much to do with fear-and-avoidance beliefs as with actual inability of tissue to carry load. For this reason, time-lost definitions without the diagnostic confirmation of a licensed healthcare professional can be very unreliable.

The National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS) formerly used time-lost to define injury, as well as to grade injury severity. One day lost meant a "minor" injury, while 7 days lost meant a "moderate" injury, and so on. The time-lost severity rating criterion was highly variable, however, so over time the NCAA decided to look at severity dichotomously as either less or more than 10 days lost from activity due to injury. (45) This allowed the NCAA to gain a better understanding of the incidence of the injuries that were most severe. (45)

In closing, we return to Orchard and Hoskins' conclusion that the only truly reliable definition of injury is one that is maximally exclusive and equivalent to the tip of the iceberg. They recommended limiting inclusion of injuries to only those that are unambiguous and easiest for all data collectors to see, comprehend, and count. In response to Orchard and Hoskins' suggestion, the members of the Cricket Association in Australia agreed to use this criterion as their definition of injury. They now intentionally do not record any injury that falls short of missed participation in a Cricket match, even if a player misses many practices because of pain or function lost. While they understand the urge to measure all injuries among their players, they concede that not every data recorder would be able to swim 20 meters below the surface to detect the size of the submerged iceberg. They acknowledge that their injury reporting system would be valid only if the bar to inclusion were set at a level that made it foolproof for the least experienced and least motivated injury recorders to use reliably 100% of the time. (44) This continuum-end measurement method has been endorsed by other sports epidemiologists. (27)

Dance medicine and science practitioners must decide what the tip of their iceberg will be; that is, what criteria will be agreed upon for defining injury among dancers? Many dancers do not have regular performance seasons, so using a missed-performance-only definition probably would not provide enough information about dance injuries. One thing seems certain: a useful definition of injury for the field will need to be one that can be documented reliably by even the least experienced practitioners charged with collecting the data.

After evaluating the alternatives and conferring with content experts, the SMCI concluded that the best practice definitions in dance medicine and science for dance injury and dance exposure would be consistent with those that have been used for the ISS over the past 30 years.

Recommendation #2:

Defining Injury: The term "injury" refers to an anatomic tissue-level impairment as diagnosed by a licensed health care practitioner that results in full time loss of activity for one or more days beyond the day of onset. "Activity" for the sake of this definition means participation in a class, rehearsal, or performance (i.e., further "exposure," see Recommendation #3). For those events that fall short of this strict definition of injury the term "musculoskeletal complaint" should apply. Musculoskeletal complaints do not rise to the level of a reportable injury event within the surveillance system.

III. Defining Exposure

While the number of injured dancers is often known, the rate of injuries relative to the amount of time spent dancing and the number of dancers at risk for the injury is often not known or recorded. Absolute numbers of the occurrence of injuries mean little without the context of injury rate and injury risk. For injury surveillance information to have meaning, it must be considered relative to exposure: how many dancers participated in the activity and for how long. Five injuries distributed over 100 dancers participating in a week-long dance festival means something very different than five injuries distributed over 20 dancers participating in a 6 hour rehearsal. Therefore, exposure data must be collected on all dancers within the scope of each injury surveillance system. Lindenfeld, Noyes, and Marshall give a good illustration in their 1988 article (27) of what can happen when the denominator for rate and risk is not known. Over a period of several years a physician saw three times more injuries in football than basketball. He concluded that football was three times more dangerous than basketball, and therefore began encouraging all his patients to quit football and take up basketball. Upon further analysis, however, he found that there were four football leagues in his town and just one basketball league. Thus, he realized that he might well be seeing more football injuries because there were more football players!

