Musculoskeletal Pain in Latin American Formation Dance Localization, Assessment, and Related Behavior

Eileen M. Wanke, MD, PhD, Jasmin Haenel, MSc, and David Alexander Groneberg, MD, PhD

Abstract joint, forefoot, and toes) were significantly Rumba, Cha-Cha-Cha, PasoDoble, Competitive Latin formation dance, more affected in females than in males (p and Samba), as defined by the WDSF a form of dancesport, places extreme < 0.05). Sensory and affective pain percep- (World DanceSport Federation).1,2 In physical demands on dancers that can tion ranged from “hardly” to “moderate,” addition to dance movement patterns cause pain. Due to the sex-specific re- with female dancers being more severely that are typical of single couple dance, quirements of dancesport, sex-specific affected. Almost 80% of each sex contin- ued dancing despite pain. Intrinsic mo- a number of formation dance-specific differences in pain are probable. The and rating-relevant movement ele- aim of this study was to analyze pain tives and solidarity with the dance team were most often given as reasons for this ments (e.g., round about) associated with regard to prevalence, localization, with large and asymmetrical loads perception, assessment, and related be- behavior. Primarily, sex-specific physical havior in male and female Latin formation requirements seemed to be most relevant on the musculoskeletal system of a dancers. The quantitative cross-sectional in the occurrence of pain; in addition, dancer’s body are performed by for- observational study was carried out pain assessment characteristics and per- mation teams. Despite the movement with 41 female and 31 male dancers of sonal behavior were related to attitudes specificity in formation dance that a national premier league by use of an regarding pain and injury. Therefore, in promotes injuries (e.g., close proxim- anonymous online survey, with 3- and addition to sex, motivational and socio- ity of couples, high dynamics), studies 12-month pain intervals being recorded. cultural factors should be considered in of formation dance related injuries future studies of this subject. Of all participating subjects, 33 females remain very limited.3,4 McCabe et al.,5 and 26 males confirmed having been in in particular, suggested the need for ancesport is a competition- pain during the most recent 3 months further research in this subject. and performance-oriented and provided detailed information on Several studies have, however, con- the pain factors being studied. In order variant of ballroom dancing sidered the matter of injuries in these to operationalize pain characteristics, andD is one of the technical and aes- dance genres, with specific emphasis existing pain assessment measures were thetic types of sport. Among other on sex differences and the role played adapted for dancers. For the most painful dancesport disciplines, there is stan- by pain. Miletic et al.6 showed sig- body regions, accompanying symptoms, dard and Latin formation dance, with nificant differences between males and pain intensity, pain perception, and pain generally eight dance couples form- evaluation were surveyed. The pain be- females in the following pain regions ing one team. The aim of the eight havior section included questions about of standard and Latin dancers: hip couples is to move in synchronization, trusted persons and dancing despite pain, (female: 10%; male: 35%, p = 0.005), precisely, and for the most part sym- as well as pain management strategies. As lower thigh (female: 6%; male: 24%, metrically on a dance floor performing to pain localization, several parts of the p = 0.016), and toes (female: 45%; the five formal Latin dances (Jive, lower extremity (hip joint, groin, ankle male: 22%, p = 0.025). With regard to injury sites in Latin Formation Dance, Eileen M. Wanke, MD, PhD, Jasmin Lampe, MSc, and David Alexander Groneberg, MD, PhD, Johann Wolfgang von Goethe University, Institute differences between males and females of Occupational, Social, and Environmental Medicine, Frankfurt am Main, are particularly evident at the thigh Germany. (female: 25%; male: 8%), knee (fe- male: 6%; male: 22%), and foot and Correspondence: Eileen M. Wanke, MD, PhD, Goethe-University Frankfurt toes (female: 28%; male: 16%).7 To Main, Institute of Occupational, Social, and Environmental Medicine, Theodor- what extent pain signals a health risk Stern-Kai 7, 60590 Frankfurt am Main, Germany; [email protected]. for dancers depends on the intensity

