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The Influence of Fatigue on Star Excursion Balance Test Performance in Dancers.

Dance is an intermittent form of exercise associated with movements requiring balance, athleticism, and artistry. (1) All dance genres utilize balance, which can be influenced by fatigue. (2) Fatigue is the decline in force or power produced by a muscle (3) resulting in a transient decrease in muscular performance (4) and may lead to disrupted movement patterns with the potential for injury. (5,6) Injury is multifactorial, (7) and dance injury rates of between 0.77 and 8.4 injuries per 1,000 hours dancing have been reported, with most injuries occurring in the lower limb and attributable to an overuse mechanism. (8,9)

The maintenance of balance is complex, involving static (ligaments, articular surfaces) and dynamic neuromuscular components. (10) Muscular fatigue may necessitate a balance strategy change specific to the affected area, (11) and the compensatory strategy may increase injury risk during dynamic movements. (12) The increased mechanical demand on joint stability associated with fatigue can alter muscle coordination resulting in inadequate stabilization of the joint and impaired control of joint motion. (13)

Dynamic balance performance and the interaction between proprioception and joint stability can be assessed via The Star Excursion Balance Test (SEBT), which is a musculoskeletal screening tool that can determine changes in movement (14) and sporting performance. (15) Specifically in dance, the SEBT has been reported to be a predictor of functional turnout angle (16) and has been used to measure the effects of proprioceptive training. (17) The original SEBT (18) involves the use of a grid on which participants reach in eight directions (anterior, medial, lateral, posterior, anterolateral, anteromedial, posterolateral, and posteromedial) spaced 45[degrees] apart and is used to measure the performance of dominant and non-dominant legs. Subsequent observation of shared variance between the eight directions has led to the recommendation that only anterior (ANT), posterolateral (PL), and posteromedial (PM) reach directions should be performed. (19) The SEBT provides a relevant functional challenge for dancers, (20) with an established relationship between technical proficiency and injury risk. (21-23)

However, the influence of fatigue on SEBT performance in dancers has not been considered. Given the potentially negative impact of fatigue on balance performance, (11-13) the authors hypothesized that SEBT performance would be impaired following dance-specific exercise and this would have implications for increased risk of injury. In order to standardize the exercise component of the experimental design, the Dance Aerobic Fitness Test (DAFT) (24) was used in this study. The study's aim was to consider the influence of dance-specific fatigue on both dominant and non-dominant legs in SEBT performance.

Methods

Subjects

Thirty-five university dancers (30 females: age 20.09 [+ or -] 0.97 years, height 160.77 [+ or -] 6.10 cm, mass 57.73 [+ or -] 5.36 kg; 5 males: age 20.62 [+ or -] 2.43 years, height 172 [+ or -] 2.08 cm, mass 64.26 [+ or -] 2.26 kg) enrolled in an undergraduate dance program, who performed primarily contemporary dance, volunteered to participate in this study. Inclusion criteria specified that subjects were injury free in the 30 days prior to testing, that they were 18 years of age or older, and attended dance classes for a minimum of 6 hours per week. Subjects completed a medical screening questionnaire prior to participating in the study, and those who had heart disease or were pregnant were excluded. Participation was voluntary, all subjects signed informed consent forms and were given an information sheet prior to beginning the study and a debrief sheet following participation. The Edge Hill University Research Ethics Committee provided ethical approval of the study, which also adhered to the Declaration of Helsinki.

Procedures

Subjects presented to the dance studio on two separate occasions, completing a familiarization of the DAFT and an experimental trial, which were separated by 7 days. On both occasions a university dance lecturer provided a demonstration of the required movements. For the 48 hours prior to these sessions subjects were asked to eat their normal pre-dance meal while avoiding performance enhancing energy drinks, supplements, and strenuous exercise.