Based on the models used in sports, exposure in dance might be defined by:

1. Annual contracted work hours: one dancer contracted for "x" number of hours per year;

2. Dancer exposure: one dancer participating in one class, rehearsal, or performance (which can, with added effort, be weighted for time doing activity);

3. Time exposure: one dancer participating in one minute/hour/day of activity (which can, with added effort, be weighted for intensity of activity); and

4. Element exposure: one dancer participating in one element of activity (e.g., jete, pratt fall, pirouette).

From top-to-bottom in this list of possible exposure definitions the measurement becomes more precise, but also much more difficult to collect with accuracy.

Measuring exposure by contracted work hours is generally frowned upon because it is too crude; it can incorporate a substantial amount of time when dancers are not actually at risk doing dance activity, but rather are involved in tasks like costume fittings, photo shoots, company meetings, or tour-related travel. Exposure is meant to be a measure of time when a dancer or athlete is truly at risk. Furthermore, this method of exposure measurement is not conducive to non-professional (e.g., university) settings.

A more precise measure of exposure is what is known as an "AE" (athlete exposure), which could be labeled as a "DE," or dancer exposure. One dancer exposure is defined as one dancer participating in one class, rehearsal, or performance in which he or she is exposed to the possibility of dance injury, regardless of the time associated with that participation. One AE as defined in most sports studies may be equivalent to 2 to 3 person-hours of exposure, depending on the length of practice or competition. (46) The ISS uses the AE measurement of exposure for collegiate athletes because this system guarantees that only participants with actual playing or movement time are counted as having an exposure. Simply showing up to a practice or game (or, in the case of a dancer, to a class, rehearsal, or performance) without participating does NOT count as an exposure.

In dance this definition can become tricky, as there is considerable variability between the various types of dance exposures in terms of the duration and intensity of the class, rehearsal, or performance. While there is a general sense of what constitutes the content of a typical practice session or a game and season in sports, there is less consistency with regard to what constitutes the content of a rehearsal and a performance season in dance. For example, one dancer might have five short rehearsals of 15 minutes duration each to run through the repertoire of that weekend's performance, while another may have a single five-hour rehearsal to learn a new piece for a performance the following week. If we were to apply the convention for measuring exposure in athletics to the example above, the dancer who danced 1 hour and 15 minutes would be credited with five exposures, while the dancer who danced 5 hours would be credited with only one exposure. A similar problem can arise with regard to performances. Imagine that a ballet dancer is doing a character role in Giselle one evening, which gives her one exposure, while a dancer at a different theater is a soloist in four repertoire pieces, giving him four exposures. They both arrived and left their respective theaters at the same time that evening, but one dancer had four exposures while the other had one. Is this the best way to measure exposure?

Going down the list of exposure definitions above, the precision of exposure measurement improves. For example, a weight can be assigned to the measures of exposure based on how much time during that exposure the athlete or dancer actually was moving. Another way to measure exposure is to describe particular movement elements within each exposure time period, and count how many minutes of overall dance time were spent doing each of those. Then the energy cost or biomechanical load of each element could be quantified to calculate a physiologically precise degree of exposure. However, collecting such data consistently is complex and challenging. As precision increases so does the difficulty of collecting the data, which may compromise the compliance of recorders as well as the reliability of their assessments.

After evaluating the alternatives and conferring with content experts, the SMCI concluded that the best practice definition for dance exposure is that which has been used by the ISS for the past 30 years, because it is expected to yield the highest level of reliability. It will also allow for a direct comparison of injury incidence between dance and athletics.

Recommendation #3

Defining Exposure: Any participation in a class, rehearsal, or performance in which the dancer was exposed to the possibility of a dance injury constitutes one exposure.

IV. Dance-Specific Screening

The definition of health is critical to an understanding of the need for, and specifics of, screening. The World Health Organization (WHO) model is briefly described below. (41) This model uses body structure and function, activities, and participation to serve as a basis for understanding the biopsychosocial interactions related to health (Fig. 4). (41)

The WHO model of health identifies three areas of focus: 1. body structure and function, 2. activity, and 3. participation. (41) For example, a dancer with a hip labral tear (body structure) might be unable to execute ronde de jambe en l'air (activity) and consequently not be able to perform (participation). However, the arrows go both ways; lack of participation may decrease a dancer's ability to perform a certain activity and may even alter, over time, body structure. The WHO model also recognizes environmental and personal factors. For example, dancing on a concrete floor (environment) or having nutritional status dysfunction (personal) may impact at any or all of the three previous areas, ultimately leading to decreased health.

