Safety Guidelines for Implementing Chest Stands Into Dance And

Safety Guidelines for implementing chest stands into dance and acrobatics training Presented at the International Association of Dance & Science Medicine Montreal 2019

Sarah Reis BKin, MEd

1 Introduction

What are chest stands? Chest stands are a balance involving hyperextension of the spine. Chest stands can be performed with a variety of leg positions and there are a variety of ways to enter and exit the skill. Concern for what is happening With the rise of social media dancers and non-dancers alike are being exposed to dance and flexibility content online. Children are trying stunts at home, without the supervision of qualified instructors and the proper fundamental training to execute tricks safely. There has been an increased demand for rapid flexibility gains. There is concern for the pressure social media is putting on dancers as it relates to safe practice and the prevention of injuries. We are seeing more contortion-like elements and chest stand pictures surfacing online. Some of these are executed with proper alignment and technique, supplemented by strength and control – some are not. What are the consequences of this? What risk do dancers have if they are performing chest stands before they are physically ready?

Chest stands with poor technique A comprehensive list of concerns are outlined in this document. The largest technical error seen in chest stand work is “crunching” in the lower back. This manifests as a sharp angle or bend in the lumbar spine. Without solid anatomical structures to pro- vide support for the lumbar spine the vertebrae in this section are greatly vulnerable.

The dancer in the image above has a strong sharp angle of compression into the lumbar spine. This angle of compression puts her lower back in danger of injury.

2 Breakdown of Concerns

Low back pain is highly prevalent in acrobats and multiple epidemiologic studies and reviews have documented this with prevalence ranging from 25% to 85%. Lack of supervision and a mismatch between the ability of the performer and the level of skill attempted were the most commonly attributed causes.

Degeneration of the Pars Interarticularis Pars Interarticularis refers to a small segment of bone that joins the facet joints in the back of the spine.

Spondylolysis Spondylolysis is a crack or stress fracture that develops at the pars interarticularis, which is a small, thin portion of the vertebra that connects the upper and lower facet joints. Most commonly in dancers, this fracture occurs in the fifth vertebra of the lumbar spine, although it sometimes occurs in the fourth lumbar vertebra. Fracture can occur on one side or both sides of the bone. The pars interarticularis is the weakest portion of the vertebra. For this reason, it is the area most vulnerable to injury from the repetitive stress and overuse that is a characteristic of acrobatics. Spondylolysis can occur in people of all ages but, because their spines are still developing, children and adolescents are most suscepti- ble.

Spondylolisthesis If left untreated, spondylolysis can weaken the vertebra so much that it is unable to maintain its proper position in the spine. This condition is called spondylolisthesis. In spondylolisthesis, the fractured pars separate and the injured vertebra slips forward on the vertebra directly below it. In children and adolescent dancers, this slippage most often occurs during periods of rapid growth—such as an adolescent growth spurt. During periods of growth it is very important that dance teachers use caution when working on chest stands and should supplement the training with focus on strengthening muscles and stabilizing joints. In addition, the training should be paired with foundational work in other styles of dance such as ballet which will develop posture, poise and understanding of alignment.

Worsening of Scoliosis Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. There is some research that suggests contortion and gymnastic-like activities such as

3 acrobatics may increase scoliosis as a result of the athlete repetitively sitting into the defective spinal curvature in an unsupported manner. Types of Scoliosis

Healthy Thoracic Lumbar Thoraco-Lumbar Combined Scoliosis Scoliosis Scoliosis Scoliosis

Preservation of the Cervical Spine Cervical spine injuries often involve permanent complete or partial loss of sensory function. There are many associated complications. As is the case with all injuries of the spinal cord, injuries located higher on the spine will be more severe, with high cervical spinal cord injury often being fatal. Danc- ers who are disproportionately placing stress into their chin and neck could be compromising their cervical spine.

Dislocation of the Jaw/Damage to the Teeth Dancers putting a lot of pressure into the chin during chest stand could be at risk for jaw related complications as well as damage to the teeth as a result of this pressure. Issues with headaches could be an indication of this developing.

Weakening or Inhibition of the Abdominal Muscles Most weakness in the core is, to varying degrees, a combination of underuse; a lack of direct training; as well as inhibition due to overused/overdeveloped antagonistic opposing groups of muscles. Due to the lengthening of the abdominals that occurs while in chest stand training there is potential risk for the abdominals to be weakened over time unless properly supported with strengthening and stability training.

Concern for the Skeletal Development Timeline Spinous processes and facet joints

Spinous process is a bony projection off the pos- terior (back) of each vertebra. The spinous process protrudes where the laminae of the vertebral arch join and provides the point of attachment for muscles and ligaments of the spine.

The facet joints are a set of synovial joints between the articular processes of two adjacent vertebrae.

