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Chapter 1: Introduction Musculoskeletal Injury in Professional Dancers: Prevalence and Associated Factors. An International Cross-sectional Study by Craig Loren Jacobs A thesis submitted in conformity with the requirements for the degree of Master of Science Graduate Department of Institute of Medical Science University of Toronto © Copyright by Craig Loren Jacobs 2010 Musculoskeletal Injury in Professional Dancers: Prevalence and Associated Factors. An International Cross-sectional Study Craig Loren Jacobs Master of Science Institute of Medical Science University of Toronto 2010 Abstract Purpose: To determine the prevalence and factors associated with injury in professional ballet and modern dancers, to explore dancers’ attitudes and perceptions of injury, and to assess if dancers are reporting their injuries and reasons for not reporting injuries. Methods: A cross-sectional survey was undertaken in professional ballet and modern dance companies in Canada, Denmark, Israel, and Sweden. Results: The point prevalence of injury in dancers is high (55% ballet; 46% modern) and most have chronic pain. Years dancing professionally and rank were associated with injury in ballet dancers. Attitudes towards injury vary and some dancers are continuing to dance when injured. Greater than 15% of all injured dancers have not reported their injury. Conclusions: Injury is common in dancers and there is an urgent need to investigate interventions to help control injury and understand the long-term implications of these conditions in this population. ii Acknowledgments and Contributions I wish to express my sincere gratitude to my supervisor Dr. J. David Cassidy for his guidance, supervision, and scientific integrity and for providing me with such an important and exciting research opportunity. I am truly grateful to my cosupervisor, Dr. Pierre Côté, for his belief in the importance of my research. His excitement for research and science is truly infectious and inspiring. I would like to thank Dr. Eleanor Boyle for her collaboration, contributions and guidance with the statistical analysis. I am so grateful for her time, patience, and expertise. I thank Dr. Carlo Ammendolia for his invaluable insights, input, and suggestions for my work. I am so appreciative of my entire program advisory committee, each of whom has provided me with guidance and inspiration. This was a truly collaborative international effort that would not have been possible without the contributions of Dr. Eva Ramel, Dr. Jan Hartvigsen, and Dr. Isabella Schwartz. They were instrumental in applying for the ethics board applications in Sweden, Denmark and Israel respectively. Dr. Ramel helped to develop relationships and communication with both the Royal Swedish and Royal Danish Ballets. Additionally, Dr. Ramel’s previous scholarly work regarding professional dancers has been an invaluable source of knowledge, and her willingness and excitement to discuss dance health issues with me was extremely helpful. All three collaborators reviewed the study questionnaire and made site specific recommendations. They provided me with support during the survey completion in each country. They provided supplies, helped with logistics and communication and gave me a greater understanding of social support and work conditions in each country. I am so thankful for the amount of time and energy they have contributed to this project. Dr. Cesar Hincapié published the first systematic review of injury and pain in dancers which served as a springboard and inspiration for my study. He guided me through the best evidence synthesis systematic review update process and served as the second reviewer for all the literature. I wish to thank him for that guidance and for his contribution to my research. I would also like to thank Dr. Paula Stern for her encouragement over all these years, her role in the pilot of the questionnaire, and for starting me off on this path. My deepest gratitude also goes to Dr. Heather Shearer who has always been ready with advice and support whenever I needed it, without question. I commend and thank Monica Alder for her wonderful design of the iii questionnaire which played an integral role in its success and appeal. The staff, scientists, and students at CREIDO were so helpful over the years in so many ways, and I thank them all for their input, suggestions, and incredible help. Of course, this work would not have been possible without the participation of the dance companies involved. I thank all the dancers, artistic staff, and administrative staff of the National Ballet of Canada, Toronto Dance Theatre, Royal Swedish Ballet, Cullberg Ballet, Royal Danish Ballet, Batsheva Dance Company and Ensemble, and the Kibbutz Contemporary Dance Company and its junior company. I would like to especially thank those individuals from these companies who facilitated the implementation and logistics of the study including Joanna Ivey, Bridget Cawthery, Lars Anderstam, Jane Salier-Eriksson, Karen Bonnesen, Yaniv Nagar, Claire Bayliss-Nagar, and Rachel Ariel. I wish to thank all of the organizations who provided financial support for my research and graduate studies: the Canadian Institutes of Health Research, the Artists Health Centre Foundation, the University of Toronto, and the Canadian Memorial Chiropractic College. This project was also partially funded by the Centre for Research Expertise in Improved Disability Outcomes (CREIDO) which received substantial funding through a grant provided by the Workers’ Safety and Insurance Board (WSIB). I thank my parents, Michael and Shelley, for their never ending support and love. I am so grateful to my partner Atsmon who has constantly reminded me of the importance of my work at every stage and has been an incredible source of strength, encouragement, and love. iv Table of Contents ABSTRACT.................................................................................................................................. II ACKNOWLEDGMENTS AND CONTRIBUTIONS .............................................................III TABLE OF CONTENTS .............................................................................................................V LIST OF TABLES .....................................................................................................................IX LIST OF APPENDICES .......................................................................................................XI LIST OF ABBREVIATIONS .................................................................................................. XII CHAPTER 1: INTRODUCTION................................................................................................ 1 1.1 Statement of Problem ............................................................................................................. 1 1.2 Literature Review ................................................................................................................... 2 1.2.1 Screening for relevance...................................................................................................... 2 1.2.2 Critical review of the literature.......................................................................................... 3 1.2.3 Characteristics of musculoskeletal injury in dancers......................................................... 3 1.2.4 Prevalence and associated factors of musculoskeletal injury and pain in dancers. ........... 4 1.2.5 Incidence of and risk factors for musculoskeletal injury and pain in dancers................... 8 1.2.6 Definition of Injury............................................................................................................ 8 1.2.7 Injury Reporting............................................................................................................... 10 1.2.8 Assessment Tools for Musculoskeletal Injury and Pain in Dancers................................ 10 1.3 Environmental Scan of Healthcare and Social Programs................................................. 11 1.4 Summary and Rationale....................................................................................................... 13 1.5 Primary Objectives and Research Questions..................................................................... 13 CHAPTER 2: METHODS AND MATERIALS ...................................................................... 15 v 2.1 Study design........................................................................................................................... 15 2.2 Source population/Setting ................................................................................................... 15 2.3 Inclusion/Exclusion Criteria ................................................................................................ 17 2.4 Recruitment/Survey Methodology ...................................................................................... 17 2.5 Description and Pilot-Testing of the Questionnaire .......................................................... 18 2.5.1 Description of the study questionnaire ............................................................................ 18 2.5.2 Pilot-testing of the study questionnaire............................................................................ 18 2.6 Measurement and Definition of Variables.......................................................................... 19 2.6.1 Sociodemographic variables ............................................................................................ 19 2.6.2 The Self-Estimated
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