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Pain Coping Styles of Ballet Performers.

Although ballet is considered a major division of the performing arts, ballet dancers and athletes experience similar levels of physical and mental stress during training and performances (Heil, 1993; Tajet-Foxell & Rose, 1995). Although the high prevalence of injury in ballet is well documented, no studies have focused on how ballet performers address pain. Therefore, the purpose of this study was to quantify pain coping styles of ballet dancers and to investigate possible differences in regard to skill level and gender. Following written informed consent, the Sports Inventory for Pain (SIP; Meyers, Bourgeois, Stewart, & LeUnes, 1992b) was administered to 135 ballet dancers (mean age 19.2 [pm] 0.6 yrs; 114 females, 21 males). MANOVA and subsequent Wilks's lambda criterion indicated no significant skill effect, F(14,250) = 1.662; p = 0.064, among academy, pre-professional, or professional level dancers. Subtle differences between genders across all subscales collectively revealed a more positive overall pain coping style among females as observed in the composite HURT and OUCH scores. In conclusion, ballet dancers do not exhibit pain coping styles similar to other sport performers. The nonsignificant differences in response styles between skill levels may simply be attributed to greater psychological uniformity of individuals that are drawn to this type of competitive environment.

Although ballet is considered a major division of the performing arts, ballet dancers and athletes experience similar levels of physical and mental stress during training and performances (Heil, 1993; Tajet-Foxell & Rose, 1995). Both dancers and athletes are also exposed to extensive treatment and rehabilitation following injury (Micheli, Gillespie, & Walaszek, 1984; Tajet-Foxell & Rose, 1995). In short, ballet dancers are considered an athletic group by the sports medicine community (Harrington, Crichton, & Anderson, 1993; Patterson, Smith, Everett, & Ptacek, 1998; Teitz, 1991).

Improper form, inattention to proper technique, overtraining, and unanticipated accidents contribute to the remarkable number of injuries observed in ballet (Quirk, 1994), with trauma occurring more frequently at the beginning and conclusion of a stage production (Arnheim, 1980). In order to maintain their position or status among their peers, dancers may overlook or deny the presence of existing trauma. As the problems go unidentified and untreated, injuries may progress from acute to chronic disorders (Ende & Wickstrom, 1982). In addition, dancers may continue to exceed their normal joint range of motion resulting in further ligamentous strain and subsequent musculoskeletal trauma (Arnheim, 1980; Schon, Biddinger, & Greenwood, 1994). In 1989, Bowling observed 47% of dancers with injuries had recurring trauma and 42% experienced an injury within the past six months that ultimately inhibited performance (Ende & Wickstrom, 1982).

The high prevalence of injury in ballet is well documented in the literature, and like many professional athletes, careers in ballet may be shortened due to severe trauma. Injuries range from musculoskeletal strains, various forms of tendinitis, and impingement syndromes to degenerative joint disease (DJD), subluxations, avulsions, and stress fractures (Bachrach, 1987; Bowling, 1989; Ende & Wickstrom, 1982; Hardaker, 1989; Khan et al., 1995; Milan, 1994; Miller, 1987; Quirk, 1994; Teitz, 1991). The subsequent trauma results in decreased performance capacity, particularly when compounded by physical fatigue and excessive training. As physical performance begins to deteriorate, psychological factors resulting in fear, lack of attention, and low self-assurance typically arise (Pease, 1991). In many cases, the dancer will attempt to perform without seeking immediate medical attention. This may lead to continued psychological impairment and further reinforce a cyclic decline in performance (Ende & Wickstrom, 1982 ; Pease, 1991).