Thus far the dance medicine literature has been making progress toward standardized measurements of body structure and functioning (ankle and hip ROM; total turnout) and of activity (tests of calf strength; maximal oxygen uptake; biomechanical assessments of jump landings). Fewer studies have been done on the "participation" level, where we might capture an understanding of what is required to succeed at working in the full "role" of a dancer over time. At this level, environmental and personal factors may play a larger role. Factors like personal strategies for coping with harsh criticism; fear and avoidance beliefs about musculoskeletal pain; long touring schedules; and exposure to variable and unknown floor surfaces, lighting, costumes, and live music may all impact the health of the dancer.

[FIGURE 4 OMITTED]

IADMS has long acknowledged the role of screening in the overall consideration of dancer health and safety. The third issue of its first volume of the Journal of Dance Medicine and Science in 1997 was devoted to the topic of screening, and it embodied an international, multi-disciplinary, and developmental perspective on the topic. (5) Screening can provide dancers with early detection of sub-clinical health problems or illness behaviors that might otherwise go unaddressed, particularly for the many dancers who lack health insurance (47,48) or who may be afraid to report an injury for fear of losing work or being told to stop dancing. (49,50)

Screening is also a concept that long predates the emergence of dance medicine as a professional sub-specialty. For years, organized efforts have been underway in Canada, New Zealand, Australia, and the European Union nations to monitor sports injuries in an effort to reduce their occurrence. (51) Several major organizations, including the Council of Europe, WHO, and the NCAA, have developed policies and procedures for screening athletes, with all such organizations agreeing on the importance of identifying musculoskeletal deficiencies that may predispose athletes to injury or ill-health during activity. (52) In 1976 the American Medical Association's Committee on Medical Aspects of Sports developed a statement entitled The Rights of the Athlete, which proposed that every athlete is entitled to adequate health supervision, including a thorough pre-participation history and medical examination. (53) One year later a standardized athlete screening form with testing guidelines was proposed (49,53) and, over time, was endorsed by numerous organizations based on the understanding that an easy to use and responsive clinical screening tool would be a useful and necessary mechanism for health promotion and injury prevention among athletes. Consensus on the screening content was achieved by expert physicians, drawing on the tendencies they had observed in athletes who had been injured, as well as traditional examination approaches for the common types and frequencies of injuries they encountered while caring for athletes in various sports. (54)

When studying the literature on screening, it becomes clear that there are two fundamental reasons for performing screens aimed at ascertaining general health and functional capacity:

1. Screening establishes a profile of normative data on a group of non-injured individuals within a given form of activity at a given level of skill in order to understand the stress-capacity relationship between performance and performer. (24,55,56) The underlying assumption is that the normative data can be used as a basis of comparison for individual participants to determine if they possess the attributes necessary to safely meet the demands of that activity at that level of participation. (55)

2. Screening is also conducted to establish individual baseline health information, to uncover sub-clinical or residual pathology from prior injury, to quantify risk for performers while providing them with an individually tailored prescription for remediation, and to quantify risk for parents or organizations, sometimes fulfilling an employer's or institution's legal and insurance requirements. (54,57,58)

To gain an understanding of how screenings are being conducted in the dance medicine and science community, the SMCI facilitated email blasts and newsletter announcements to IADMS members from March 1, 2005, through March 31, 2006, calling for voluntary submission of sample screening forms used in the field. Collaborative efforts to disseminate this call for information were achieved through intra- and interorganizational efforts in cooperation with various IADMS country correspondents and with point persons at sister organizations, including the Australian Dance Council, the Dance Kinesiology Teachers Group, DanceUK, DanceUSA, the Performing Arts Networking Group of the NATA, the Performing Arts Special Interest Group of the APTA, and the Case Western Reserve University's Dance Wellness Project. All screening forms collected were anonymously analyzed to produce a report on the breadth and frequency of screening form items under three broad categories: history, function, and outcome, and these data were presented at the IADMS annual conference in West Palm Beach in 2006. Institutional Review Board approval to publish these data was granted.

