A cross-sectional study of elite adult Irish dancers: biopsychosocial traits, pain, and injury. (2024)

Irish Dancing (ID) is a highly athletic and technically demandingart form practiced by growing numbers of people internationally. (1) Thegenesis of elite adult ID can be attributed to renowned internationalproductions, such as "Riverdance," which have led to theemergence of the professional Irish dancer. Subsequently, for thecompetitive Irish dancer increasingly challenging choreography isplacing unprecedented demands on the physical and aesthetic resources ofthe performer. ID predisposes the dancer to preferentially andconsistently select one lower limb for weightbearing over the other. (2)Biomechanical modeling has estimated that certain ID steps generatecontact forces of up to 14 times body weight at the ankle joint. (3)Research has found that significant plantar forces are sustained by thedancer's foot, particularly around the vulnerable forefoot region.(1) A retrospective electronic survey of 178 professional Irish dancersreported an injury rate of 76.6%, with lower limb injuries accountingfor 74.7% of the total. (4) The main factors perceived to contribute toinjury in that study were accidents, fatigue and overwork, repetitivemovements, and unsuitable floor surfaces. (4) Another study of youngcompetitive Irish dancers found that lower limb injuries, especiallystress fractures and soft tissue pathologies in the foot and ankle, weremost common. (5) That research indicated that foregoing a warm-up orcool-down, not using split-shoe sneakers for training, and performing athigher competitive levels were potentially linked to increased injuryfrequency. (5)

Among elite populations of participants involved in heterogeneousdance forms, studies have identified many similar risk factors forinjury, with comparable injury rates being reported, particularly inballet and contemporary dance. (6) Psychological difficulties, such asstress, anxiety, and work dissatisfaction, which have also beendesignated as risk factors for injury in dancers, (6) have yet to beinvestigated in ID. The significant level of injury sustained acrossmultiple dance traditions prompted the International Association forDance Medicine and Science (IADMS) to provide guidelines forstandardized, evidence-based injury surveillance and screening. (7)These guidelines cite the dual aim of distinguishing dancers at risk forinjury and collecting healthy baseline data on specific dancerpopulations. Substantial research in ballet and modern dance hasproduced robust physical and psychosocial dancer profiles in both eliteand amateur cohorts. (7) No such profiles have been developed in ID todate.

There is a limited but growing body of literature examining painand injury in the ID cohort. Much of it, however, relies on clinic data,such as retrospective medical charts, which could not determine overallrates or underlying causes of injury. (8,9) Factors includingpsychological health (10) and physical attributes, (11) both of whichhave been shown to have impact on rates of injury in other forms ofdance, have been poorly investigated in ID. In ballet, negative lifestressors, such as worry and lack of confidence in one's danceability, are shown to increase a performer's susceptibility toinjury. (12) Paradoxically, appropriate coping strategies (13) andstrong social support (14) have been found to provide a buffer againstlost time due to injury. Low levels of muscle strength and power, (15)in addition to poor cardiovascular fitness and endurance, (16) have alsobeen found to be predictive of injury in dance. Joint hypermobilitysyndrome places dancers at a greater risk for pain and injury than theirnon-dancer peers with generalized joint hypermobility (GJH), (17) andrecent research suggests a trend linking rearfoot pronation and lowerlimb injury in dancers. (18)

This study expands upon previous research by examining unexploredbiopsychosocial features of Irish dancers. Its objectives, which formpart of a larger prospective investigation into risk factors for painand injury in ID, were to collect baseline data on the biopsychosocialcharacteristics of elite adult Irish dancers and to investigate anyrelationships between these characteristics and the incidence ofmusculoskeletal pain and injury.

Methods

Subjects

The study cohort was composed of professional Irish dancers, elitecompetitive Irish dancers, and students in full-time universityeducation studying ID. Subjects of both sexes, aged 18 years or older,were invited to participate. Recruitment was facilitated through thecontacts of the first investigator because of her background as an IDteacher and former professional Irish dancer. Ultimately, dancers from12 countries, including Ireland, were recruited for the study. Writteninformed consent was obtained from all subjects, and ethical approvalwas granted by the research ethics committee of the local university.