Subjects completed a standardized 10-minute warm-up prior to completion of the DAFT. The warm-up consisted of 5 minutes of gradual pulse raising via jogging, joint mobility exercises, and self-directed dynamic stretches. All tests were conducted under supervision of the same investigator who demonstrated the movements and provided verbal feedback during the experimental trial. Leg dominance, defined as the leg used to kick a ball, (25) was recorded, and height was measured using a stadiometer (Leicester Height Measure, Child Growth Foundation, Leicester, UK). Body mass was recorded during familiarization using digital scales (Salter 9028, Kent, UK). Prior to the experimental trial, subjects were familiarized with Borg's 6-20 Rate of Perceived Exertion Scale (RPE) (26) and were fitted with a heart rate monitor (Garmin Forerunner 210, Southampton, UK). The RPE and heart rate were determined at the end of each incremental stage of the DAFT.

Star Excursion Balance Test

Due to the recommendation that three SEBT directions produce the required outcome, (19) the influence of the DAFT was considered in relation to the SEBT composite score and ANT, PL, and PM directions, and the protocol of this shortened version was followed. (19) The SEBT was demonstrated to the subjects by the lead researcher before they performed it. Star Excursion Balance Test scores were collated by a physical therapist with 12-years experience in SEBT assessment. Intra-rater reliability was calculated prior to performance of the SEBT using interclass correlation coefficients ([ICC.sub.3,1]) via measuring the ANT, PL, and PM scores (Fig. 1) and limb length. This calculation used 10 subjects (5 females, 5 males) from the same university as the study participants, who were measured on two separate occasions 1 hour apart to allow for determination of test-retest reliability

Maximum reaching distances and associated kinematic displacement values of the stance limb have been shown to stabilize by the fourth trial in each reach direction (27); therefore, four practice trials were performed with 10 seconds between each trial, which was followed by a 1-minute rest period before reaching distances were measured on the fifth attempt. The SEBT was performed with dominant and non-dominant legs in randomized order.

Subjects stood on both feet with the middle of their stance foot over the intersection mark and were told to keep their hands on their hips, head facing forward at all times, and their stance foot flat on the floor (Fig. 1). Subjects were told to reach in ANT, PL, and PM directions with the non-stance foot, touch the tape, and return to the starting position of bilateral stance without allowing contact to affect overall balance. They were not allowed to slide their foot along the floor or maintain their end-point reach position. Those who lost balance by failing to maintain hands on hips or return their reach leg to the starting position or removed their stance leg from the standing position repeated the trial. (27) Immediately following completion of the DAFT, subjects completed the post-exercise SEBT trial. Only a single trial was completed post-exercise to minimize recovery, and the trial was performed in the same order as the pre-DAFT SEBT.

Leg length (cm) was measured using a standard tape measure from the anterior superior iliac spine to the distal end of the medial malleolus with the subject lying on a plinth. Foot length (cm) was measured and the distance reached was normalized to limb length by the following calculation: excursion distance / limb length x 100 = percentage maximized reach distance. (28)

Dance Aerobic Fitness Test

The DAFT is a dance-specific field test that provides a reliable and valid measure of a dancer's ability to cope with the physiological demands of performance. It involves a 16-beat dance sequence consisting of 5 x 4-minute stages of increasing intensity associated with increased size of movement or additional movements. Subjects were removed from the test if the supervising investigator observed that they fell behind the beat of the test or their performance of the movement was judged to be compromised. The RPE (arbitrary unit) and heart rate (b*[min.sup.-1]) were recorded at the end of each stage of the DAFT. For those subjects who did not complete the five stages of the DAFT, these measurements were taken immediately following the end of their participation. The recording of RPE and heart rate allowed for assessment of physiological response and perceived difficulty.

Statistical Analysis

A Shapiro-Wilk test was used to determine that the data were normally distributed, and box plots were used to identify any potential outliers. The percentage of change in SEBT scores was calculated pre- and post-DAFT. A paired samples t-test was used to analyse SEBT scores pre- and post-DAFT to determine the influence of fatigue. This analysis was applied to ANT, PL, and PM directions, and means, standard deviations, and confidence intervals were recorded. The percentage contribution of limb length was calculated as the sum of the three distances for non-dominant and dominant limb, respectively, divided by 3. (28)

A paired samples t-test was used to analyze the difference between both RPE and heart rate at stages 1 and 5. The percentage change was calculated between stages 1 and 5, and means, standard deviations, and confidence intervals were recorded. Statistical analysis was performed using IBM SPSS Statistics software version 23 (IBM, Armonk, New York) with significance level set at p [less than or equal to] 0.05.