Although limited research on the psychology of ballet exists, limited studies have addressed pain coping styles of ballet performers (Macchi & Crossman, 1996). With the extremely high prevalence of injury reported among ballet dancers, further research has been strongly suggested (Lavallee & Flint, 1996; Schnitt & Schnitt, 1987; Tajet-Foxell & Rose, 1995). Numerous studies have established a strong relationship between level of pain and physical/ psychological dysfunction (Kremer & Atkinson, 1981; Macchi & Crossman, 1996; Sternbach & Timmermans, 1975; Sternbach, Wolf, Mundy, & Akeson, 1973). Jensen and Karoly (1991) reported that strategies coping with pain (i.e., diverting attention, ignoring pain) were associated with the ability to function physically and psychologically. Therefore, an athlete's attitude toward pain and the strategies used while experiencing pain may subsequently be reflected in his or her level of athletic performance and adherence to prescribed medical care (Crossman, 1997; Meyers, Bour geois, LeUnes, Erick, & Havelka, 1992a; Meyers, Bourgeois, Murray, & LeUnes, 1993; Meyers, et al., 1992b).

Efforts to address psychological indices of performance as they relate to injury have increased in the last decade due to an observed increase in athleticism and a concomitant rise in the number of severe injuries (Blackwell & McCullagh, 1990; Heil, 1993; Kerr & Minden, 1988; Petrie, 1993). These efforts, however, have typically focused on psychological response following injury. Taking a proactive approach to understanding an individual's response to injury prior to actual trauma, rather than simply attributing physical trauma to the inherent nature of performing, would enhance the opportunity to head off potential risk factors. Also, with the growing interest in the performing arts, it may become increasingly important to have a greater understanding of these nontraditional performers. Therefore, the purpose of this study was to quantify pain coping styles of ballet dancers and to investigate possible differences in regard to skill level and gender. It was hypothesized that participants with a high level o f talent and a long-standing exposure to rigorous training and injury would possess greater pain coping skills than less experienced, lower-skilled participants.

Methods

Participants

Prior to the study, 45 directors from various ballet companies across the country were contacted by investigators via phone to discuss the proposed study. Of the total number of companies contacted, 15 (33.3%) agreed to participate. Efforts resulted in a total of 135 ballet dancers (mean age 19.2 [pm] 0.6 yrs; 114 females, 2l males) representing skill levels ranging from academy to professional performers, and included distinguished ballet companies from coast to coast.

Procedures

Packets containing written instructions and the Sports Inventory for Pain (SIP; Meyers et al., 1992b) were mailed to each ballet director to administer to participants at the dance studios before ballet practice. Directors were instructed to fully inform each participant of the nature of the study and written informed consent was obtained in accordance with the American College of Sports Medicine (1997) guidelines. Based on feedback, total time to read and complete the informed consent form and the SIP was approximately 15 minutes. Directors were then instructed in writing to return SIP inventories in a self-addressed, stamped envelope that was also included in the packet. No incomplete inventories were returned, and all returned inventories were completed within a 90-day period during the winter season.

Ballet dancers were also asked in writing to rank their overall ability according to the level they consistently and comfortably perform. Ratings were used in accordance with industry standards (Preston-Dunlop, 1995). In this system, the lowest level of skill is rated 1.0, while the highest skill levels are rated 12.0. The ballet dancers who volunteered for this study were academy (levels 1-6; n = 46), pre-professional (levels 7-8; n = 38), and professional (level 9 or apprentice, 10 or corps, 11 or soloist, 12 or principal; n = 51) performers.

Instrumentation

Sports Inventory for Pain. The SIP is a 25-item sport specific instrument that measures five subscales relevant to competition: coping (COP), cognitive (COG), catastrophizing (CAT), avoidance (AVD), and body awareness (BOD). There are also two composite scores, HURT (COP + COG - CAT - AVD) and OUCH (COP + COG - CAT), which serve as overall indices of pain coping capabilities.