Sixty-eight forms were received from 13 countries over a period of 12 months. The countries represented were: Australia, Canada, China, England, Finland, Greece, Ireland, Israel, Italy, Japan, Spain, Sweden, and the USA. Healthcare professionals submitted 82% of forms and dance educators 18%. The number of tests per topic heading varied widely among forms, so a decision was taken to utilize a simple dichotomous (yes or no) analysis. For example, some forms contained up to 12 different foot structure measurements, and others had none at all. Items that fell under a topic heading were counted only once per form, such that the form containing 12 separate foot measurements was counted as only one item under that topic heading.

There was enormous variability among forms in terms of content and volume. Screens ranged in length from half a page to 20 pages. Testing methods also varied greatly within topic headings. For example, some screens used rotation discs or a "total leg rotation" formula to determine a turnout score, while others used passive sitting hip external range of motion as their measure of turnout. Many used 5/5 break test scores for strength, while others used hand-held dynamometry or isokinetic devices. Some of the testing instrumentation was in accordance with gold-standard testing procedures well known in the orthopedic or exercise science literature, while other testers employed what appeared to be home-made tests lacking in evidence of validity, or modified versions of the gold-standard tests without evidence that the modification preserved the test's validity.

This analysis revealed disparity among dance medicine practitioners with regard to the depth and manner of screening procedures currently used in the field to assess intrinsic dancer capacity. It also indicated a lack of consistency among practitioners in terms of an evidence-based (59,60) approach to the construction of screening forms. For example, despite strong evidence in the dance and sports medicine literature of the predictive value of prior injury on future injury occurrence, (54,61-65) only 15% of screens asked dancers for this information. Similarly, 5% of forms asked dancers for information about menstrual history or nutritional behavior, and 8% measured body composition, even though the risks associated with menstrual irregularity, restrictive dieting, and thinness are well known. (66,67) None of the screening instruments in this analysis contained a measure of emotional or cognitive function, despite evidence that some psychometric variables possess predictive value. (68-77)

By contrast, posture and alignment were included on all forms, even though there is no clear evidence that posture or alignment play a role in injury occurrence. (78,79) Many screens measured passive range of motion at the hip for turnout, although the ability of that information to predict functional turnout has been suggested to be minimal. (80,81) Further, 95% percent of forms assessed turnout, even though functional measures of turnout, (82,83) like measures of muscular flexibility, (78) possess only weak evidence of predictive value. On the other hand, topics possessing stronger predictive value for injury, such as dynamic balance, (63,66,79,84,85) functional motor control, (65) muscular strength, and muscular balance, (64,86-88) were assessed up to 50% less often, with cardiovascular function and body composition at the bottom of the functional test ranking, despite strong evidence that fatigue plays a role in injury (4,89-96) and moderate evidence that body mass index is a key indicator of health. (64,97)

Five percent of forms contained an actual screening outcome plan for the dancer on the form itself. There was no way of knowing from this analysis if another mechanism, such as a companion tear sheet to give to the dancer, might have been employed on the other 95% of forms to educate the dancer about his or her screening outcome. On face value alone, the communication of results and a follow-up plan with the dancer should be an essential part of the screening process. (For a complete list of topics derived from this analysis by percentage of forms on which they appeared see Table 2.)