Copyright © 2020 J. Michael Ryan Publishing, Inc. 24 https://doi.org/10.12678/1089-313X.24.1.24 Journal of Dance Medicine & Science • Volume 24, Number 1, 2020 25 of the perceived pain and how danc- The purpose and content of the Contents of the Questionnaire 8-10 ers respond to it. The stronger the survey, as well as the persons and in- Information on each participant’s pain and the more it limits dancing, stitutions responsible for the research, dance training was solicited. This the more it is perceived as a “nega- were explained to potential study par- included the main dance style per- tive” that poses a problem requiring ticipants in a letter. The chosen design formed, years of dance experience, 8,9 medical attention. Two studies in of the study (i.e., on an anonymous training hours per week, and prepara- dancesport used the Self-Estimated and voluntary basis) did not neces- tion for competitions or performanc- Functional Inability Because of Pain sitate written consent on the part of es. Demographic data such as age, (SEFIP) test to measure pain intensity the participants. The inclusion criteria height, weight, and current diseases in different body regions in relation for the study were non-professional or injuries were also queried (Table 1). 6,11 to performance capability. Dance- dancers who were at least 18 years of The pain questionnaire contained five limiting pain (levels 3 and 4) was age and participated in Latin forma- “Blocks”: 6,11 rare ; thus, only 3 out of 86 standard tion dance. In total 72 subjects (41 A. Pain prevalence, and Latin dancers had to avoid certain females, 31 males) participated in this B. Pain localization, 6 movements due to pain. Continu- study. C. Pain perception, ing to dance despite being in pain Study procedures were approved by D. Pain assessment, and is a frequently practiced behavior in the University Research Ethics Com- E. Pain-related behavior 8,12 dance. In one study of Latin For- mittee of Johann Wolfgang Goethe- Block A consisted of four items. mation Dance, 55.8% of males and University, Frankfurt, Germany. These contained questions on pain 35.4% of females ignored injuries and the resulting pain.7 Important behav- ioral motives were involved, including responsibility to the dance team and Table 1 Population and Dance Training-Related Data of Female (N = 41) performance pressure.7 and Male (N = 31) Dancers It must also be considered that the Female Male P-value dancer’s sex seems to play a role in pain perception and management as Age (years)* well as his or her attitude toward and x̅ (SD) 22.7 (4.6) 25.9 (7.2) 0.03 coping behavior for pain.13-15 Only Height (cm)† the aforementioned few studies have x̅ (SD) 167.7 (6,8) 180.7 (6.8) 0.00 investigated pain in dancesport. Lack- Weight (kg)† ing are studies that in a sophisticated x̃ (I50) 60.0 (10.0) 75.0 (15.0) 0.00 manner present various dimensions Body mass index (kg/m2)† of pain (location, perception, assess- x̃ (I50) 21.2 (3.4) 23.2 (3.6) 0.00 ment, behavior) sustained by either Diseases yes/no sex in dancesport. The aim of this M (VR) no (0.18) no (0.17) 0.89 pilot study was to begin to fill that Missing [N (%)] [2 (4.9)] [1 (3.2)] void, with concentration on Latin formation dancers. Injury yes/no M (VR) no (0.23) no (0.16) 0.47 Methods Missing [N (%)] [2 (4.9)] - Study Design and Population Years of dancing (total) The data of this quantitative obser- x̅ (SD) 9.9 (5.5) 10.1 (6.9) 0.89 vational study were generated by a Missing [N (%)] [1 (2.5)] - fully structured cross-sectional online Years of dancing (main dance style) questionnaire. The pain aspects of x̃ (I50) 5.0 (5.0) 5.0 (9.0) 0.42 the questionnaire were based on pat- Missing [N (%)] [2 (4.9)] - terns of pain perception, assessment, Hours per week and related behavior according to x̃ (I50) 6.0 (5.0) 7.0 (5.0) 0.91 Birbaumer and Schmidt,16 who used Missing [N (%)] [1 (2,4)] - a 12-month time period for general Competitions yes/no information on pain and a 3-month M (VR) yes (0.05) yes (0) 0.50 period for more detailed information. Performances yes/no* The operationalization of pain aspects M (VR) yes (0.25) yes (0.38) 0.04 was carried out by modifying existing Missing [N (%)] [3 (7.3)] [2 (6.5)] pain measuring instruments used in *p < 0.05; †p < 0.01; x̃: median; I50:interquartile range; x̅ : mean; M: mode; VR: variation 8,9,12 the dance-specific literature. ratio. 26 Volume 24, Number 1, 2020 • Journal of Dance Medicine & Science

