Survey of Musculoskeletal Disorders Among Indian Dancers in Mumbai and Mangalore

Shruti Prabhakaran Nair, MPTh, Shruti Kotian, BPTh, Claire Hiller, PhD, MAppSc, BAppSc, and Rajani Mullerpatan, PhD, MScPT

Abstract different dance forms. For both current of dramatic or expressive acting, or 1 Classical Indian dance has earned rec- pain and past injury, dancers reported abhinaya. ognition across the globe; however, the back (42.5%) followed by the knee Bharatanatyam is one of the most the health of dancers who are carrying (28.3%) and ankle (18.6%) as the most sublime and ancient of Indian classi- forth this heritage has not received due common sites. Stress was the most com- cal dances; it originated in Tanjore, monly perceived cause of injury (34.4%), attention. Therefore, this study aimed a town of Tamil Nadu in Southern to explore musculoskeletal pain and followed by over work (24.7%), tiredness 1 (17.2%), and falls (13.5%). Warm-up ex- India. This dance form lays its foun- injury prevailing among Indian dancers dation on the aesthetic beauty of in Mumbai and Mangalore. A second- ercises were always performed by 43.30% of dancers, whereas only 20% performed angles and lines formed by various ary aim was to compare pain tolerance 2 levels between dancers and non-dancers. stretching after dance. Almost 60% of positions of different body parts. Fifty-one dancers trained in different dancers participated in forms of exercise Bharatanatyam is distinguished by its traditional Indian and Western dance other than dance, e.g., swimming, yoga, grace and style, it includes traditional forms and 164 recreational dancers were and aerobics. Pain sensitivity was not sig- poses, rhythmic foot stamping, jumps, recruited as participants. An indigenous nificantly different between dancers and pirouettes, and positions where the questionnaire was designed and validated non-dancers (p = 0.159). Level of training knees are in contact with the floor. by physical therapists across various lev- and gender did not influence pain. Another dance form, Kathak, is a els of experience and dancers across partially narrative form character- various training levels. The question- ndian traditional dance encom- ized by fast foot work (tatkar), spins naire recorded dance, pain, and injury passes various indigenous dance (chakkar), and innovative use of bhav profiles. Additionally, pain tolerance was styles across India that originate (expression) in abhinaya.1,3 Odissi, evaluated using the Pain Sensitivity Ques- Ifrom temple dancing. They are catego- tionnaire among dancers and healthy a temple dance tradition from the rized into seven major kinds, namely Orissa state of India, is characterized age- and gender-matched controls (N = Bharatnatyam, Kathak, Manipuri, 200). Descriptive statistical analysis was by movement of the hips. This dance Kathakali, Odissi, Kuchupudi, and form includes variations of sitting, performed to present results of the site of Mohiniattam.1 All Indian classical current pain, site of past injury, perceived walking, leaping, and elevations that causes of injury, and exercise routine. The dances are rooted in Natyashastras reinforce some of the basic therapeutic Student’s t-test was used to compare Pain (Indian treatise on performing arts) movements of the dance.1 Kuchipudi Sensitivity Questionnaire scores between in varying proportions and, there- embraces quick movements with rapid dancers and non-dancers, and inde- fore, share common features such as footwork and sharp turns requiring pendent one-way ANOVA was used to mudras (gestures made with hands or good balance. The therapeutic effect compare scores among dancers practicing fingers), body positions, and inclusion of this dance form is embedded in its grace and fluid movements.1 Shruti Prabhakaran Nair, MPTh, Shruti Kotian, BPTh, and Rajani Mullerpatan, Indian classical dance is considered PhD, MScPT, MGM Institute’s University Department of Physiotherapy, a high form of art and was practiced MGMIHS, Navi Mumbai Maharashtra, India. Claire Hiller, PhD, MAppSc, BAppSc, Faculty of Health Sciences, University of Sydney, Sydney, Australia. in courts, temples, and on special occasions, while folk dance forms Correspondence: Shruti Prabhakaran Nair, MPTh, MGM Institute’s University are practiced in groups in rural areas Department of Physiotherapy, Sector-1, Plot No.1 & 2, Navi Mumbai - 410209, as an expression of their daily work Maharashtra, India; [email protected]. and rituals. Many folk dances are

A B C

D E F