Results

Intra-Rater Reliability

The following ICC's were recorded for SEBT: ANT 0.93, Confidence Intervals 0.87-0.95; PL 0.92, Confidence Intervals 0.86-0.95; PM 0.92, Confidence Intervals 0.89-0.94, which demonstrated excellent intra-rater reliability. The ICC for limb length was 0.98, Confidence Intervals 0.97-0.99, which also demonstrated excellent intra-rater reliability.

Fatigue Effects on SEBT

Table 1 summarizes the influence of DAFT completion on SEBT performance in dominant and non-dominant legs. Mean SEBT is presented as a percentage of leg length, with mean values supplemented with standard deviations (SD). No significant effect of fatigue on SEBT performance was found for all SEBT directions and composite scores in both dominant and non-dominant legs. Percentage changes in SEBT performance ranged from -2.0% in non-dominant ANT to +7.0% in non-dominant PM as a result of DAFT completion.

RPE and Heart Rate

Both RPE and heart rate (HR) demonstrated increases from stage 1 to 5, with the highest RPE (17.83 [+ or -] 1.98 au) and heart rate (193.25 [+ or -] 13.83) values recorded during stage 5. Paired samples t-test analysis between RPE stage 1 and RPE stage 5 revealed a significant difference (p = 0.01, t = -28.21, df 34, CI -10.66 to -9.23), with a percentage change of 41.73%. Paired samples t-test analysis between HR stage 1 and HR stage 5 revealed a significant difference (p = 0.01, t = -19.20, df 34, CI -80.41 to -65.02), with a percentage change of 66.11%. Table 2 illustrates the physical response of the RPE and heart rate to the DAFT.

Discussion

The aim of this study was to determine the influence of dance-specific fatigue on SEBT scores in dancers. Following completion of the fatigue protocol, the mean SEBT composite score, ANT, PL, and PM directions all demonstrated non-significant findings for both dominant and non-dominant legs. Therefore, following exercise dancers demonstrated a resistance to fatigue, which allowed performance levels to be maintained, and this may have implications for dance performance and injury prevention.

It can be hypothesised that fatigue induced by DAFT might result in a reduction in performance on the SEBT. Fatigue has previously been found to result in deficits in reach distance on all directions of the SEBT in healthy men and women (29) and had a negative effect on the dynamic postural control of healthy participants and those with chronic ankle instability. (30,31) The current study did not support these findings, and this could be due to a number of factors. First, dance involves several movements that mimic the SEBT; therefore, dancers may be better equipped to resist any potential fatigue effects when performing the SEBT and may already possess a good level of proficiency at performing it. Second, dancers may have enhanced balance in comparison to other populations and may demonstrate more distinct and variable kinematic strategies (32) that facilitate performance of the SEBT. Dancers with a number of homogenous characteristics have been observed to employ a variety of different strategies for the same reach direction, including movement of the torso en bloc versus segmentally. (20) It is possible that our dancers employed strategies that demonstrated reduced movement quality but still allowed them to obtain their maximum reach distance. The creative nature of dance encourages problem solving, and multiple degrees of freedom are a reflection of dance training, (33) which frequently involves the use of a small base of support to transition from one movement to another in a coordinated manner (34) as required by the SEBT.