Table 2 Pain Prevalence in Latin Formation Dancers and accompanying symptoms used Female Male a four-level Likert scale from “not” N (%) N (%) P-value (1) to “very” (4). The body regions (Table 3) were chosen by the subjects 12-month prevalence from those of the SEFIP test.18 The Pain while dancing 34 (82.9) 22 (71.0) 0.34 authors of this study, however, chose Pain within 24 hours after dancing 33 (80.5) 23 (74.2) 0.90 to supplement and present selected 3-month prevalence body regions in a more differentiated Pain while dancing 32 (78.0) 24 (77.4) 0.95 way (e.g., upper and lower extremi- Pain within 24 hours after dancing 31 (75.6) 23 (74.2) 0.89 ties, head, and foot regions). Tension and perceived limitations related to perceived while dancing or within 24 Block B also consisted of four mobility and resilience were queried as hours thereafter (taking into account items. It contained questions on pain accompanying symptoms in the most the fact that muscle soreness occurs up locations and the most severely af- severely affected body regions. to 24 hours after exercise17) during the fected body regions. The subjects were In Block C, two questions were most recent 3 and 12 months (Table asked to choose one of the named asked, focusing on pain perception 2). pain regions. Grading radiating pain of the most severely affected body

Table 3 Painful Body Regions in Latin Formation Dancers During the Most Recent 3 Months (Female: N = 41; Male: N = 31) Female Male N (%) N (%) P-value Head and Trunk Head 3 (9.1) 0 0.25 Neck, cervical spine 17 (51.5) 7 (26.9) 0.06 Upper back, thoracic spine 12 (36.4) 5 (19.2) 0.15 Lower back, lumbar spine, iliosacral joint 17 (51.5) 12 (46.2) 0.68 Stomach 3 (9.1) 2 (7.7) 1.0 Hip/pelvis 5 (15.2) 1 (3.8) 0.15 Upper Extremity Right Left Right Left Right Left Shoulder*(right) 16 (48.5) 6 (18.2) 6 (23.1) 4 (15.4) 0.05 1.0 Upper arm 5 (15.2) 2 (6.1) 2 (7.7) 1 (3.8) 0.45 1.0 Elbow 1 (3.0) 1 (3.0) 0 0 1.0 1.0 Forearm 2 (6.1) 1 (3.0) 0 1 (3.8) 0.499 1.0 Wrist 5 (15.2) 2 (6.1) 1 (3.8) 0 0.22 0.499 Hand†(right) 0 0 6 (23.1) 2 (7.7) 0.01 0.19 Lower Extremity Right Left Right Left Right Left Hip joints*(left) 6 (18.2) 9 (27.3) 1 (3.8) 1 (3.8) 0.12 0.03 Groin*(right/left) 6 (18.2) 6 (18.2) 0 0 0.03 0.03 Upper thigh (anterior) 2 (6.1) 2 (6.1) 1 (3.8) 1 (3.8) 1.0 1.0 Upper thigh (posterior) 2 (6.1) 2 (6.1) 1 (3.8) 1 (3.8) 1.0 1.0 Knee 14 (42.4) 10 (30.3) 7 (26.9) 7 (26.9) 0.22 0.78 Lower thigh anterior (tibia) 0 0 1 (3.8) 1 (3.8) 0.44 0.44 Lower thigh (posterior) 2 (6.1) 2 (6.1) 2 (7.7) 2 (7.7) 1.0 1.0 Ankle joint*(right/left) 6 (18.2) 6 (18.2) 0 0 0.03 0.03 Back- and mid-foot 7 (21.2) 8 (24.2) 6 (23.1) 9 (34.6) 0.86 0.38 Forefoot and toes (except big toe)*(left) 14 (42.4) 13 (39.4) 5 (19.2) 4 (15.4) 0.06 0.04 Big toe†(right) 16 (48.5) 14 (42.4) 4 (15.4) 5 (19.2) 0.01 0.06 *p < 0.05; †p < 0.01. Journal of Dance Medicine & Science • Volume 24, Number 1, 2020 27

Table 4 Assessment of Sensory and Affective Pain Perception on a Four-Level Scale (1 = Does not Apply; 2 = Applies a Little; 3 = Applies Largely; 4 = Applies Exactly) of Female (N = 33) and Male (N = 26) Dancers Female Male Missing Missing x̃ (I50) N (%) x̃ (I50) N (%) P-value Sensory pain statements Throbbing 1.0 (1.0) 2 (6.1) 1.0 (0) 0 0.19 Tingling 1.0 (0) 2 (6.1) 1.0 (0) 0 0.55 Dull 1.0 (1.0) 2 (6.1) 1.0 (1.0) 0 0.72 Pressing 2.0 (2.0) 1 (3.0) 2.0 (2.0) 1 (3.8) 0.59 Cramping 1.0 (1.0) 2 (6.1) 1.0 (0.75) 2 (7.7) 0.29 Tugging 2.0 (1.5) 0 2.0 (2.0) 1 (3.8) 0.70 Tearing 1.0 (1.0) 1 (3.0) 1.0 (1.0) 1 (3.8) 0.72 Shooting 1.0 (1.0) 2 (6.1) 1.0 (1.5) 1 (3.8) 0.91 Stabbing 2.0 (2.0) 2 (6.1) 1.0 (2.0) 1 (3.8) 0.55 Sharp 1.0 (1.0) 2 (6.1) 1.0 (0) 1 (3.8) 0.22 Burning 1.0 (1.0) 2 (6.1) 1.0 (0) 1 (3.8) 0.50 Searing* 1.0 (1.0) 2 (6.1) 1.0 (0) 2 (7.7) 0.02 Affective pain statements Tiring or exhausting 1.0 (1.0) 2 (6.1) 1.0 (0) 1 (3.8) 0.06 Fearful 1.0 (0.25) 3 (9.1) 1.0 (0) 1 (3.8) 0.83 Wretched* 1.0 (1.0) 2 (6.1) 1.0 (0) 2 (7.7) 0.02 Ghastly 1.0 (0) 5 (15.2) constant 1.0 1 (3.8) 0.18 Dreadful 1.0 (0) 4 (12.1) 1.0 (0) 1 (3.8) 0.28 Terrible* 1.0 (1.0) 4 (12.1) 1.0 (0) 1 (3.8) 0.02 Paralyzing* 1.0 (0) 2 (6.1) 1.0 (0) 1 (3.8) 0.05 Unbearable 1.0 (1.0) 3 (9.1) 1.0 (0.5) 1 (3.8) 0.16