It is worth noting that research in the broader discipline of sports medicine has produced little evidence that screenings are sufficiently able to measure differences in intrinsic variables to predict risk of injury. (54,98,99) By the same token, in 2008 Gamboa and associates (99) determined that there were relatively few significant differences between the injured and non-injured dancers in their study of 359 elite, pre-professional ballet dancers over a 5 year period. They hypothesized that the homogeneity of the population and the heterogeneity of their injuries make it difficult to use broad-spectrum screening tests to detect injury risk. The WHO model (41) suggests that achieving benchmarks for body structure and activity measures alone will fail to predict which dancers will become injured.

The SMCI recognizes, however, the important role that screening plays in dancer education and in rapport building (52) with healthcare practitioners, which may positively influence future health and injury reporting behaviors. Ultimately, the central purpose of screening is to identify dancers at increased risk for underlying health concerns, and refer them into the healthcare system for more extensive examination (this has the added advantage of creating inroads for the dancer to the health resources available to them).

Screening for the sake of injury prevention is far more effective when undertaken in the context of a broader, longitudinal healthcare program approach (24,100,101) that addresses the biopsychosocial aspects (9,10,102) of the dancer's life, as in the context of the ongoing and iterative epidemiologic process of injury prevention described earlier in this report and illustrated in Figure 2. (24,25) While there is a great deal of interest in existing dance screening forms for the measurement of anatomical, biomechanical, and neuromuscular factors, current research suggests that these measures alone have little predictive validity for future injury occurrence. (51,52) Factors which have shown greater levels of predictive validity for general health concerns and which are recommended by the SMCI are: systems review; prior injury history; menstrual status; nutrition, hydration, and smoking behaviors; medication consumption; psychometric measures; and environmental factors. Many of these factors form the basis of the Pre-participation Physical Evaluation (PPE), which is a universal screening form used for athletes and adopted by consensus and used by major medical associations for sports around the world over the past 30 or more years. Given the current lack of a standardized approach to screening in the dance medicine and science community, the SMCI recommends that the Pre-participation Physical Evaluation (PPE) form be used as the foundation for dance-specific screening. Additional tests and measures that have special relevance to dancers may be added as they are developed and validated.

Recommendation #4

Dance-Specific Screening: The SMCI recommends that the Pre-participation Physical Evaluation (PPE) be utilized as the basis for dance-specific screening forms. The PPE is the universal screening form used for athletes and adopted by consensus by major medical associations for sports around the world over the past 30 years. (51,53,103)

[FIGURE 5 OMITTED]

V. Risk Reduction Strategies

In the Sequence of Prevention Model depicted in Figure 2, Step 1 is to determine when an injury has occurred. The previous four SMCI recommendations inform Step 1. Step 2 attempts to determine the degree to which one or more of several possible risk factors are likely to cause injuries. Understanding the cause of injury is central to advancing knowledge, particularly regarding prediction and prevention. (12) Dance injuries result from the complex interplay between human (intrinsic) risk factors and environmental (extrinsic) risk factors, as well as unique situational factors that may alter the behavior or status of the dancer (Fig. 5). (69,104,105) These variables are known as risk factors. Risk is defined as the probability of an adverse outcome, (106) and risk factors are those entities that may contribute to adverse outcomes. Current theory suggests that risk factors are not directly causative of injury; rather, they are markers for particular conditions which, by virtue of association with other determinants of the same condition, may compound as a causal factor. (12,107) To date, attempts to understand the root causes of dance injuries have largely concentrated on the physical aspects of dance as an activity and on the physical vulnerabilities of dancers as participants. However, even when physical deficiencies in a dancer are established prior to participation, the correlation of any single risk factor with later injuries is very low. (100) This is because injuries are theorized to result from a summating combination of multiple variables. (12)