The SEBT measures dynamic balance, which requires a compromise between forward propulsion of the body and the maintenance of lateral stability (35) and is influenced by lower extremity strength (36) and ankle, knee, and hip range of motion. (31) Although the SEBT may produce a measure of dynamic balance, the use of total reach distances does not provide an indication of the quality of movement, and the use of biomechanical analysis via video to identify movement patterns may prove beneficial. Previously, biomechanical analysis has shown that a reduction in SEBT performance is associated with decreased knee flexion in all reach directions, that women may be more resistance to a decline in performance in the posterior direction, (29) and improvements on the SEBT are due to increased stance knee and hip flexion rather than strength or core stability. (27)

Our findings cannot be generalized beyond the exercise protocol and functional test used, as the influence of fatigue on balance is likely specific to these components. (12) Previous studies that reported a negative influence of fatigue on SEBT performance (29-31) used isokinetic fatigue protocols and involved injured participants. (30,31) In contrast, a study of male handball players that used a treadmill and step-ups to induce fatigue reported that those whole body and local fatigue protocols did not effect maximum reach distances on the SEBT, (37) thus supporting our finding of a resistance to fatigue. Fatigue can reduce neuromuscular and sensorimotor control, which may contribute to increased risk of lower limb injury. (37) In our study, the maintenance of performance levels indicates that the sensorimotor mechanisms are able to function effectively following exposure to acute fatigue. Our study ensured that the DAFT had the appropriate fatigue effect by asking participants to perform until volitional failure. The statistically significant findings between stage 1 and stage 5 RPE and stage 1 and stage 5 HR indicate that the DAFT was of sufficient physiological demand to have the desired fatigue effect.

Although not statistically significant, in the present study scores in the ANT direction were reduced post-fatigue protocol, and as this direction is thought to be the most difficult movement of the SEBT to perform, the ability of the dancers to maintain performance levels in this direction may represent another performance adaptation. Star Excursion Balance Test performance requires a narrow base of support, utilization of mobility and stability concurrently, and a high degree of motor control, which are also required in dancing. Anterior movement scores have been shown to be lower than PM and PL on performance of the SEBT and Y balance test. (38) Maximal movement in an ANT direction requires a greater displacement of the individual's center of gravity and as much knee and hip flexion as possible. (29) Furthermore, vastus medialis oblique and vastus lateralis electromyography activity has been shown to be greater in the anterior direction than in other directions of the SEBT. (39) However, these studies were all conducted in a non-fatigued state.

There are several limitations to the present study. First, the results are generalized to the cohort of dancers and exercise protocol used, and the ANT, PM, and PL components of the SEBT. Future studies could profitably explore dancers at different skill levels, dancers with an injury history, and different exercise protocols. Second, the current study considers an acute fatigue response and the influence of chronic fatigue, and overuse injury risk could be investigated using cumulative fatigue stressors, as the frequency and severity of dance injuries are a function of dance exposure. (40) Third, there is a need to perform screening in a fatigued state across a variety of dance genres to see if our findings are replicated, and utilizing video analysis may facilitate identification of changes in movement patterns. Fourth, the sample size was based on a convenience sample, insufficient data were available prior to testing to enable a power analysis, and a retrospective calculation of statistical power revealed that a sample size of 70 or more would be appropriate. Therefore, future studies with a larger sample size would be beneficial.

With regard to the health, well-being, and injury risk of dancers, the participants in this study were able to maintain SEBT performance levels despite the fatigue protocol, highlighting a potential performance adaptation. Although the changes observed were minimal in all directions, fatigue may still have an impact on injury risk due to the potential contribution of abnormal movement patterns secondary to joint position faults. (23) Other movement screening tools, such as the Functional Movement Screen (41) that assess a number of key functional movements, may identify important changes.

Conclusion

No previous studies have investigated the influence of fatigue on SEBT performance. In this study the minimal changes identified in SEBT performance suggest that in dance it is not influenced by fatigue. This is contrary to other sporting populations in which sport-specific fatigue has been shown to impair balance strategy and performance. (12,13) In dance, a specific adaptation may allow for the performance of varied movement patterns to achieve a desired outcome. This could provide a protective mechanism against injury; however, future studies should consider the actual movement kinematics involved.