*p < 0.05; x̃: median; I50: interquartile range. regions, pain intensity (Numeric tions or classifications of statements dance schools, and social networks on Rating Scale, NRS),19 and sensory on a four-point scale for confidants, the Internet. The questionnaire was and affective pain quality based on 20 information on dancing despite pain, created online via the SoSci Survey pain statements ranging from “does reasons for dancing despite pain, and web server. Practicality and quality of not apply” (1) to “applies exactly” pain management strategies according the questionnaire regarding clarity, (4) in a modified version of Thomas to a modified version of Kleinert’s usefulness, order of the questions, and Tarr,9 Nagel et al.,20 Geissner,21 “Dimensions of adaptive pain man- reasonableness of effort in answering Radvila et al.,22 and Stein et al.23 agement in sport”25 (Table 6). Only the questionnaire, and possible answer (Table 4). Sensory pain perception participants who had confirmed tendencies were checked in a pre-test describes the nociceptively mediated having been in pain during the most with representatives of the target sensory perception of pain.16 Affective recent 3 months answered the ques- population. Additional comments pain perception refers to affective- tions on detailed aspects of pain.26 were encouraged in the pre-test. emotional perception of pain.16 Block D consisted of statements Procedure Data Analysis based on Anderson and Hanrahan24 The data collection took place during Statistical evaluation of the quantita- (Table 5). Pain was assessed on the a 3-month period. A convenience tive data was carried out by use of basis of these statements using a scale sampling was used, designating a IBM SPSS Statistics software version ranging from “does not apply” (1) to non-random version of sampling.27 24 (IBM, Armonk, New York, USA). “applies exactly” (4). Participants were acquired via various Descriptive statistics of the variables Block E consisted of four ques- dance related associations and institu- were based on position and dispersion tions that contained selection op- tions, e-mail distribution to individual measures. For most metric variables, 28 Volume 24, Number 1, 2020 • Journal of Dance Medicine & Science

Table 5 Pain Assessment on a Four-Level Scale (1 = Does not Apply; 2 = Applies a Little; 3 = Applies Largely; 4 = Applies Exactly) of Female (N = 33) and Male Dancers (N = 26) Female Male Missing Missing x̃ (I50) N (%) x̃ (I50) N (%) P-value Influence of dancing on pain Cause of pain 3.0 (1.0) 2 (6.1) 3.0 (1.0) 0 0.81 Relief of pain 1.0 (0) 5 (15.2) 1.0 (0) 1 (3.8) 0.52 Worsening of pain 2.0 (1.0) 4 (12.1) 2.0 (2.0) 0 0.299 Performance and injury pain Pain is harmless and belongs to dancing as a natural consequence 2.0 (2.0) 0 2.0 (2.0) 0 0.19 Pain is alarming and could be a warning signal of an injury 2.0 (1.0) 2 (6.1) 1.0 (1.0) 0 0.37 Pain is induced by an injury 1.0 (1.0) 2 (6.1) 1.0 (2.0) 0 0.23

x̃: median; I50: interquartile range. Table 6 Pain Management by Sex on a Four-Level Scale (1 = Never; 2 = Rare; 3 = Frequent; 4 = Always) Female Male Missing Missing x̃ (I50) N (%) x̃ (I50) N (%) P-value Distraction by Meeting friends 1.0 (1.0) 0 1.0 (1.0) 2 (7.7) 0.26 Watching films or listening to music 1.0 (1.0) 1 (3.0) 1.0 (1.0) 2 (7.7) 0.69 Relaxation or sleep 2.5 (2.0) 1 (3.0) 2.0 (2.0) 2 (7.7) 0.198 Restructuring by Thoughts, e.g., ‘it’s been worse’ 1.5 (2.0) 1 (3.0) 1.0 (1.0) 2 (7.7) 0.195 Concentration on others 2.0 (2.0) 0 1.0 (2.0) 1 (3.8) 0.51 Thoughts about the pain passing 3.0 (2.0) 1 (3.0) 3.0 (2.0) 1 (3.8) 0.11 Physical tension regulation by Release of pain-related tensions 3.0 (1.0) 1 (3.0) 3.0 (1.0) 2 (7.7) 0.94 Relaxation of muscles 3.0 (1.0) 1 (3.0) 2.0 (2.0) 1 (3.8) 0.09 Taking helpful postures* 3.0 (2.0) 1 (3.0) 2.0 (2.0) 1 (3.8) 0.04 Massage of painful body parts 3.0 (2.0) 1 (3.0) 3.0 (1.0) 1 (3.8) 0.83 Search for information by Analyzing the feeling and source of pain 3.0 (2.0) 1 (3.0) 2.5 (2.0) 2 (7.7) 0.67 Thinking about what the pain means 2.0 (1.0) 1 (3.0) 1.0 (1.0) 3 (11.5) 0.59 Physical activation by Exercise or sports 2.0 (1.0) 1 (3.0) 2.0 (1.0) 2 (7.7) 0.78

*p < 0.05; x̃: median; I50: interquartile range. with the exception of age, height, and chi-squared test had not been met. males. Population-related and dance total years of dancing, the median (x̃) The Mann-Whitney U-test was used training-related data are shown in and interquartile distance (I50) were for ordinally scaled or abnormally dis- Table 1. Males were significantly given, since no normal distributions tributed metric variables. Significance older (p = 0.03), taller (p < 0.001), were available. In order to compare level throughout was set at α = 0.05. and heavier (p < 0.001), and had the other three variables by sex, the t- significantly higher BMI (p < 0.001) test was used for independent samples. Results than their female counterparts. Ex- For nominal scaled data the chi- Study Population cept for the variable “performances,” squared test was used, or the Fischer The sample included 72 Latin for- no significant sex-specific differences Exact Test when requirements for the mation dancers, 41 females and 31 were observed. Journal of Dance Medicine & Science • Volume 24, Number 1, 2020 29

