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Leaps and Bounds.

Dance medicine has made progress in preventing injuries and their mounting cost, in creating new joint replacement techniques, and in further understanding the biomechanics of the dancing body. Here are some of the findings concerning those issues that were reported at the Boston Dance Medicine Conference held last year and a description of new replacement advances performed in Los Angeles.

"Dancers started to come to us twenty-one years ago," said Lyle J. Micheli, M.D., during the dance medicine conference at the Children's Hospital in Boston, where he is director of the Sports Medicine Division and associate clinical professor in the Department of Orthopaedic Surgery at Harvard Medical School. "Our sports people got interested in dance, so we created the dance medicine division. Financial support for dance medicine has had to come from therapists and physicians who care about the art because dance is never going to pay for itself. For us, it's a public service. Personally, I just like the dancers. They're nice people"

REDUCING THE COST OF INJURIES

Micheli and his wife, Anne, donated the therapy rooms backstage at the Boston Ballet. These rooms are a crucial component in Boston Ballet's three-year success story. The cost of injuries has been reduced through immediate attention and by using the company's "self-insurance" policy, rather than workers' compensation insurance, for lesser injuries.

Ruth Solomon, professor of theater arts--dance at the University of California at Santa Cruz and one of the coauthors of a published medical report on the subject, gave an enthusiastic update on the cutting of costs. The findings in the report were the result of her commitment to a five-year, biweekly statistical documentation of Boston Ballet injuries. BB's three-year experiment was impressive--savings of approximately $59,000, $157,500, and $246,000 annually in premiums far outweighed payments made directly to healthcare providers for services to the dancers.

The necessary elements for BB's project were:

1. A company physician who acts as a gatekeeper for treatment;

2. In-house therapists;

3. An insurance policy for lesser injuries: the major ones are assigned to workers' compensation coverage;

4. Carefully kept financial and treatment records.

"A strong component in this project," says Solomon, "has been in the caring attitude of everyone involved. When a disabling accident required retraining, the company has done just that. The slightest physical cause for complaint is immediately investigated by a health-care person and the dancers have grown in confidence that they are receiving the best care."

Physical therapists at BB, who are available throughout the year, are employed to conduct pre- and postseason screenings at which each individual dancer's injury history, current problems, and physical characteristics that might predispose him or her to injury are carefully reviewed. And special "transition classes," instead of regular technique classes, ease the injured dancer back into active performing. "This project works both ways," Solomon adds. "The dancer is saved from injury by immediate care and the company is saved from the cost of replacing an injured dancer."

Solomon's paper also identifies 60 to 65 percent of the most frequently diagnosed injuries in the seventy-member company as overwork. At least half of the less serious complaints each year are diagnosed as strains, sprains, and tendinitis.

The frequency of a specific injury is comparable in studies made by other companies and schools. In order of frequency, foot and toe injuries (more often in females) are first on the list, followed by ankle, lower leg, knee (slightly more frequent in males), hip and thigh, lumbar spine (equal in males and females), thoracic and cervical spine, rib cage (more reported by females), shoulder (more reported by males), head, forearm, and hand (a surprising female complaint).

Are injuries seasonal? Solomon's report discerns a pattern. September, the month in which dancers return from their summer hiatus, produces cumulatively the greatest number of injuries, followed by March, with February and November equal in injuries. Some choreographies are more likely to produce overuse or injury complaints. But on that subject, the report is silent.

IMPORTANCE OF CROSS-TRAINING

Micheli's lineup of speakers at the Boston conference included Peter G. Gerbino II, M.D., a member of the sports medicine team at Children's Hospital. "There are a great many more dance students than ever before," Gerbino observed, "and many of them have body types not suited to dance, which results in injury. There is no selectivity except in the large schools. The focus of activity is more intense and competitive than ever before. In the past, youngsters played in the street, and, by cross-training in this manner, improved their endurance and developed strength. Today, many sit in front of the television or computer screen until their specific activity begins and the result is injury from overuse, too much, too soon.

"The most frequent complaint we hear concerns the discomfort of `growing pains.' The doctor has to know where to look for the cause. Discomfort may be due to a normal growth period, a congenital condition, trauma, a new workload, or a biomechanical fault--use of the body in a way that is incorrect and harmful--what you would call improper technique.

"Doctors are learning more about dance, and dancers are learning more about the body. But dance medicine is still in its infancy. We both have much to learn."

RELATED ARTICLE: Connected to the Hip Bone

METAL-METAL HIP REPLACEMENT

"I lost flexibility," says William Starrett, "and the pain from lost cartilage resulting in bone-on-bone contact was a nightmare. Choreographers always wanted me to use my natural flexibility, especially in split jetes en manege. My hip joints just wore out from overuse as well as from the probable result of a congenital weakness. Surgery was the last resort but the only solution."

Patient: William Starrett, artistic director of Columbia City Ballet in South Carolina, since 1986; former student, School of the Royal Winnipeg Ballet; principal dancer, RWB; medal winner Jackson competition.

Doctor: Harlan C. Amstutz, M.D., pioneer in metal-metal surface hip replacement, professor emeritus of orthopedic surgery, and former chief of orthopedic surgery at the University of California at Los Angeles.

Hospital: Joint Replacement Institute at Orthopaedic Hospital, Los Angeles.

Procedure: Bilateral metal-metal surface hip replacement; time required: 5 hours.

Prosthesis: Conserve Plus surface replacement components (Wright Medical Technology).

Hospital Stay: four to five days.

Rehabilitation Time: Six weeks; dislocation precautions; crutches; low-impact exercises, pool exercises, and individually approved exercises (such as barre work), bicycle, and weight exercises.

Cost: Comparable to conventional replacements; $40,000 to $50,000 including hospital stay, with insurance paying 50 to 70 percent; patient responsible for deductible and copayments, which are "capped."

FDA Approval: Implant accepted as "custom" device exemption.

Amstutz says: "Research has shown that the metal-polyethylene implant used for the past three decades in hip replacements produces particulate debris. Polyethylene is a relatively soft material and wears down through repeated use. That can lead to implant loosening, pain, and eventual complex and costly revision surgery.

The major benefits of metal-metal surface replacements are that the femoral head of the hip joint is not amputated nor is bone in the femur removed. This hybrid replacement (femoral device is cemented onto head; acetabular device is cementless, press-fit) preserves bone, increases stability, and provides a greater range of motion. The procedure also decreases the risk of dislocation. As for using metal-metal replacements for younger, active adults--after all, high performance engines use metal-metal bearings and no one would dream of putting a plastic bearing in an Indy 500 race car!"

"It's a miracle," says Starrett. "My Fifth Position is even better, and my extension is not limited to 90 degrees. There's no doubt in my mind that I'm ready to perform again this season."

For further reference, you may read Preventing Dance Injuries: An Interdisciplinary Perspective, an excellent book on the biomechanics of dance by Ruth Solomon, Sandra C. Minton, and John Solomon; it is available from Ruth Solomon, University of California at Santa Cruz, Santa Cruz, CA 95064, (408) 459-2974. An informative article on the topic is "The Cost of Injuries a Professional Ballet Company: A Three-Year Perspective," by Ruth Solomon, B.A., Lyle J. Micheli, M.D., John Solomon, Ph.D., and Tom Kelley, B.S., which ran in Medical Problems of Performing Artists, September 1996.
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Title Annotation:1997 Boston Dance Medicine Conference report on dance medicine and injuries; includes related article on metal-metal hip replacement surgery
Author:Horosko, Marian
Publication:Dance Magazine
Date:Feb 1, 1999
Words:1367
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