One hundred and four subjects completed a questionnaire, of whom 84also underwent a physical assessment using portable equipment atmultiple locations in Ireland. Of the 104 dancers, 36 (34.6%) wereprofessionals, 28 (26.9%) were students, and the remaining 40 (38.5%)were competitive dancers. Those involved at more than one level, forinstance both a competitive and a student dancer, were instructed tolist the category representing the greater proportion of time spentdancing. The physical screening was completed by 23 professionals(27.4%), 28 students (33.3%), and 33 competitive dancers (39.3%). Themean ages of the 74 (71.2%) female and 30 (28.8%) male dancers were 21.2([+ or -] 3.1) years and 23.0 ([+ or -] 4.0) years, respectively. Thethree groups were significantly different in terms of age (p <0.001), male to female composition (p [less than or equal to] 0.002),and years of dancing experience (p < 0.001). These demographics aresummarized in Table 1 (the 1:1 male: female ratio in the professionalgroup reflects the greater number of male dancers requiredproportionately in performance dancing relative to males at the otherlevels of ID).

Data Collection: Questionnaire Dance and Activity Levels

Data collected included hours of practice, frequency of warm-up andcool-down, footwear worn, type of stage or practice floor normallyavailable, and the type and frequency of any cross-training undertaken.Warmup was divided into those who did or did not always complete awarm-up.

Physical and Psychological Health

Subjects provided baseline demographic data, details of any generalsubjective health complaints, (19) any medication taken, smoking status,and levels of drug or alcohol consumption. Any psychological issuesexperienced by subjects in the preceding month were selected from a listof common psychological ailments. (20) These included episodes ofgeneral anxiety, tension with people, performance anxiety, depression,externally mediated stress (such as home-sickness), overuse of drugs oralcohol, disordered eating, lack of self-confidence, difficultiesconcentrating during performance and rehearsal, and sleep problems.Female subjects provided data on the onset and frequency of their mensesand recorded any pregnancy in the previous 12 months. Sleep quality andquantity in the prior month was recorded. (21) A selection of valid andreliable psychometric tools were used to examine a number ofpsychosocial issues. These included the catastrophizing subscale of theCoping Strategies Questionnaire (CSQ), which assesses the frequency ofpatients' use of pain coping strategies. (22) Three subscales ofthe Profile of Moods State (POMS), (23) namely tension-anxiety,anger-hostility, and confusion-bewilderment, were completed, as were thestress subscale of the Depression Anxiety Stress Scale (24) and theAthletic Coping Skills Inventory-28 (ACSI-28), (25) which examinescoping and self-efficacy under seven domains. The risk of eatingdisorders was analyzed using the Sick, Control, One stone, Fat, Food(SCOFF) questionnaire. (26)

Pain and Injury

Subjects were asked to report any pains or injuries that had causedabsence from dancing for more than 1 week over the previous 5 years.(27) Using the Standardized Nordic Questionnaire (SNQ), (28) subjectsidentified any body parts where they had experienced physicaldifficulties over the previous year. "Difficulty" was definedas any aches, pains, discomfort, numbness or tingling that had affectedtheir normal activity or changed their daily routine for more than 1day. Data for the most troublesome body area, the perceived cause ofinjury, related diagnosis if known, and number of days of performanceand rehearsal consequently missed over the previous 5 years werecollected. Subjects were asked how often they danced in pain, how oftenthey experienced pain generally, and how bothersome that pain had beenover the previous month. (29) They were also asked to specify if any ofa range of psychological difficulties were present at the time of theirmost severe injury. (20) Under a "time-loss" description ofinjury, minor injuries were defined as requiring up to 7 days toresolve, moderate injuries between 8 and 21 days, with severe injuriestaking longer than 21 days to resolution. (27)

Data Collection: Physical Screening

Based on IADMS recommendations, (7) with amendments reflecting thespecificities of ID, screening tests were performed by qualifiedphysiotherapists, always in the same order (Table 2). To minimize bias,a coin toss decided which lower limb would be assessed first.Consecutive subjects commenced testing on the opposite leg from theprevious subject. In all screening elements where active performance wasrequired, this was demonstrated and subjects were allowed a consistent,predetermined amount of practice for familiarization. All screeningelements were conducted in the same order for each participant to ensureuniformity.