The coping and cognitive subscales were developed to reflect the positive dimensions of an athlete's pain coping style. The coping subscale seems to measure the extent to which an athlete utilizes "direct" coping strategies. High scorers tend to ignore pain, realize that pain is part of competition, and in general, tend to "tough it out". A sample item is "When injured, I tell myself to be tough and carry on despite the pain". The cognitive subscale appears to be a measure of whether a person uses "mental" strategies such as imagery in attempting to deal with pain. Individuals scoring high on the coping subscale might also score well on the cognitive subscale. A sample item is "When hurt, I play mental games with myself to keep my mind off the pain".

The avoidance subscale was designed to be a measure of the extent to which a person employs avoidant strategies to cope with pain. Thus, high scorers were thought to be less competitive when injured. A sample item is "When in pain, I have to be careful not to make it worse". Preliminary data suggests, however, that exemplary athletes may also score high on this subscale since, if injured, they tend to reserve activity until actual competition, i.e., "when it counts". The catastrophizing subscale detects those who tend to despair when injured. They dwell on the pain, feel that it is unbearable, and have essentially "given up". A sample item is "When injured, I feel pain is terrible and that it's never going to get better".

The body subscale was intended to be a measure of whether a person is hyposensitive or hypersensitive to painful stimuli. As such, it was designed to serve as a possible covariant in pain studies with athletic populations. The subscale has emerged as a potent predictor of pain response and athletic performance in some athletic populations. A sample item is "I seldom notice minor injuries".

The difference between HURT and OUCH is the use of the AVD subscale. Whereas some individuals may consider avoiding pain to be beneficial to a performer, others may deem avoidance detrimental in order to successfully achieve a competitive level of accomplishment. Hence, the choice of which composite to use is left to the individual.

The items, developed according to pre-defined scale construct techniques (Anastasi, 1989), are scored using a 5-point Likert format. The SIP has provided a reliable, predictive indicator of pain-induced psychological distress and subsequent physical response. Adequate internal consistency ([alpha] = .61 to .88), test-retest reliability (r= .69 to .86), and low social desirability (r = - .28 to -.13) have been well established in a number of sport populations (Meyers et al., 1992a; Raaum, Bourgeois, Meyers, & LeUnes, 1992; Reed, Bourgeois, & LeUnes, 1994; Tallman, Meyers, Skelly, LeUnes & Bourgeois, 1998).

More recent work utilizing confirmatory factor analysis (CFA) in a general undergraduate collegiate population indicated reasonable coping and cognitive validity but poor goodness-of-fit concerning the catastrophizing, avoidance, and body awareness subscales of the SIP (Bartholomew, Edwards, Brewer, Van Raalte, & Linder, 1998b). An additional study by essentially the same group questioned the validity and inability of the SIP to predict sportspecific, coping strategies (Bartholomew, Brewer, Van Raalte, Linder, Cornelius, & Bart 1998a). These studies, however, utilized nonsport-specific, short-term pain stimulation tasks such as tibial gross pressure and wall sit/phantom chair endurance, in a noncompetitive environment. Of equal concern, is the CFA's restrictive nature that assumes multivariate normality and an unrealistic model-fit (McCrae, Zonderman, Costa, Bond & Paunonen, 1996; Raykov, 1998). The inflated Type I error and excessive statistical power associated with CFA may lead to the rejection of the maj ority of personality inventories being used today that have been proven to significantly delineate between successful and unsuccessful indices of sport behavior (Curran, West, & Finch, 1996; Hu, Bentler, & Kano, 1992; McCrae et al., 1996). Therefore, it is strongly suggested that studies that place too much emphasis on CFA may be premature in their judgment and may wish to revisit the use of such a restrictive model in juxtaposition with reallife situations.

Data Analyses

Data were grouped for analyses by skill level (academy, pre-professional, and professional) and gender. During the conceptualization of this study, the authors realized that ballet is typically a female dominated activity and obtaining an adequate sample size on male performers would be difficult. It has been strongly indicated, however, that psychological investigation of gender differences/consequences is lacking in the literature (Duda, 1990, 1991; Fasting, 1990), and that scientists should attempt to quantify and compare gender response as it relates to actual physical competition and training techniques (Birrell, 1984; Duda & Allison, 1990). For these results, pain coping data on male performers are included for descriptive purposes only.