Figure 1 Common dance postures in Indian classical dance. A, Kurma (turtle) pose: excessive lordosis of lumbar and cervical spine with bilateral hip knee flexion and external rotation. B, Bhramari (jump) involves high impact jumping activities wherein dancers land directly on their toes. It also involves lateral flexion and rotation of the trunk along with flexion of both knees while taking off. C, Arimandi (plie): bilateral hip-knee flexion in full squat position with hip external rotation and ankle dorsiflexion. The trunk is erect. D, Tandav (dance) pose involves unilateral weightbearing on right leg along with left hip hyperxtension and passive knee flexion and ankle plantar flexion. The trunk is required to be maintained in extension and lateral rotation. E, Nritta (dance) pose: the right knee bears the entire weight in flexed position with right hip in flexion and external rotation. F, Matsya (fish) pose: the right knee is in slight flexion and bears the entire weight. The trunk is bent forward and maintained in horizontal position in line with left lower limb. This requires good balance and control. performed by ordinary people, rather control, and regular practice.1 (12.4%), and the shoulder-neck com- than professional dancers, during Despite wide practice of several tra- plex (7.5%) as the most common sites harvesting, planting, marriages, and ditional Indian dance forms, extensive of musculoskeletal pain.4 Another religious holidays.1 Some of the popu- length of training, and performance study on Bharatnatyam dancers from lar folk dances that are performed life, Indian classical dancers’ health two different dance schools also re- across villages and cities are Bhangra, problems are rarely explored. An anal- ported the knee to be the body part Garba, Lavani, and Bihu. Irrespective ysis of musculoskeletal problems in fe- most prone to injury, followed by the of type of dance form, an exercise like male Bharatnatyam dancers reported foot, ankle, hip, and shoulder.2 dance requires much confidence, body knee (48.8%), low back (24%), ankle In addition to classical Indian Journal of Dance Medicine & Science • Volume 22, Number 2, 2018 69 dance, many Indians are now exposed as sport athletes to injury.2 Therefore, folk dance. The Western group exclu- to a variety of Western dance forms. the present study aimed to explore sively trained in international dance The most common dance forms prac- musculoskeletal disorders (pain and forms like hip hop, contemporary, ticed in Western countries include: injury) in Indian dancers, dancers’ salsa, free style, jazz, ballet, and so ballet, modern, tap, theatrical, folk, perception of the causes of injury, forth. The Mixed group practiced or flamenco, break-dancing, ballroom and their exercise routine. Lack of performed both Indian classical and dancing, and ice dancing.5-11 In the research, particularly in Indian clas- Western dance forms. United States, many surveys of the sical dancers’ health, acts as a barrier A questionnaire was designed to incidence and nature of injuries sus- to providing scientific recommenda- explore dance type, pain, and in- tained by ballet dancers have reported tions to prevent injuries and offer jury profiles, along with demographic pain in the lower extremity as the most appropriate treatment. A secondary data to provide a brief overview of common problem, followed by inju- aim of this study was to compare pain a dancer’s career. The questionnaire ries associated with the knee, ankle, tolerance levels between dancers and included: medical history, dance foot, and lower spine.5-7 A 5-year non-dancers. form or style, length of dance career, analysis at the Alvin Ailey American duration of dance training, presence Dance Center identified 58% of all Methods of supervised training, inclusion of dancers’ injuries as occurring in the After the study had received in- warm-up and cool-down exercises lower extremity, with 34% at the foot stitutional ethical clearance, 215 as a part of routine training, site of and ankle and 17% in the low back dancers across different age groups, present pain, past history of injury, and pelvis.8 Consistent with research dance forms, and training levels from and perceived causes of injuries. Pain findings in the United States, the dance institutes and academies were was defined as any pain present at back and lower limb were shown to recruited. Informed written consent the time of filling out the question- be particularly vulnerable to injury in was obtained from all participants. naire. Injury was defined as any past 141 dancers from seven professional The majority of dancers belonged to injury that caused dancers to miss a ballet and modern dance companies four well known dance institutes from dance class, rehearsal, or performance. in the United Kingdom.9 Mumbai and Mangalore (southern Content validity of the questionnaire Western Dancers reportedly have part of India). Almost one-third of was established with the assistance of a 90% lifetime injury incidence the dancers were university under- a panel of experts comprised of senior rate,11 with approximately 70% of all graduate physical therapy students physical therapy faculty members and dance-related injuries involving the who were trained in dance or who experienced dance instructors. All par- lower extremity.12 The best available performed dance as a recreational ticipants completed the questionnaire evidence suggests that musculoskel- activity. A small number were re- independently. etal injury is an important health cruited through passive snowballing Additional information on pain issue in dancers at all skill levels.13,14 from