Pain and Injury Group Stratification

Subjects were stratified into two groups based on the severity andimpact of their pain and injury. Two criteria were used to discriminatebetween these groups: 1. the number of performance and rehearsal daysthe dancer missed due to pain or injury and 2. how severe their painwas. Pain severity was dichotomized into severe and less severecategories based on existing literature, (29,39,40) with dancers whoexperienced pain when dancing often or always, who reported everydaypain at least several times a week, or described their pain as at leastmoderately bothersome classified as "severe." (29,39,40)Participants were identified as significantly injured (SI) if theymissed at least 1 day from performance or rehearsal due to their injuryAND were categorized as "severe" by at least two of the threepain criteria. Those who did not meet the above criteria were classifiedas not significantly injured (NSI).

Statistical Analyses

Descriptive statistics are reported using the mean and standarddeviation (SD) for symmetrically distributed variables, median(interquartile range) for skewed variables, and percentage forcategorical variables. The distributions of all numeric variables wereassessed for skewedness using formal tests and through visual inspectionof histograms. Differences in demographic, psychosocial, and physicalvariables between SI and NSI subjects were tested using the independentsamples t-test, the Mann-Whitney U test for skewed variables, and the[chi square] test of independence for categorical variables. Asignificance level of 0.05 was used throughout the between groupanalyses. A classification tree, using the Chi-squared AutomaticInteraction Detector (CHAID) method, was constructed to distinguish riskfactors jointly associated with being in the SI group from thosevariables found to be significant in the between group analyses. TheCHAID algorithm assessed the statistical significance of the bivariateassociation between each variable and the dichotomous outcomemeasure--SI. The algorithm identified the variable with the moststatistically significant value of [chi square], and the sample waspartitioned according to the values of that variable. The procedure wasthen repeated for each of the sample partitions, creating a treestructure with parent and child nodes. The minimum sample sizes forparent and child nodes were set at 10 and 5, respectively. Thepercentage of correctly classified cases in both the SI and NSI groupswas used as a measure of the success of the selected tree indiscriminating between the groups, and the 0.05 significance level wasused as a necessary condition for variable selection. A logisticregression model was fitted to the data to determine the variablesindependently associated with the SI group. A two-step approach wastaken to fit this model. First, the variables found to be significant inthe between group analyses were considered as potential explanatoryvariables. Then, the model was fitted using the forward selection, andthe model fit was assessed using the likelihood ratio test. Statisticalanalyses were performed using IBM SPSS[R] Statistics 20 (Armonk, NewYork, USA).

Results

Baseline Data

Sex specific baseline physical data generated by the physicalscreening protocol and self-reported psychosocial data are presented inTables 3 and 4, respectively.

Pain and Injury Data

Pain data were dichotomized into severe and less severe categoriesas described previously. (29,39,40) When pain severity was considered inconjunction with days lost to injury, 33 (31.7%) subjects wereclassified as SI, with the remaining 71 (68.3%) subjects falling intothe NSI category. Twenty-eight (37.8%) female and five (16.7%) malesubjects met the criteria for the SI category. The mean number ofinjuries sustained to all body parts over the previous 5 years was 1.49(SD 1.2), with a mean of 126.1(SD 193.3) days lost annually to injuryover that period. The mean number of days lost to injury over theprevious 5-year period due to the most troublesome body area was 82.5(SD 139.5) days. Under the aforementioned "time-loss"definition of injury, (27) 24 (23.1%) subjects were uninjured during theprevious 5 years. The remaining 80 (76.9%) subjects incurred a total of153 injuries over that period; 24 (15.7%) were minor, 42 (27.4%) weremoderate, and the remaining 87 (56.9%) were severe. (41)

Three hundred and thirty-seven complaints of troublesome bodilyareas over the previous 12 months were reported. One hundred and onesubjects identified which body part had proven to be most troublesome inthe previous year. Three (3%) subjects reported no troublesome bodyregion in the previous year. Foot and ankle injuries were most common,with injuries to the knee, calf or shin, and lower back also prevalent(Table 5). Subjects were most likely to be unaware of their diagnosis,with muscle strain and joint sprain the most commonly reported diagnosesby subjects aware of the nature of their complaint (Table 5).