Pain Prevalence pronounced in females than in males, 0.61; Fig. 2). Male dancers consulted Prevalence of pain sorted by sex is with significantly stronger statements medical specialists significantly less shown in Table 2. Fifty-nine dancers such as “miserable” (p = 0.02), “ter- often (x̃ = 2.0; I50 = 2.0; p = 0.01) and were found to have been in pain while rible” (p = 0.02), and “paralyzing” (p distinctly more often did not talk to dancing and 24 hours after dancing in < 0.05) reported by the females. anyone about their pain (p = 0.04). the most recent 3 months (female: N Pain Assessment Behavior in the Context of Dance = 33, 80.5%; male: N = 26, 83.9%). No significant differences in the Activity Pain Localization statements of pain assessment could The majority of female dancers (26, In total, 354 body regions affected be found between female and male 78.8%) and male dancers (20, 76.9%) by pain could be observed over the dancers (Table 5). stated that they train to the full extent 3-month period (female: N = 245; despite being in pain, while 15.2% of Pain Related Behavior— the females (N = 5) and 15.4% of the male: N = 109). The female dancers Confidants showed significantly more affected males (N = 4) continued to train but regions, x̅ = 6.0 (I50 = 6.0), than male Regarding the acknowledgment of favored the affected body part. One dancers, x̅ = 3.0 (I50 = 4.0), (Table 3). pain, females frequently confided in male dancer said he had trained under Hence, it is concluded that significant members of their dance team (p = the influence of medication. Only two sex-specific differences were observed. Male as well as female dancers most frequently reported the lower back, lumbar spine, and iliosacral joint (female: N = 6; 18.2%; male: N = 5; 19.2%) as the most severely affected body region. The right shoulder (N = 6; 18.2%) was also frequently indi- cated by female dancers, and the right knee by male dancers (N = 3; 11.5%), (Table 3). With regard to tension as an ac- companying symptom of pain, the body region affected by pain was said to be “rather” tense (x ̃ = 3.0; I50 = 3.0) by the average female dancer and “a little fixed, hard, tense, tight” (x ̃ = 2.0; I50 = 2.0) by male dancers. However, this difference was not significant (p Figure 1 Frequencies of pain intensity on the Numeric Rating Scale (0 = no pain; 10 = 0.08). Both mobility (female: x̅ = = worst conceivable pain) in the most severely affected pain region of female (N = 33) 2.0; I50=2.0; male: x̅ = 2.0; I50 = 2.0; and male (N = 26) dancers. p = 0.15) and resilience (female: x̅ = 2.0; I50 = 1.0; male: x̅ = 2.0; I50 = 2.0; p = 0.48) were “a little” restricted on average in both sexes. Pain Perception Pain intensity tended to be more pronounced in female dancers, with x̅ = 5.0 (I50 = 2.0), than in their male counterparts, with x̅ = 4.0 (I50 = 3.0), (Fig. 1). However, the difference was not statistically significant (p = 0.29). Most of the sensory pain statements were rated “does not apply” (Table 4). A significant difference was found regarding a “searing” pain percep- tion, which was more pronounced in females than in males (p = 0.02). The Figure 2 Confidants of female (N = 33) and male (N = 26) dancers regarding their affective pain perception was more pain (multiple selection possible). 30 Volume 24, Number 1, 2020 • Journal of Dance Medicine & Science female dancers and one male dancer to the hip joint and groin, specifically dancers, the knee has been found did not train with pain. The main rea- in the female subjects, the picture is to be more frequently affected than sons given by both sexes for training ambivalent compared to previous in females (female: 11.5%; male: despite being in pain were “passion for findings in dancesport, especially in 15.2%).29 Miletic et al.6 cited the 6,7,28 dancing” (females: x̅ = 4.0; I50 = 1.0; the hip and pelvic region. Miletic turnout performed in rapid rhythms 6 males: x̅ = 3.0; I50 = 1.0; p = 0.15) and et al. observed significantly more by standard and Latin male dancers “not to let the team down” (females: males than females reporting hip as a cause of hip problems. Turnout x̅ = 4.0; I50 = 1.0; males: x̅ = 3.0; I50 pain. The weekly training hours of can also be forced at the knee, leading = 2.0; p = 0.64). The statement “I their dancers were comparable to the to increased strain.30 This mechanism want to be the best” was rated by the present study; however, the dancers may have led to increased pain in female dancers as “largely true” (x ̃ = in the Miletic et al. study had fewer the knees of the male subjects in our 3.0; I50 = 1.0) and “slightly true” (x̃ = years of dance experience (females: x̅ study. 