Intrinsic factors that can influence injury occurrence include: age, sex, general and mental health, prior injury history, fitness level, body mass index, body alignment, morphology, limb dominance, muscular flexibility, joint range of motion, joint laxity, muscular strength, muscular balance, and muscular reaction time. Extrinsic factors to which dancers are exposed in the workplace that potentially impact health include: floor construction and incline, ambient temperature, noise and light, live music tempo, costume and set design, level of performance, level of skill, preparation of the facility to handle emergencies, employer policies regarding breaks, hydration, stretching, time-loss discipline, conditioning practices and body weight regulations, and shoe type and shoe-surface interface. Situational variables also come into play in the form of workplace attitudes, peer pressure, and support structures, as illustrated in Figure 5. (12,77,107) Relatively few studies in dance have examined the influence of environmental and psychosocial risk factors on injury occurrence. Nonetheless, it may well be that dancers' psychological attributes and social influences play a significant role in the occurrence of injury and in the progression and outcome of work-related musculoskeletal disorders. Studies from several medicinal specialties have shown that psychological factors can be as important, and sometimes more important, than physical factors in determining health. (10,11,101,102)

As already indicated, injury does not typically arise from a single intrinsic or extrinsic factor, but rather from combinations thereof (13) in what MacMahon and Pugh (108) refer to as a "web of causation." Intrinsic variables, only some of which are relatively stable by nature, fit into a predictive equation in a stepwise fashion unique to each person. Complicating this already complex picture is the influence of extrinsic and situational variables, which are also extremely dynamic in nature--and can interact to increase the chances of injury. (24-26,109) These inter-relationships can be conceptualized as a long chain of factorcausation, where the longer the chain the weaker the etiologic association of any single factor to the injury. (12)

It is plausible, with time and careful observation, to quantify risk for a group of people pursuing a common activity (e.g., motorcycle riders, skydivers, dancers) with some exactitude by measuring the proportion of injured individuals relative to the population at risk as a result of exposure to the activity. However, it is simply not possible to be precise about which individuals in a group are at particular risk of injury. (26,30,109) This has prevented healthcare professionals from predicting injury accurately for any given individual dancer. Even in well-designed, longitudinal, prospective studies, many sports medicine professionals have failed to achieve individual predictability. Statistically, such studies carry large variability within groups of injured and non-injured persons with significant overlap between groups thereby making a distinction between the groups impossible. Even the most sophisticated battery of predictor indices will not account for all the variance. (12) Therefore, forecasting injury for a specific individual is likely to be beyond our capabilities for some time to come. That being said, at the population level (all the dancers in a studied group), valid information about risk factors that is translated into risk reduction strategies may help reduce injury rates on average across the population.

Although prediction models attempting to identify risk for individuals have met with limited success to date, the predictive power of these models may be improved with designs that appropriately identify how constellations of risk factors interact in ways that make dancers vulnerable to an injury event. As recommended by Fuller and associates on page 194 of their article, "studies should be of a prospective, cohort design to minimize the occurrence of errors associated with recall, which is a problem with retrospective study designs. Cohort studies that record players' exposures enable relations between the incidence of injury and risk factors in the study population to be explored." (110) A multi-factorial approach may yield greater understanding of injury causality and efficacy of injury prevention programs. Multifactorial analyses are used to accommodate a wide variety of data and account for complex interactions between them. This is a favored approach when striving to understand clinical phenomena, as its primary advantage is that it accounts for the relationships among several dependent variables. (111)

The difficulties involved in reaching certainty about causes of injury should not deter us from trying, but they should certainly sober us to the enormity of the task and encourage acceptance of the need for a logical and systematic approach to injury surveillance, including definitions of injury and exposure. Injury is something that every dancer and his or her associates wish to avoid, and prevention is the preferred and cost-effective method of promoting good health. The more we know about who gets injured and under what specific conditions, the better positioned we will be to develop predictive models that move beyond entering one intrinsic or extrinsic factor at a time into the black box of "may cause injury."