Subjects reported a total of 130 perceived causes of pain andinjury. Overuse (30%), accident (14.6%), and inadequate warm-up andstretching (12.3%) were the leading causes of injury. Other perceivedintrinsic causes of pain and injury cited included muscle weakness(10.8%), generalized fatigue (6.2%), and lapses in concentration (2.3%).Perceived extrinsic causes included unsuitable floor surfaces (7.7%),footwear (3.8%), and difficulties with choreography (2.3%).

Factors Significantly Associated with Injury

There were no significant differences in any of the physicalscreening tests between the SI and NSI groups. Factors significantlyassociated with SI group membership were female sex, higher number ofsubjective health complaints and psychological health complaints, lowermood (tension-anxiety and confusion-bewilderment subscales), highercatastrophizing, and reported failure to complete a warm-up (Table 6).Analysis between subjects according to dance status (professional,competitive, and student) was not performed, as groups weresignificantly different in their demographic composition and of smallsize. The CHAID classification tree (Fig. 1) partitioned the sample onthe variable warm-up ([chi square](1) = 7.5, p = 0.025), followed by sex(female) in the warm-up (not always) group ([chi square] (1) = 4.038, p= 0.044), and catastrophizing in the warm-up (always) group ([chisquare](1) = 18.932, p < 0.001). Female dancers who did not alwayswarm-up were identified as the subgroup with highest SI percentage(52.6%). The tree correctly classified 78.8% of the SI group and 71.8%of the NSI group. A classification tree that included the number ofsubjective health complaints was explored, but this tree was found tohave poor classification results for the SI group, classifying only 46%correctly. The variables associated with lower mood and psychologicalhealth complaints were not found to be significant in the CHAIDanalysis. The results of the exploratory logistic regression model areshown in Table 7. This model found warm-up (not always) (OR = 2.69, 95%CI: 1.05, 6.92), high number of subjective health complaints (OR = 1.21,95% CI: 1.04, 1.40), and female sex (OR = 3.12, 95% CI: 0.98, 9.94) tobe associated with being in the SI group. The Nagelkerke pseudo[R.sup.2] value for the model was 0.202.

Discussion

This study has found that musculoskeletal pain and injury isextensive in elite adult ID. The lower limb, in particular the foot andankle, is most commonly affected, with dancers frequently being unawareof their diagnoses. Female sex, a high number of subjective general andpsychological health complaints, low mood, higher catastrophizing, and areported failure always to warm-up were significantly associated withmusculoskeletal pain and injury in this cohort. Perceived causes ofinjury identified by the subjects included overuse, fatigue andweakness, inappropriate footwear, stages or floors, and challengingchoreography.

Incidence of Pain and Injury

The findings of this study regarding the epidemiology and incidenceof pain and injury in ID correlate well with reports from other forms ofelite dance. (42) The reported injury rate of 76.9% in the current studyis similar to that recorded previously in a cohort of professional Irishdancers (76.6%). (4) The mean career injury rate of 2.25 injuriesrecorded previously in professional Irish dancers (4) exceeds the 5 yearinjury rate of 1.49 injuries reported in the current cohort. This ispossibly due to the younger age profile and comparatively shortercareers of the current study group. As in other genres, injuries to thelower limb, particularly the foot and ankle, were most prevalent. (43)In this study, where a diagnosis was known, dancers were more likely tosustain soft tissue injuries to muscle or tendon as opposed to bonyinsults. This is also reflective of findings across many forms of elitedance. (44)