2.0; I50 = 1.0, p = 0.53) by the male = 5.8; males: x̅ = 6.7). Our dancers The pain intensity of formation dancers. The statement “dance is more seem to have been performing other dancers was mainly observed to be in important than my health” was rated dance styles, since the total period of the middle range, with most sensory “applies a little” (female: x̅ = 2.0; I50 = dancing reported was longer than time and affective pain statements rated 2.0; male: x̅ = 2.0; I50 = 2.0, p = 0.93). dancing in the main dance style (Table “does not apply.” The study by Miletic The statements “pressure by the coach” 1). Dance experience may influence et al. also showed rather mild mani- (female: x̅ = 1.0; I50 = 1.0; male: x̅ = the execution of dance techniques festations of pain perception. Most 1.0; I50 = 1.0, p = 0.13), “pressure by such as lower extremity turnout, and competitive dancers recorded a score members of the team” (female: x̅ = execution of techniques is generally of 1 (“some pain”) on the five-level 6 1.0; I50 = 1.0; male: x̅ = 1.0; I50 = 1.0, considered to influence the occurrence SEFIP scale from 0 to 4. Stronger p = 0.44), and “by parents (female: of pain in dance. manifestations were tangentially constant at 1.0; m: x̅ = 1.0; I50 = 0, p On the whole, female subjects found in females’ numeric rating scale = 0.27) were rated as “not true.” indicated significantly more painful compared to males (female: x̅ = 5.0; body regions than the males. Possible I50 = 2.0; male: x̅ = 4.0; I50=3.0; p = Pain Management reasons remain speculative since no 0.29). Significantly stronger expres- Regarding pain management, strate- training intensity differences (weekly sions were present in one sensory gies to relax and release pain-related training units and hours) between the and three affective pain statements tension were frequently used (Table sexes were observed. This trend was of females. Wandner et al.,14 using 6). Female dancers used significantly validated in the study by Wanke et al.,7 case vignettes, showed that female more pain relieving postures than where 77.6% of females and 69.3% athletes rated the extent of their pain their male counterparts (p = 0.04). of males reported at least one injury distinctly higher than male athletes. Little or no significant difference in their sports career. What should Tajet-Foxell and Rose31 observed sig- could be found between males and also be taken into consideration are nificantly lower pain thresholds and females in all other items of pain the different measuring instruments pain tolerances in female ballet danc- management (p > 0.05). used regarding pain localization in ers compared to males using the Cold the various studies. Miletic et al.,6 for Pressor Test (dancers age: x̅ = 25.3; SD Discussion instance, used the seven body regions = 6.0). These findings of differences Sex-specific differences concerning of the Self-Estimated Functional In- between the sexes are comparable pain localization, perception, and, to ability Because of Pain (SEFIP), which to the results of Keogh and Herden- some extent, behavior were observed does not differentiate between sides feldt,13 who used the Cold Pressor between female and male dancers. of the body.18 Considering the region Test on students with an average age Due to the high prevalence of pain most affected by pain, it is noteworthy of 24.1 years (SD = 5.8). However, sex in the most recent 3 or 12 months, that strikingly more males than fe- differences regarding perceived pain it becomes clear in this study that males reported pain in the knee joint. intensity were not found among ballet pain is a highly relevant issue in Latin Various studies of pain and injury dancers by Tajet-Foxell and Rose.31 A formation dance. Regarding pain frequencies in dancesport point to the possible higher sensitivity to pain in localization, significantly more pain knee as being significantly more af- females could hypothetically also have was observed in the lower extremity fected in male dancers than in female led to the stronger manifestations of region of female dancers compared dancers.6,7,28 In