participating dancers. Inclusion tolerance levels in dancers was sought A high prevalence and incidence of criteria were a minimum 1 year of using the Pain Sensitivity Question- lower extremity and back injuries, formal dance training and the ability naire (PSQ), which is a valid self- with soft tissue and overuse injuries to comprehend questions in English. rating measure of pain perception.19 predominating, have been commonly There was no age restriction. Partici- Higher pain sensitivity scores indi- reported in dancers.5-14 However, it is pants were divided into Trained and cated lower levels of pain tolerance. not known whether similar pain and Recreational groups based on their Healthy age- and gender-matched injury characteristics occur in Indian training duration. The Trained group individuals without any dance train- dancers, irrespective of practicing was composed of dancers who had a ing and who did not perform dance traditional or Western dance styles. minimum of 5 to 7 years of formal even for recreational purposes formed Health problems of dancers are training along with a formal degree the control group for PSQ score com- worthy of attention for several rea- or qualification in dance; those in parison. Control group participants sons. First, as most professional danc- the Recreational group did not fulfill were recruited from the Physiotherapy ers begin dancing at the age of 5 or 6,15 these criteria. Institute. repetitive practice of movements that Dancers were also sub-divided into require extreme flexibility, strength, four groups based on their training in Data Analysis and endurance makes dancers prime different dance forms: Bharatnatyam, Data were analyzed using IBM SPSS candidates for overuse injuries, creat- Traditional, Western, and Mixed. Statistics software version 16 (IBM, ing the potential for a greater impact The Bharatnatyam group included Armonk, New York). Descriptive on their future health.16,17 For many dancers who were exclusively trained statistical analysis was performed for people, dance may not spring to mind and performed Bharatnatyam. The variables such as site, type and per- when thinking about sports, but the Traditional group included dancers ceived cause of pain, exercise routine, physical demands placed on dancers’ engaged in one or more of the other and training level. The PSQ score fol- bodies18 make them just as susceptible Indian classical dance forms or any lowed a normal distribution in both 70 Volume 22, Number 2, 2018 • Journal of Dance Medicine & Science groups. Therefore, the Student’s t-test Pain Profile Injury Profile was used to compare pain sensitiv- Among combined trained and recre- The back (42.5%) followed by the ity scores between dancers and non- ational groups of female dancers, 81% knee (28.3%) and ankle (18.63%) dancers, and an independent one-way reported pain. Among male danc- were the most frequently reported ANOVA was used to compare scores ers, all trained dancers (N = 3) and sites of past injury suffered by the between different dance forms. approximately 61% of recreational dancers. The prevalence was exactly Results dancers reported pain. The most the same for the pain question and common site of pain in both genders the injury question (Table 2). Danc- Table 1 presents demographic and across different dance forms and levels ers reported that stress (34.4%) was dance characteristics of the partici- of training was the back (42.5%), the major reason for sustaining these pants. Of 215 dancers, 69 (32%) were followed by the knee (28.3%) and dance-related musculoskeletal inju- males and 146 (68%) were females. ankle (18.63%; Tables 2 and 3). The ries, followed by overwork (24.7%), Average training duration in dance prevalence of pain was similar among tiredness (17.2%), and falls (13.5%). was 7.70 ± 3.67 years. Among males, trained and recreational groups of Suggestions reported by dancers to 3 (4.3%) were trained, whereas among female dancers, indicating that the help them prevent injury included females 48 (32.87%) were trained. level of training did not influence the warm-up exercises (43.7%), followed Descriptive analysis of dance forms occurrence of pain. by rest (31.6%), fitness programs revealed that 16% were purely Bharat- The mean PSQ score was higher (30%), strengthening exercises (26%), natyam dancers, 15% exclusively in dancers compared to non-dancers, and the presence of an on-site physical practiced traditional dance forms, but the difference was not significant therapist (23.7%). 45.5% were engaged in Western dance (p = 0.159). Among the dance groups, forms, and 24% practiced mixed Bharatnatyam dancers reported a Exercise Routine dance forms. A large number of senior lower mean PSQ score compared to The majority of dancers (43.30%) dancers refused to participate because traditional and Western dancers, but always performed warm-up exercises, they did not wish to answer questions again the difference was not signifi- whereas only 20% included stretching pertaining to pain. cant (p = 0.34; Table 4). as a part of their cool-down routine.