Recommendation #5

Risk Reduction Strategies: The development of risk reduction strategies should embrace the World Health Organization's biopsychosocial model of functioning that recognizes that the risk of injury is due to the interaction of causative factors over time. (41) Successful predictive models can only be built once there is broad acceptance of standards for reporting as recommended by the SMCI.

VI. Collaborative Data Management

Independent groups of dance medicine researchers have begun storing the privacy-protected personal health data of their dancer students and patients in various shared, Web-based databases. The use of such databases can be extremely valuable in terms of their ability to rapidly assimilate large chunks of data for comparisons across dancer groups and for generating the volume of data needed to conduct valid statistical analyses. However, there can also be pitfalls to participating in such data repositories if terms of agreement between database owners and data contributing parties regarding data security, data ownership, data access, data quality control, publication timelines, authorship order, and data responsibility are not explicitly understood from the outset of their involvement. (112-114)

[FIGURE 6 OMITTED]

The SMCI has developed a best practice model of collaborative data management for the International Association for Dance Medicine and Science community (Fig. 6). This model emphasizes the critical nature of policy-guided practice which emphasizes secure and legally compliant pathways for sharing data. The model recommended by the SMCI is a composite concept derived from review of five long-standing systems already in use by the following organizations: the Indiana University Data Management System, the Sports Injury Monitoring System, the International Federation of Football Association Medical Assessment and Research Center, the Australian Football League, and the National Collegiate Athletic Association's Injury Surveillance System.

While there are multiple organizations attempting to create and use a shared data management model, a single parent organization to set policy around data storage, management, and collection has not been recognized. One strategy would be to fund the establishment of a Foundation for Dance Medicine & Science to act as an independent grant making and data management organization to facilitate broad-scale injury surveillance and predictive modeling. Healthcare is rife with examples of independent foundations supporting the broader mission and vision of a profession through grants and centralized data management (e.g., the Foundation for Physical Therapy, the Athletic Orthopedics Research Foundation, Society for Pediatric Research) in order to facilitate substantial advances in the evidence standing behind prevention and risk reduction.

Recommendation #6

Collaborative Data Management: Collaborative data management for the dance medicine and science community is realistic and encouraged. Under optimal conditions, it should be overseen by a parent organization that is responsible for determining policy for secure and legally compliant practices of data collection, storage, and sharing. An Independent Data Manager should be responsible for maintaining quality control, while data collection would involve three tiers of responsibility: data stewards, who recommend policy to the parent organization; data supervisors, who ensure adequate resources and staff compliance with data collection standards; and data collectors, who assume responsibility for acquiring the training needed to apply data collection standards consistently.

Concluding Remarks

Given the human and economic burdens of musculoskeletal injury among dancers, it is imperative to develop an evidence-based approach to the prevention and reduction of dance injuries. Given current practices, however, our community is having difficulty achieving true understanding of dancer injuries and developing meaningful risk reduction strategies. At present, the dance medicine and science community cannot even compare injury incidence estimates among dancers because: 1. investigators have used very different methods for collecting injury data, without agreed upon standard definitions of injury and time at risk (i.e., exposure); and 2. investigators do not report their methods in sufficient detail to be reproducible.

The six recommendations offered by the SMCI are aimed at improving the ability of the dance medicine and science community to reduce the risk of injuries to dancers based on valid scientific information. They are also intended to expand the amount of useful data available for developing predictive models and risk reduction strategies. The recommendations are based on a review of dance and sports medicine literature, as well as current best practices among the international dance medicine and science community.

Caption: Figure 1 Survey results of injury reporting behaviors from a sample of 98 dance medicine and science professionals.

Caption: Figure 2 The sequence-of-prevention model. (Copyright, Wolter Kluwer Pharma Solutions. Reprinted with permission from van Mechelen W. Sports injury surveillance systems: one size fits all? Sports Med. 1997 Sep;24(3):164-8. (25))

Caption: Figure 3 Photo image of iceberg as visual metaphor to describe the omission of non-time lost injuries from standardized surveillance measures as discussed by Orchard and Hoskins. (44)

Caption: Figure 4 World Health Organization (WHO) model of health and functioning. (41) Published with permission from the World Health Organization.