Without strength and control supporting the extension demands in chest stand training, there is concern for the skeletal development of the spinous processes and facet joints.

4 Screening Assessment for the readiness to begin chest stand training

Review of muscle length, hip flexor length via a modified Thomasest T

The dancer lays on their back on an examination table or modified stack of mats in acrobatics class and holds the uninvolved knee to his or her chest. The dancer should allow the involved extremity to lie flat, working to hold the knee to the chest as it flattens out the lumbar lordosis and stabilizes the pelvis. If the iliopsoas muscle is shortened, or a contracture is present, the lower extremity on the involved side will be unable to fully extend at the hip. This constitutes a positive Thomas test.

Sometimes, with a very flexible patient, the Thomas test will be normal despite a iliopsoas dysfunction being present, which could be a concern for the dancer population. However, a positive test is a good indicator of iliopsoas hypertonicity. The chart below provides indication of what to look at when you complete this screening. With this information you can better target stretching specific muscles to prepare for chest stand work. The psoas is very important for chest stand training because it connects to the five lumbar vertebrae.

Other signs from the Thomas test:

Symptom Potential Concern Opposite hip flexes without knee extension Tight Iliopsoas

Hip abducts during test Tight Tensor Fascaie Latae

Knee extension occurs Tight Rectus Femoris Lateral rotation of the tibia Tight Biceps Femoris

5 Review Relationship of Athletes Hip Flexors and Gluteals Hip flexors and gluteals, both are often weak but for different reasons. Often to correct one a dancer needs to also correct the other. Hip flexors are typically tight in the vast majority of dancers, which may be a result of sitting in desks at school all day. Tight hip flexors lead to inhibition of their function and strength, which will not effectively be corrected through direct training but rather through stretching and fascial release. Gluteals can be weak for many reasons but often it may simply be lack of use in day-to-day life and training. Gluteals need direct strength training but they may be equally inhibited due to the antagonistic tight hip flexors. The ability to train the gluteals effectively often requires the release of the hip flexors, and the key to the prevention of tight hip flexors is having strong glutes. In assessing the dancer for readiness for chest stand work, review the hip flexors and firing of glutes. The glutes will be important in stabilizing the chest stand when the dancer is working to get their feet together and the body lifted out of the lower back, at the same time the hip flexors will be extending.

T-Spine Extension and Posture If Kyphosis is present in the dancer, there is concern for more extension in the lower back. Kypho- sis is a spinal disorder in which an excessive outward curve of the spine results in an abnormal rounding of the upper back. It can occur at any age, but is common during adolescence.

Stability in an Arched Position Can the dancer demonstrate stability in an arched position? If the dancer is in a chest stand do they wobble consistently in any direction? Do they have refined control in the ability to show good articulation of the spine in bridge to wall touch extension?

Straight and Controlled Can the dancer demonstrate a straight and controlled chest stand before anything else? This demon- strates they are working to master the control required to execute chest stands safely. Dancers who are unable to demonstrate a straight chest stand are likely to “flop” into compromised positions and/or are lacking strength.

Abdominal Strength Test In addition to the strength assessment featured later in this document, can the dancer show effec- tive use of the ab rolling exercise? Using plank to assess strength only activates the muscles in an isometric (isotonic) position, which means the muscles remain the same length. Abdominal rollers

6 force the dancer to use a dynamic component that closer simulates the conditions of the chest stands requiring the dancers to be continually firing and activating their abdominals in a dynamic way.

Breathing Assess the dancer’s ability to breathe while in extension and bridges before attempting chest stands. This will identify if the dancer may hold their breath while doing chest stands, which may lead to dizzi- ness, headaches, fainting, muscular fatigue and jaw clenching.

Flexibility Assessment

Cobra Can the dancer demonstrate cobra with good form?

The dancer in this photo shows forward sinking As the dancer works to fix her shoulders, her hips of the shoulders. Her legs are wider than rise even more off the ground and she shows shoulder width apart. tightness of the hip flexors. Bridge or Kneeling Bridge Can the dancer show a bridge in good form? Are they able to push their shoulders open and over the top of their wrists? Do they show restrictions in their hip flexors or thoracic spine while in bridge?

Can the dancer bridge with weight past their wrists? 7 Checklist for Dancer Readiness for Chest Stands

Chest Stand Prerequisite Complete Yes/No Review gluteals and muscle length/accessibility of hip flexors (modified Thomas Test)

Review thoracic spine extension and posture

Can the dancer demonstrate stability in an arched position?

Assess abdominal strength through plank and abdominal roll out conditioning elements

Can the dancer breathe properly in bridges? Is the dancer properly breathing in chest stands? Focus on small frequent sips of air

Is the dancer clenching their teeth/jaw or applying a lot of pressure to the jaw during chest stands?