Table 1 Demographic Characteristics—Age and Dancing Duration Across Gender and Training Levels (Mean and Standard Deviation) Males (N = 69) Females (N = 146) Trained Group Recreational Group Trained Group Recreational Group (N = 3) (N = 66) (N = 48) (N = 98) Percentage 1.39% 30.69% 22.32% 45.58% Age (years) 22.66 ± 2.51 19.70 ± 7.72 23.06 ± 7.36 19.32 ± 4.97 Dancing Duration (years) 6 5.88 ± 3.06 13.32 ± 7.60 5.90 ± 4.48

Table 2 Distribution of Pain Among Dancers Based on Level of Training (N = 215) Males (N = 69) Females (N = 146) Trained Group Recreational Group Trained Group Recreational Group Site of Pain (N = 3) (N = 66) (N = 48) (N = 98) Back 100% 35.93% 43.75% 48% Knee NP 25.56% 33.33% 26% Ankle 33.33% 14.06% 22.91% 19% Shoulder 66.66% 9.37% 14.58% 16% Neck 33.33% 14.06% 20.83% 16% Hip NP NP 4.16% 7% Thigh NP NP 10.41% 2% Hand NP NP NP 2% Wrist NP NP NP 1% Presence of Pain 100% 61% 81% 81% NP indicates “No Pain.” Journal of Dance Medicine & Science • Volume 22, Number 2, 2018 71

Table 3 Distribution of Pain Among Dancers Practicing Different Dance likely that commonly reported causes Forms (N = 215) of back pain, such as poor core muscle Bharatnatyam Traditional Western Mixed strength, excessive anterior pelvic tilt, Site of Pain (N = 34) (N = 32) (N = 98) (N = 51) tightness of back extensor muscula- ture, and weak and long hamstring Back 38.2% 25.0% 48.5% 47.1% muscles23-26 were responsible for back Knee 20.6% 21.9% 24.7% 31.4% pain in Indian dancers. Ankle 26.5% 15.6% 16.5% 21.6% In the typical postures of most Shoulder 5.9% 6.2% 12.4% 29.4% dance forms, the low back can be hyperlordotic (see Fig. 1). Hyperlor- Neck 17.6% NP 16.5% 21.6% dosis often results from an attempt to Hip NP NP 6.2% 5.9% increase turnout at the hip by putting Thigh NP NP NP 9.8% the hip joint in a position where the capsular ligaments are loosened (hip Hand NP NP NP NP flexion, or anterior pelvic tilt), which Wrist NP NP NP NP allows the femur to rotate more in the NP indicates “No Pain.” hip socket. The resulting hyperlordosis elongates the abdominal muscles, Table 4 Pain Sensitivity Questionnaire Scores Between Dancers and making them prone to weakness, Non-Dancers Across Different Dance Forms (Mean and Standard whereas the erector spinae and hip Deviation) flexor muscles remain shortened.27 Such an imbalance in the lumbopelvic Group PSQ P-value segment caused by forced turnout Dancers (N = 215) 70.90 ± 27.56 0.159 at the hip is likely to reinforce an Non-Dancers (N = 200) 67.55 ± 19.56 exaggerated lumbar lordosis dur- 27 Dance Forms ing relaxed standing. Additionally, lordotic posture places more weight Bharatnatyam (N = 34) 63.68 ± 22.94 on the facets, which are not predomi- Traditional (N = 32) 70.08 ± 24.56 nantly weightbearing joints but are 0.344 Western (N = 98) 74.05 ± 29.34 sites of nociceptive tissue. Excessive narrowing of the intervertebral fora- Mixed (N = 51) 70.70 ± 27.84 men caused by approximation of the pedicles as a result of hyperlordosis Almost 60% of dancers participated forms of exercise, namely swimming, compresses nerve roots and their dural in other forms of exercise apart from yoga, and aerobics, apart from dance. sheaths, contributing to back pain.28 dance, the most common being swim- Dancers were better aware of the ben- It is known that in young danc- ming, yoga, and aerobics. efits of warm-up exercises compared ers mechanical low back pain could to cool-down exercises. represent a transient “overgrowth” Discussion It was observed that sites of present syndrome wherein the growth of The present study revealed that 73.5% pain and those of past injuries were bony elements outstrips ligaments of Indian dancers reported experi- similar. Possibly these dancers consid- and tendons during the adolescent encing musculoskeletal pain in their ered them to be the same construct. growth spurt29-31 resulting in a com- dancing careers. Irrespective of dance It is also likely that they did not seek bination of tight