Multivariate analysis of variance (MANOVA) was performed using General Linear Model procedures of SYSTAT (SYSTAT 6.0 for Windows, 1996) to determine significant skill effect. Least square means procedures were employed due to unequal number of observations upon which to compare differences between variables. Significance was determined at the 0.05 level of confidence.

Results

Pain coping styles of ballet performers by skill level are shown in Table 1. Interestingly, Wilks's Lambda criterion indicated no significant main effect, F(14,250) = l.662;p = 0.064) among academy, pre-professional , or professional level dancers. There was a trend, however, for professionals to score lower on cognitive and catastrophizing subscales but higher on body awareness than less-skilled participants.

Comparisons of pain coping styles of male and female performers are shown in Table 2. Although limited in the number of available participants, there was a trend for males to exhibit lower coping, cognitive, and catastrophizing responses than indicated in females. Interestingly, males also scored higher on body awareness than female performers. Subtle differences between gender across all subscales, however, collectively revealed more positive overall pain coping styles among females as observed in the composite HURT and OUCH scores.

Discussion

Although psychometric testing has been successfully used in the assessment of skill level, injury, and stress in prior studies with other athletic populations (May, Veach, Reed, & Griffey, 1985; Meyers, LeUnes, & Bourgeois, 1996; Raglin, Morgan, & Luchsinger, 1990), no studies to our knowledge have addressed pain coping responses in ballet. Therefore, this study was conducted to quantify pain coping styles of ballet dancers and to investigate possible differences in regard to skill level and gender.

Although not statistically significant, pain coping differences were evident, especially between professional and academy ballet performers. The trend for the higher-skilled professionals to exhibit lower coping and cognitive scores than less-skilled or novice academy performers agrees with prior research reporting similar responses among elite and subelite college rodeo athletes (Meyers et al., 1992a) but in contrast to competitive versus recreational runners (Reed, Bourgeois, & LeUnes, 1994). The lack of significant differences agrees with prior studies on professional tennis and elite equestrians (Meyers et al., 1993; Meyers, Sterling, Treadwell, Bourgeois, & LeUnes, 1994) and may be indicative of the automaticity of psychological response gained through additional experience required in reaching the top level in this extremely competitive environment. In short, top-skilled dancers are simply seasoned to withstand the daily preparation and expectations that come with ballet. Mean coping responses observed among the professionals in this study may also be attenuated by an ephemeral response to injury and subsequent pain typically observed in top level athletes participating in other traumatic sport environments (Fenz, 1975; Gould, Horn, & Spreeman, 1983; Meyers, Elledge, Sterling, & Tolson, 1990).

The lack of significance observed in this study between skilled groups could also be attributed to other factors. The high variability within groups across SIP subscales may have influenced statistical findings. Lack of significant differences between skill level may also have been a function of sample size, prior performance levels, subject selection, and task difficulty which influence present physiological and psychological outcome (Campbell & Stanley, 1963; Gould, Weiss, & Weinberg, 1981; Landers, 1980; Meyers et al., 1994). Data in this study, however, represented a substantial cross section of ballet dancers from major companies across the country. This should have optimized the opportunity for psychological differences to occur independent of performance history and selection.

Due to limited research addressing psychological differences in gender response, but hampered by the limited number of males participating in ballet, pain coping styles of male and female performers were presented strictly from a descriptive standpoint. The higher responses in coping, cognitive, HURT, & OUCH observed among female dancers when compared to males, is in contrast to prior research citing either nonsignificant differences between gender (Meyers et al., 1993) or higher pain coping response among male competitors (Koltyn, Focht, Ancker, & Pasley, 1998; Meyers et al., 1992b).