Caption: Figure 5 Process of interactions among intrinsic and extrinsic factors relative to the occurrence of injury. (Copyright, Wolter Kluwer Health. Reprinted with permission from Meeuwisse WH. Assessing causation in sport injury: a multi-factorial mode. Clin J Sports Med. 1994; 4:166-70.12)

Caption: Figure 6 Collaborative data management model recommended to the dance medicine and science community by the SMCI.

Acknowledgments

We thank the editors and publisher of the Journal of Dance Medicine and Science, as well as the Journal's reviewers, the IADMS Board of Directors, Research Committee, and membership for their support of the efforts of the SMCI committee.

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Marijeanne Liederbach, Ph.D., P.T., A.T.C., C.S.C.S., Marshall Hagins, Ph.D., P.T., Jennifer M. Gamboa, D.P.T., O.C.S., and Thomas M. Welsh, Ph.D.

Correspondence: Marijeanne Liederbach, Ph.D., P.T., A.T.C., C.S.C.S., Director of Research and Education, Harkness Center for Dance Injuries, NYU Hospital for Joint Diseases, NYU Langone Medical Center, 301 East 17th Street, New York, New York 10003; Marijeanne.Liederbach@nyumc.org.
Table 1 Components of a Robust Injury Reporting System (26)

                          Descriptive

How many?      To whom?          Where?

Occurrence     Performer         Anatomic
* frequency    * biology
* prevalence                     Geographic
* incidence    Participation
               * level           Surface

               Participation     Apparatus
               * role/function

                           Descriptive

How many?      When?             What outcome?

Occurrence     Onset             Severity
* frequency    * traumatic       * injury type
* prevalence   * insidious       * time lost
* incidence                      * function lost
               Chronometry       * cost
               * time of day
               * time of year
               * activity type

                            Analytical

How many?      Why?             How?

Occurrence     Intrinsic        Mechanism
* frequency    * the person     * inciting events
* prevalence
* incidence    Extrinsic
               * from without

PREVENTION

Reprinted with permission from Caine CG, Caine DJ, Linder KJ.
The epidemiologic approach to sports injuries. In: Caine CG,
Caine DJ, Linder KJ (eds): Epidemiology of Sports Injuries.
Champaign, IL: Human Kinetics, 1996, p. 3. (26)

Table 2 Elements Included in Dancer Screening Form

Item                                               Frequency

History
  Past Medical History                                 100%
  Dance Training History                                18%
  Past Injury History                                   15%
  Systems Review Testing                                10%
  Menstrual History                                      5%
  Nutritional History                                    4%
  Validated Functional Inventories                       4%
    (e.g., Oswestry, SF36, FABQ, EDI)
  Open/Qualitative History (e.g., "Is                    2%
    there anything you'd like to add?")
  Depression or Other Mental Health History              0%
Functional Tests
  Posture/Alignment                                    100%
  Turnout                                               95%
  Flexibility, ROM, or Hypermobility Indexing           95%
  Foot Structure                                        87%
  Spine Motion Testing                                  70%
  Strength                                              70%
  Balance                                               55%
  Function (e.g., plie, releve, turn, jump)             48%
  Cardiovascular (e.g., Harvard bench step test)         8%
  Body Composition (e.g., calipers, impedance,           8%
    underwater weighing)
  Outcome
  Prevention Plan Delineation, Exercise                  5%
    Prescription, or Recommendations
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Title Annotation:International Association for Dance Medicine & Science
Author:Liederbach, Marijeanne; Hagins, Marshall; Gamboa, Jennifer M.; Welsh, Thomas M.
Publication:Journal of Dance Medicine & Science
Date:Oct 1, 2012
Words:11867
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