lumbodorsal fascia form, back pain was the most preva- any intervention for past injuries and and hamstrings posteriorly and weak lent followed by knee and ankle pain. continued to train with them, result- abdominal muscles anteriorly.23,32 Re- The level of training and gender did ing in aggravation of symptoms that peated stress on a dancer attempting not influence the prevalence of pain. ultimately presented as recurrence of to use his or her body the way it was Surprisingly, there was no difference pain. For the purposes of this discus- prior to the growth spurt could lead in pain tolerance between dancers and sion pain and injury will be considered to stress fractures.33 Considering that non-dancers. Back, knee, and ankle simultaneously. half the dancers in the present study were also the most common sites of As previously noted, back pain was were teenagers, poor pelvic strength past injury reported by dancers. They reported as the most prevalent site of and control could explain the com- attributed their injuries to varied fac- pain in both genders irrespective of mon complaint of low back pain. tors, such as stress, overwork, tired- dance form or level of training. Other Some of the common postures ness, falls, inadequate exercises, hard studies have reported similar findings in Bharatnatyam and other classical flooring, and inadequate diet. Most in professional dancers,10,13,20,21 but dance forms are highly demanding in dancers routinely participated in other not among amateur dancers.22 It is terms of muscle control and balance, 72 Volume 22, Number 2, 2018 • Journal of Dance Medicine & Science challenging the stability requirements common stretching exercises as a part One factor that may influence of the dancers and making them more of their routine dance practice. There- the development of overuse injury is vulnerable to back pain. Matsya (fish), fore, it is possible that dancers experi- the hypothesis that dancers have an Nritta (dance), Kurma (turtle), and ence tightness in biarticular muscles increased pain tolerance48 that allows tandava (see Fig. 1) are common poses like hamstrings and gastrocnemius, them to keep dancing despite pain.40 that are likely to result in an increased resulting in knee pain.4 Our hypothesis was that dancers risk of back pain due to the high veloc- Exploration of the dancers’ per- would report a high pain tolerance ity twisting and bending required.33 ception of common factors causing because dancing through pain and in- Knee pain was the second most dance-related musculoskeletal injuries jury is a traditional practice ingrained prevalent site of pain reported in revealed stress, overwork, tiredness, in a dancer’s mindset. Contrary to dancers across all dance forms. Several falls, inadequate physical exercise, what was expected, dancers had no factors could explain knee pain among hard flooring, improper diet, unsuit- difference in pain tolerance compared dancers. One would be the aramandi able stages, and cold environment as to non-dancers. Possibly the young position in Bharatnatyam (see Fig. 1), commonly suggested causative factors, age of the dancers along with a low which is similar to a demi-plié in bal- similar to those reported previously.39 average training duration would not let.2 A high incidence of chondroma- Most studies that report dancers’ sur- yet have allowed for maturation of the lacia patellae among ballet dancers is vey responses have emphasized that attitude required for tolerating pain. substantiated and known to be related dancers felt pressured to return to Another reason for the lack of dif- to the use of plié.34 Aramandi posture dance before injuries healed because ference may be that senior dancers has a closed chain knee flexion with of the belief that since they have in- refused to share information regarding hip abduction and external rotation vested a great deal of time in dance, dance-related pain, thus removing (see Fig. 1). Rhythmic stamping