one study, the knee of pain perception on the numeric rat- to males. The fact that the ankle competitive male dancers aged from ing scale and in the four significant joint and toes are primarily regions 15 to 17 years was the most frequent sensory and affective pain statements of discomfort for female dancers in pain region with 44.7% of the total, of female dancers. That study is not, our study is congruent with previous and the second most frequent pain however, about an experimentally findings on injury and pain localiza- region with 49.3% in the age group comparable pain stimulus, and there- tion in dancesport.6,7,28 With regard above 25 years.11 Even in male ballet fore the results should be interpreted Journal of Dance Medicine & Science • Volume 24, Number 1, 2020 31 with caution. our questionnaire (Tables 4, 5, and 6) References The majority of our dancers con- could be an indication of the extent to 1. Smith KL. Popular Dance: From Ball- tinued to dance despite being in pain which pain details could be remem- room to Hip-Hop. New York: Chelsea or injured. This behavior is congru- bered and the questions answered. House, 2010. ent with previous findings.7,8,12 These Relatively few missing answers to the 2. Thierse N, Grüninger R. Tänze und attitudes and behavior patterns seem pain questions seems to indicate a Tanzdisziplinen. In: Wanke EM to be more related to identification memory of the pain. (ed): TanzSportMedizin. Handbuch as an athlete than to the sex of the The small sample size of this study Für Tänzer, Trainer, Therapeuten dancer,14,15 to be intrinsically mo- is a limitation. Furthermore, the in- Und Ärzte. Köln: Sportverlag Srauss; tivated (passion and performance), ternal validity is limited by the study 2011, pp. 22-26. 3. Mergenthaler K. Tanzen: Wenn selbst and characterized by a high degree design (quantitative observational das Lächeln Stress ist. TW Sport und of responsibility to the dance team. study). A non-probabilistic procedure Medizin. 1992;4:401. However, when it comes to consult- was used in the sampling, which does 4. Strauss B, von Salis-Soglio G. Sport- ing specialists in cases involving pain, not allow for clear tracing of how verletzungen und sportschäden differences between females and males representative the study population im tanzsport. Sporttraumatologie. could be observed in the present study is.27 The representativeness and gen- 1997;13(3):173-6. (Fig. 2). Females more often reported eralizability of the available results are 5. McCabe TR, Wyon M, Ambega- consulting with specialists. This therefore limited. onkar JP, Redding E. A bibliographic relatively frequent consultation of review of medicine and science specialists is contradicted, however, by Recommendations for Future research in DanceSport. Med Probl the results of Wanke et al.,7 where spe- Research Perform Art. 2013 Jun;28(2):70-9. 6. Miletic A, Kostic R, Miletic D. Pain cialists were rarely consulted by either Standardized assessments should be prevalence among competitive in- female or male dancers (female: 4.2%; used in dance medicine research to ternational dancers. Int J Athl Ther male: 5.8%). The fact that 30.8% of adequately assess and compare pain Train. 2011 Jan;16(1):13-6. our male dancers consulted specialists in dancers. Additional aspects of 7. Wanke EM, Fischer T, Pieper H, is comparable to the results of Miletic content and methodology have to be Groneberg DA. Tanzsport: verlet- et al.,11 where 28% of the male com- considered in dancesport. Since there zungsmuster im lateinamerikani- petitive dancers at an average age of 25 may exist differences between the schen formationstanz. Sportverletz years consulted a specialist in case of right and left sides of the body (e.g., Sportschaden. 2014 Sep;28(3):132- injury. It is to be noted that members the shoulder in our females, Table 8. of their dance team were the most 3), future studies should investigate 8. Harrison C, Ruddock-Hudson M. frequently consulted persons named differences of pain locality in males Perceptions of pain, injury, and tran- sition-retirement: the experiences of by the female and male subjects of our and females. Also, subsequent stud- professional dancers. J Dance Med study. ies should aim for a larger number of Sci. 2017 Jun;21(2):43-52. cases and random sampling. 