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Ross Armstrong, MSc, Christopher Michael Brogden, PhD, and Matt Greig, PhD, Sports Injuries Research Group, Department of Sport and Physical Activity, Edge Hill University, Ormskirk, Lancashire, United Kingdom. Debbie Milner, MA, and Debbie Norris, MA. Department of Performing Arts, Edge Hill University, Ormskirk, Lancashire, United Kingdom.

Correspondence: Ross Armstrong, MSc, Department of Sport and Physical Activity, Edge Hill University, St Helens Road, Ormskirk, Lancashire, L39 4QP, United Kingdom; armsross@edgehill.ac.uk.

https://doi.org/10.12678/1089-313X.22.3.142

Caption: Figure 1 A subject performing the three-directional Star Excursion Balance Test.
Table 1 Influence of Dance Aerobic Fitness Test Completion on Star
Excursion Balance Test Performance

                              Mean SEBT    Percent  Paired t-test
SEBT Direction               Score (SD)    Change       Mean

Non-Dominant Leg ANT
 Pre-exercise               75.65 (8.00)   -2.00%        1.51
 Post-exercise              74.13 (8.34)
Dominant Leg ANT
 Pre-exercise               75.57 (7.38)   -1.00%        0.53
 Post-exercise              75.03 (7.54)
Non-Dominant Leg PL
 Pre-exercise               76.76 (12.21)  +4.00%       -3.59
 Post-exercise              80.35 (12.80)
Dominant Leg PL
 Pre-exercise               77.90 (12.22)  +2.60%       -2.05
 Post-exercise              79.95 (13.47)
Non-Dominant Leg PM
 Pre-exercise               76.45 (13.17)  +7.00%       -5.05
 Post-exercise              81.50 (11.32)
Dominant Leg PM
 Pre-exercise               79.94 (11.57)  +3.00%       -2.23
 Post-exercise              82.18 (14.68)
Non-Dominant Leg Composite
 Pre-exercise               76.88 (8.82)   +1.89%       -2.96
 Post-exercise              78.33 (8.77)
Dominant Leg Composite
 Pre-exercise               77.84 (9.06)   +2.77%       -1.96
 Post-exercise              80.00 (8.95)


SEBT Direction                 95% CI         t (df)    P-value

Non-Dominant Leg ANT
 Pre-exercise                -1.98 to 5.02   0.88 (34)   0.39
 Post-exercise
Dominant Leg ANT
 Pre-exercise                -2.80 to 3.87   0.33 (34)   0.75
 Post-exercise
Non-Dominant Leg PL
 Pre-exercise                -7.71 to 0.53  -1.77 (34)   0.09
 Post-exercise
Dominant Leg PL
 Pre-exercise                -7.52 to 3.42  -0.76 (34)   0.45
 Post-exercise
Non-Dominant Leg PM
 Pre-exercise               -10.65 to 0.55  -1.83 (34)   0.08
 Post-exercise
Dominant Leg PM
 Pre-exercise                -7.42 to 2.96  -0.88 (34)   0.39
 Post-exercise
Non-Dominant Leg Composite
 Pre-exercise               -12.09 to 6.17  -0.66 (34)   0.52
 Post-exercise
Dominant Leg Composite
 Pre-exercise               -11.36 to 7.44  -0.42 (34)   0.67
 Post-exercise

Table 2 Rate of Perceived Exertion and Heart Rate Responses to the
Dance Aerobic Fitness Test

Stage  Rate of Perceived Exertion (*)  Heart Rate (beats/min)

1                7.44 (1.11)               127.75 (22.7)
2               10.00 (1.82)               151.29 (18.55)
3               13.65 (2.01)               174.93 (18.70)
4               15.12 (2.55)               189.67 (14.69)
5               17.83 (1.98)               193.25 (13.83)

(*) Arbitrary units.


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Author:Armstrong, Ross; Brogden, Christopher Michael; Milner, Debbie; Norris, Debbie; Greig, Matt
Publication:Journal of Dance Medicine & Science
Article Type:Report
Date:Jul 1, 2018
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