Physical Factors

Although none of the physical traits investigated in this studywere found to be significantly associated with injury, comparison withother dancing and non-dancing populations merits some discussion.According to the World Health Organization classification of body massindex (BMI), the majority of subjects in this study had healthy BMIvalues and waist:hip ratios. (45) A mean waist:hip ratio of 0.73 haspreviously been reported in a cohort of 40 pre-professional dancers (38female, 2 male), which compares closely with the female subjects in thisstudy (0.76). (46) Mean BMI values in this study were greater forfemales than males, which contrasts with a number of studies in eliteballet and contemporary dance. A study of 41 Norwegian professionalballet dancers reported BMI values of 21.9 and 18.6 for male and femaledancers, respectively. (41) In a cohort of 184 professional contemporarydancers, the average BMI for males was 23.6 and 20.5 for females. (47)BMI values for female Irish dancers exceed those of both their balletand contemporary peers. This may be explained by the fact that femaleIrish dancers tend to have large muscular lower limbs. Additionally, asfemale Irish dancers are not lifted, a low BMI is perhaps less importantthan in ballet or contemporary dance.

Subjects exhibited approximately 28[degrees] to 34[degrees] morehip flexion than values for age matched non-dancers. (48) Much of theresearch in elite ballet focuses on internal and external range ofmotion (ROM) of the hip, based on the importance of turnout in thatgenre. (49) However, one study measuring hamstring flexibility in amanner similar to this study reported a comparable mean of 96.0[degrees](SD 9.8[degrees]) in a mixed cohort of late adolescent dancers. (50)Values for passive dorsiflexion in the non-dancing population varybetween 5[degrees] and 10[degrees], (51) approximately 5[degrees] lessthan that demonstrated by the subjects in the current study. Limitedankle dorsiflexion has been found to increase vulnerability to injury inpediatric and sporting populations. (52,53) However, a link betweenankle ROM and injury has not been supported empirically in dance. (54)

Excessive rearfoot pronation has been linked to injury inpre-professional ballet dancers (55); it is implicated in injuries upthe kinetic chain from the foot to the lower back. (56) However,subjects in the current study fell within normal values for naviculardrop, which is estimated to be between 6 and 9 mm. (57) Recent researchcomparing posterior-medial reach and balance in female modern dancersversus active non-dancers recorded mean values of 92.6% (SD 5.6%) versus87.0% (SD 6.4%) and 93.9% (SD 6.3%) versus 87.9% (SD 6.3%) for right andleft lower limbs, respectively. (58) The current study reveals thataverage posterior-medial reach in Irish dancers lies somewhere withinthis range. It is unclear whether repeating a balance test in other axesof the SEBT would affect these findings, given the sagittal plane inwhich Irish dancers primarily perform. GJH was more prevalent amongfemale subjects than male subjects in this study and at 22% was inexcess of the 6% to 17% reported in the general population, as would beexpected. (59) Depending on the criteria used to assess for GJH, ratesof up to 44% have been identified in dancers and are particularlyprevalent among student dancers. (59) The female mean Beighton score inthis study of 2.6/9 compares to 4.6/9 in contemporary dance (17) and4.4/9 in a mixed cohort of dancers and gymnasts of varying levels ofaccomplishment. (60)

Pain pressure thresholds (PPTs) for elite dancers in any genre areunavailable to the best of our knowledge. Normative values in healthynon-dancers are also unavailable due to the wide variability ofindividual results, such as those evidenced in this study. (61)Empirically, in healthy subjects, males have been found to have higherPPTs than females. (62) Such was also the case in this study.

Professional dancers have previously been reported to demonstratefitness levels similar to age-matched healthy sedentary individuals.(63) The SPAR-Q test used in this study is designed to assess lower limbagility and endurance. Originally designed for soccer and basketballplayers, it mimics the highly explosive and relatively brief duration ofIrish dances. (35) The mean percentage of HRmax achieved by subjects inthis study indicated that they were performing in a maximal, anaerobiczone (64) closely simulating the anaerobic, short burst nature of Irishdance. Subjects dropped back into an aerobic zone within 30 s, but noinformation was collected on time required to recover to resting heartrate. This information would provide greater clarity on thecardiovascular fitness of this cohort and is an area for further study.