9. Thomas H, Tarr J. Dancers’ percep- Methodological Limitations tions of pain and injury: positive and Although qualitative validation of Conclusion negative effects. J Dance Med Sci. our questionnaire was conducted in This study demonstrates the high rel- 2009 Jun;13(2):51-9. a pre-test, no statistical validation of evance of pain and potentially injury 10. Lampe J, Wanke EM. Berufsbezo- psychometric properties was achieved. risk in Latin formation dance. With gene schmerzen und schmerzma- Therefore, it is not clear how valid regard to prevalence and localization, nagement im professionellen sport. the discriminatory power of certain sex-specific differences were observed, Teil II: Bühnentanz. Zentralblatt für items is (e.g., “hip joint” and “groin” which are presumably based on the Arbeitsmedizin, Arbeitsschutz und Ergon. 2018 Aug;68(1):50-3. as options in the localizations). From specific physical requirements of this 11. Miletic D, Miletic A, Milavic B. Age- a methodological point of view, a sta- particular dance style. As to pain related progressive increase of lower tistical validation of the questionnaire assessment and related behavior in back pain among male dance sport should have been carried out. competition-oriented dancesport, competitors. J Back Musculoskelet In addition, when answering identity as a dancer as well as the Rehabil. 2015;28(3):551-60. questions regarding pain during the socio-cultural environment in terms 12. McEwen K, Young K. Ballet and most recent 3 months, a recall bias is of desire to perform and responsibil- pain: reflections on a risk-dance conceivable. The retrospective survey ity to the team, seem to be decisive culture. Qual Res Sport Exerc Heal. period of 3 months was oriented to- factors. In addition to the differences 2011;3(2):152-73. ward validated pain sensation scales between the sexes, motivational and 13. Keogh E, Herdenfeldt M. Gender, (SES) derived from Geissner,21 but it socio-cultural influences on dancers coping and the perception of pain. Pain. 2002 Jun;97(3):195-201. is unclear to what extent this memory should be considered in the preven- 14. Wandner LD, Devlin AS, Chrisler period is valid for other scales of pain. tion of injuries and chronicity of pain JC. Sports-related pain: exploring The proportion of missing answers on in dancesport. the perception of athletes’ pain. Athl 32 Volume 24, Number 1, 2020 • Journal of Dance Medicine & Science

Insight J. 2011;3(1):1-17. gesellschaft e.V., 2015, p. 126. berg: Springer, 2005. 15. Weinberg R, Vernau D, Horn T. 21. Geissner E. Die Schmerzempfin- 27. Döring N, Bortz J.Forschungsmetho- Playing through pain and injury: dungs-Skala (SES): Handanweisung. den Und Evaluation in Den Sozial- psychosocial considerations. J Clin Göttingen: Hogrefe, 1996. und Humanwissenschaften (5. Aufl). Sport Psychol. 2013 Feb;7(1):41-59. 22. Radvila A, Adler RH, Galeazzi RL, Berlin: Springer, 2016. 16. Birbaumer N, Schmidt RF. Biologi- Vorkauf H. The development of 28. Wanke EM, Borchardt M, Fischer sche Psychologie (7. Aufl). Heidelberg: a German language (Berne) pain A, Groneberg DA. Verletzungen im Springer, 2010. questionnaire and its application in senioren-turniertanzsport. Sport- 17. Mense S. Neurobiologische grund- a situation causing acute pain. Pain. verletzung-Sportschaden. 2014 lagen von muskelschmerz. Der 1987 Feb;28(2):185-95. Dec;28(4):204-10. Schmerz. 1999 Feb;13(1):3-17. 23. Stein C, Mendl G. The German 29. Wanke EM, Arendt M, Mill H, 18. Ramel EM, Moritz U, Jarnlo G. counterpart to McGill Pain Ques- Groneberg DA. Occupational ac- Validation of a pain questionnaire tionnaire. Pain. 1988 Feb;32(2):251- cidents in professional dance with (SEFIP) for dancers with a specially 5. focus on gender differences. J Occup created test battery. Med Probl Per- 24. Anderson R, Hanrahan S. Dancing Med Toxicol. 2013 Dec;8(1):2-8. form Art. 1999 Dec;14(4):196-203. in pain: pain appraisal and coping 30. Grossman G, Krasnow D, Welsh 19. Oesch P, Hilfiker R, Keller S, et al. in dancers. J Dance Med Sci. 2008 TM. Effective use of turnout. Bio- Assessments in Der Rehabilitation. Mar;12(1):9-16. mechanical, neuromuscular, and Band 2: Bewegungsapparat (2. Aufl). 25. Kleinert J. Dimensionen adaptiver behavioral considerations. Journal of Bern: Huber, 2011. schmerzbewältigung im sport. Psy- Dance Education. 2005;5(1):15-27. 20. Nagel B, Pfingsten M, Lindena chol und Sport. 2000;7(1):3-14. 31. Tajet-Foxell B, Rose FD. Pain and G, Kohlmann T (Eds): Deutscher 26. Pioch E. Schmerzdokumentation in pain tolerance in professional bal- Schmerz-Fragebogen: Handbuch. Der Praxis: Klassifikation, Stadienein- let dancers. Br J Sports Med. 1995 (Vol. 3). Berlin: Deutsche Schmerz- teilung, Schmerzfragebögen. Heidel- Mar;29(1):31-4.