Are there flexibility issues shown in cobra, kneeling bridge or bridge?

Can the dancer hold plank for 50 to 100 seconds with excellent technique?

Can the dancer hold V-sit for 50 to 100 seconds with excellent technique?

Can the dancer perform 30 to 60 upper body lifts with excellent technique?

Can the dancer hold outcurve (superman) position for 50 to 100 seconds with excellent technique?

Can the dancer hold incurve (hollow) position with all of their lower back engaged into the floor?

Can the dancer hold a forearm stand straight and together on or off the wall?

Can the dancer perform all of the chest stand progressions safely?

Can the dancer do the chest stand straight and controlled or do their legs “slam down” or wobble without control over their head?

8 Strength Assessment

Plank V-Sit Can hold the plank position for 50 to 100 Can the Dancer hold a V-sit for 50 to 100 seconds with solid form? seconds with proper form?

Outcurve (Superman) Can the dancer hold an outcurve position with proper technique for 50 to 100 seconds? Upper Body Lifts Can the dancer perform 30 to 60 upper body lifts with proper technique? The dancer should be able to demonstrate this without crunching in the lumbar spine.

Forearm Stand Straight and Together (on or off the wall) Can the dancer do a forearm stand push- Incurve (Hollow) ing out of the shoulders and lifting feet Can the dancer hold a hollow position with prop- to the ceiling? They may use the wall for er technique? *The lower back must be in con- balance support if needed. Dancer has a tact with the floor* clear understanding of lifting through the spine and pushing feet to the ceiling.

9 Chest Stand Progressions Learn arm position with head in extension

Breathing on a block, focus on hand and weight distribu- tion

Prone fall from knees to address any fear dancers may have of “falling forward”; then progress to roll forward (hips forward) Roll forward and shoot legs up, end in cobra

Chest stand preparation, slide knees in and out, walk knees in and out

Chest stand preparation, walk toes in high and out, focus on proper placement of weight into hands and use of breath Gentle rocking in a basket, advanced rocking in a basket (optional activity)

High rocking in superman. Rock a superman high so that feet come off the floor and begin to chest stand, repeat rocking Rock from superman high into the air and return to cobra

From knees push hips forward and catch body with hands, allow body to roll smoothly. Practice adjusting the arms when ready Rock to straight chest stand and return to cobra

Master chest stand straight and together. Modify chest stands and entrances as desired (ie kick to chest stand)

Modify chest stand entrances and transitions and begin working on variations

10 Chest Stand Progressions (not all are featured)

Learn hand placement, focus on Practice breathing on a block to get comfort- breathing in extension. able with weight placement.

Prone fall from knees to reduce Roll from knees with hips forward. fear of “tipping forward.” Encourage engaged core.

Slide knees in and out; focus on breath and Walk toes high and focus on breath, pushing weight placement. hands into the floor.

11 Use basket as another opportunity to work on Advanced basket to assess dancer’s ROM. flexibility. Can you spot the restrictions?

1 2

Rock in superman as high as possible.

Roll to chest stand and return to cobra.

12 Variations There are a variety of variations and interesting ways to get in and out of chest stands.

13 Acknowledgments

Thank you to Tim Buckley and Karen Bhartu who provided consultation and support in the creation of this guide as well as the many researchers in the field of dance science who make valuable contribu- tions to our profession every day.

Thank you to the following dancers who are featured in this guide:

Asiah Almarez Austyn Lamont Brooklyn McMullin Charleigh Buettner Jayce Pickering Jessie Louder Jordan Armstrong Kylie Armstrong Marie Sandoval Maya Dombowsky Ophelia Chan Paige Thomas Rayn Hinks Zofia Kasprzyk

References

Facet Joint Image: Retrieved April 2020 from; https://www.spineuniverse.com/conditions/spinal-disorders/facet-joint-syndrome

Iliopsoas Image: Retrieved April 2020 from; https://somaticmovementcenter.com/psoas-muscle-release-tight-psoas-muscle/

Kyphosis Image: Retrieved April 2020 from; https://stenosisspinal.org/blog/kyphosis/

Scoliosis Image: Retrieved April 2020 from; https://www.health.harvard.edu/a_to_z/scoliosis-a-to-z

Spine Image: Retrieved April 2020 from; https://www.ossurwebshop.co.uk/blog/the-anatomy-and-function-of-the-spine

Spondylolisthesis Image: Retrieved April 2020 from; https://www.braceability.com/blogs/articles/lumbar-spondylolisthesis-vs-spondylolysis

Types of Scoliosis Image: Retrieved April 2020 from; https://www.spineuniverse.com/conditions/scoliosis/symptoms-scoliosis

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