Overall pain responses in this study were consistent with profiles reported in the general collegiate population (Meyers et al., 1992a, 1992b). When comparing overall pain coping styles of ballet performers to specific sport populations, however, ballet performers exhibited lower coping and cognitive skills and higher catastrophizing responses than recreational runners (Reed, Bourgeois, & LeUnes, 1994), high school and collegiate intramural athletes (Bartholomew et al., 1998b), elite equestrians (Meyers et al., 1993), and high school and collegiate rodeo performers (Meyers et al., 1992a; Tallman et al., 1998).

In the final analysis, the nonsignificant differences in pain coping styles between skill levels may simply be attributed to greater psychological uniformity of individuals that are drawn to this type of competitive environment. Also, top performers may place less emphasis on the pain and subsequent trauma associated with grueling practices and performances on a daily basis than less-skilled dancers regardless of the extensive number of injuries observed in ballet. Of greater importance, however, is that this study provided a unique look at cognitive response of a large cross-sectional profile of performers from both major and minor ballet companies across the country. These findings may be used as a point of reference for future research and could also be used to assess the influence and efficacy of various ballet-training programs on subsequent rate and severity of injury (Smith, 1980, 1989).

In conclusion, ballet dancers do not exhibit pain coping styles similar to other sport performers. The high variability within and between skill and gender concur with highly individualized responsivity noted in other cognitive, somatic, and behavioral studies in physical activity and sport. Additional multivariate research should focus on correlating performance affects in ballet with subsequent performance outcome and physiological response.

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 Pain Coping Styles of Ballet Dancers by Skill Level
 Skill
Variable Academy Pre-professional Professional
Subjects 46 38 51
Coping 24.9[pm]0.9 23.2[pm]0.9 24.5[pm]0.8
Cognitive 13.8[pm]0.5 14.7[pm]0.6 12.5[pm]0.5
Catastrophizing 12.7[pm]0.5 13.3[pm]0.6 11.9[pm]0.5
Avoidance 14.5[pm]0.4 15.5[pm]0.4 14.8[pm]0.4
Body Awareness 12.3[pm]0.4 12.0[pm]0.4 12.8[pm]0.4
HURT 11.6[pm]1.3 10.0[pm]1.4 10.1[pm]1.2
OUCH 26.0[pm]1.2 25.4[pm]1.3 25.0[pm]1.2
All values are mean [pm] SEM;
HURT = coping + cognitive - catastrophizing - avoidance;
OUCH = coping + cognitive - catastrophizing.
 Pain Coping Styles of Ballet Dancers by Gender
 Gender
Variable Overall Male Female
Subjects 135 21 114
Coping 24.3[pm]0.5 23.6[pm]1.3 24.4[pm]0.5
Cognitive 13.5[pm]0.3 11.8[pm]0.8 13.9[pm]0.3
Catastrophizing 12.6[pm]0.3 11.8[pm]0.8 12.8[pm]0.3
Avoidance 14.9[pm]0.2 15.1[pm]0.5 14.8[pm]0.2
Body Awareness 12.3[pm]0.2 13.1[pm]0.6 12.2[pm]0.3
HURT 10.6[pm]0.7 8.4[pm]1.9 11.0[pm]0.8
OUCH 25.4[pm]0.7 23.5[pm]1.8 25.8[pm]0.8
All values are mean [pm] SEM;
HURT = coping + cognitive - catastrophizing - avoidance;
OUCH = coping + cognitive - catastrophizing.
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Author:Encarnacion, Maria L.G.; Meyers, Michael C.; Ryan, Noel D.; Pease, Dale G.
Publication:Journal of Sport Behavior
Geographic Code:1USA
Date:Mar 1, 2000
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Adiarys Almeida: this Cincinati Ballet soloist, without a word of English, defected from Cuba to take control of her career.
Responses to the Sports Inventory for pain among BASE jumpers.
Bocca's good-bye.
David Adams (1928-2007).
The sports inventory for pain: empirical and confirmatory factorial validity.

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