of the they must perform through injury.40 possible pain-tolerant individuals. The feet along with high impact jumping Dancing with biomechanical dysfunc- refusal to impart pain information re- (Bhramari, Fig. 1) in this posture is tion or muscle imbalance can develop flects the acculturated perceptions31,49 likely to strain the patellar tendon be- into serious problems that require that run deep and are likely present cause notable force is transmitted via discontinuance of dance activities, in most dance environments. Future the patella while taking off or landing thereby adding to dancers’ stress research should determine if sociocul- from a jump.35,36 levels.41 Associated factors could be tural perceptions could be influenced Secondly, classical dancers (both competition among peers,5 faulty food in such a way as to improve partici- Indian and Western) commonly as- habits, irregular sleep patterns,42-44 pation in rehabilitation. Ultimately, sume postures that involve forced frequent travel, and inadequate rest,45 changes in prevailing dance attitudes turnout at the knee resulting in over- making dancers more prone to mus- could result in long-term benefits to stretching of medial contractile and culoskeletal disorders.46 prevent chronic injury. non-contractile structures. This causes Although the importance of warm- There were a number of limitations weakening of the medial structures up and cool-down in general exercise to the study. Only dancers able to and subsequent increased activity of and sports is widely acknowledged, comprehend English were included. the lateral knee stabilizers, leading awareness of their importance among Although this may be perceived as to biomechanical imbalances of the Indian dancers is poor. Less than half a bias, in reality a large percentage patellofemoral joint. This could be of dancers in the present study (43%) of Indian dancers in major cities are the reason for patellofemoral joint performed warm-up exercises, and educated in English. Secondly, the rel- syndrome as has been commonly only 20% practiced cool-down in the atively short average training duration reported among Bharatnatyam danc- form of stretching. Despite the near of 7 years meant it was not possible to ers.32 majority of dancers regularly perform- explore injuries in dancers with longer Thirdly, short hamstring muscles ing warm-up exercise, musculoskeletal training duration, possibly resulting in may predispose the knee to pain. De- pain was widely reported. This could under reporting of pain and injury. As creased hamstring flexibility is known imply that it is not lack of elasticity mentioned previously, older dancers to be a risk factor for the development that leads to musculotendinous injury, with intense grooming in the culture of patellar tendinopathy and patel- but rather injury occurs when the ten- of a dance form refused to participate lofemoral pain.37,38 Lack of flexibility sion demands of the muscle exceed the in the survey; thus, the influence of may cause early muscle fatigue and tension generating capability of the the “no pain, no gain” concept could alter normal mechanics of movement, muscle.47 Almost 60% of our dancers not be explored in depth. Thirdly, thus predisposing the dancer to pain. participated in other forms of exercise dancers were trained in multiple dance Additionally, muscle tightness may apart from dance, most commonly forms; hence the pain and injury pro- lead to overuse injury or even pro- swimming, yoga, and aerobics. This file exclusive to a single dance form duce early wear and tear changes in may have had an indeterminate effect (apart from Bharatnatyam) could not weightbearing joints. Only 20% of on their muscle tension-strength bal- be explored. Fourthly, the miniscule dancers in the present study practiced ance. sampling of trained male dancers (N = Journal of Dance Medicine & Science • Volume 22, Number 2, 2018 73

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