As in ballet, males recorded higher vertical jump heights thanfemales. (65) Double footed vertical leap values for elite male balletdancers have varied from 50.5 cm in principal dancers to 56.0 cm infirst artists. (65) The mean value of 41.7 cm achieved by male subjectsin this study reflects the differing techniques in ID, where the leapsare of a smaller magnitude and more power is expended in grounded rhythmand syncopation. Values for elite female ballet dancers ranging from33.0 cm in principal dancers to 39.0 cm in first artists compare moreclosely with the subjects in this study (34.8 cm). (65) As the majorityof leaps in ID involve a single leg take off, a protocol reflecting thisstrategy would have been more appropriate and is a limitation of thestudy.

Factors Associated with Pain and Injury

In this study, several statistically significant and inter-relatedbiopsychosocial factors were found to be significantly associated withbeing SI. These factors, listed above, have previously been associatedwith greater pain and injury in many mainstream populations. AnAustralian study of over 17,500 subjects found a significant correlationbetween levels of chronic pain and female sex, socioeconomicdisadvantage, high levels of psychological distress, and poor self-ratedhealth. In ballet an increased risk of injury has been positivelycorrelated with high stress and low mood, but this can be amelioratedwith good social support. (66) Sociological studies have indicated howthe culture in elite dance and related risk-taking behaviors may affectthe physical and emotional health of dancers. (67) Research has shownthat dancers display higher levels of distress than the generalpopulation when suffering a musculoskeletal injury, (68) and also thatstress and coping strategies impact injury frequency and duration inelite and student dancers. (6,69) A distinction has been drawn by elitedancers between performance pain and injury pain, with the formerdescribed as acute, of short duration, and under the voluntary controlof the dancer. (70) Comparatively, injury pain is a more negativesensation that can precipitate reduced self-confidence. Additionally,catastrophizing has been found to be prevalent in ballet when the dancerinterprets pain as potentially threatening. (70)

In this study, being female was significantly associated with beingin the SI group. This is in contrast to previous research in a cohort ofprofessional Irish dancers, where the sex of the dancers was notpredictive of a higher or lower rate of injury. (4) The reasons for thisare unclear, but may possibly be explained by the greater heterogeneityof dancer experience and occupation in the current study. In comparisonto males, females in the general population have been found to havelower pain thresholds and pain tolerance, experience greater painintensity, and have different analgesic sensitivity. (71-73)Additionally, a number of studies have found that female dancers suffera higher rate of injury than their male counterparts. (74,75) Numerousfactors, including the female athlete triad, may contribute to thisconclusion. (76) Although it was not possible to measure bone density inthis study, neither of the other two elements of the triad, namelyamenorrhea and disordered eating, were found to be significantlyassociated with being SI. Although not significantly different betweenthe SI and NSI groups, the mean pain pressure threshold among males(40.23 lbs) significantly exceeded that of females (32.27 lbs) in thisstudy (Table 3). This could support the previously cited findings thatsex-regulated factors, including tissue sensitivity and pain threshold,may have an important role to play in vulnerability to injury.

A reported failure to warm-up consistently was also significantlylinked to becoming SI. A 2009 study of injury in hip-hop dancers foundthat failure to perform a warm- up was identified as the primary causeof injury by 62% of participants. (77) Among aerobic dance instructors areduced injury rate was attributed to an appropriate length of warmup.(78) In a previous study of injury in professional Irish dancers, a lackof warm-up was not found to be associated with injury. (4) However, as98.8% of that cohort consistently performed a warm-up, this finding isunsurprising. Similarly, in many fields of elite dance, warm-up is anintrinsic and often mandatory part of preparing to rehearse or performand would not be omitted. It is to amateur and less-experienced cohortsthat the impact of dispensing with a warm-up may be more applicable.

The significance of the non-physical components of wellbeingundoubtedly re-enforces the necessity of adding demographic, lifestyle,and psychosocial components to any screening protocol. Mindfulnesstools, including relaxation, cognitive restructuring, and imagerytraining to improve mental preparedness, have been found to reduceinjury rates and catastrophizing in sport. (79) Such strategies mayprove equally valuable in dance for ameliorating the risk of injury andpain in at-risk performers, but this hypothesis requires further study.Undeniably, all available research suggests a high rate of injury in ID,with the current study providing an initial indication of the pivotalinfluence of general and psychosocial health. ID organizations andteachers would be well advised to replicate the calls made by othergenres of dance, the performing arts, and sport for psychosocialscreening. (79-81)

Limitations

Firstly, as this retrospective study required subjects to recallevents over a 5-year period, errors of omission and recall areinevitable, and the frequency of minor injuries is most likelyunderstated. However, the main function of the retrospective data issimply to allocate subjects to SI and NSI groups. A prospective study ofinjury and pain is currently underway to address this issue. Secondly,due to the method of recruitment, it is impossible to calculate anaccurate response rate, which may be indicative of volunteer bias and astudy cohort that is potentially non-representative of the wider eliteIrish dance population. Thirdly, some elements of the functionalscreening were basic and generic and would benefit from greaterspecificity to ID. Fourthly, anonymity of the questionnaire data couldhave allowed for more candid responses, particularly regarding drug andalcohol use and food consumption. Finally, greater detail of the typeand duration of warm-up and cool-down routines would have beenbeneficial.

Conclusions

Despite the growing popularity of ID, limited data are available onthe physical and psychosocial characteristics of elite adult Irishdancers and the association, if any, between these features and levelsof pain and injury. This study found that there is a significant levelof pain and injury in ID, with the foot and ankle most often affected.These findings are largely consistent with the current literature inother forms of elite dance. SI dancers were defined based on a time-lossdefinition of injury and the severity and impact of pain experienced.Statistically significant factors related to SI group membership werefemale sex, poor subjective and psychosocial health, a high level ofcatastrophizing, and a reported failure always to perform a warm-upprior to dancing. This biopsychosocial melange of factors represents asignificant challenge to dancers and those healthcare providers whooversee the management of their pain and injury. Screening programsshould consider demographic, lifestyle, and psychosocial factors, aswell as the physical traits that affect performance. A prospective studypresently being undertaken by the current investigators will elaborateon these findings.

Caption: Figure 1 Classification tree allocating SignificantlyInjured (SI) and Not Significantly Injured (NSI) group members.

http://dx.doi.Org/10.12678/1089-313X.19.1.31

Acknowledgments

The investigators would like to thank Sean McAuliffe and MaryO'Keeffe, physiotherapists, all the dancers who participated inthis study, the Irish World Academy of Music and Dance at the Universityof Limerick, Lord of the Dance and the Marie Duffy Foundation, andmanagement of the 2012 "Take the Floor" production. Inaddition, the authors are grateful to the Faculty of Education andHealth Sciences at the University of Limerick and the CharteredPhysiotherapists in Musculoskeletal Therapy for their financial supportof this study.

References

(1.) Tregouet P, Merland F. The effects of different shoes onplantar forces in Irish dance. J Dance Med Sci. 2013;17(1):41-6.

(2.) Cromie S, Greenwood JG, McCullagh JF. Does Irish-dancetraining influence lower-limb asymmetry? Laterality. 2007Nov;12(6):500-6.

(3.) Shippen JM, May B. Calculation of muscle loading and jointcontact forces during the rock step in Irish dance. J Dance Med Sci.2010;14(1):11-8.

(4.) Cahalan R, O'Sullivan K. Injury in professional Irishdancers. J Dance Med Sci. 2013 Dec;17(4):150-8.

(5.) Cahalan R, O'Sullivan K. Musculoskeletal pain and injuryin Irish dancing: a systematic review. Physiother Pract Res.2013;34(2):83-92.

(6.) Jacobs CL, Hincapie CA, Cassidy JD. Musculoskeletal injuriesand pain in dancers: a systematic review update. J Dance Med Sci.2012;16(2):74-84.

(7.) Liederbach M, Hagins M, Gamboa JM, Welsh TM. Assessing andreporting dancer capacities, risk factors, and injuries: recommendationsfrom the IADMS Standard Measures Consensus Initiative. J Dance Med Sci.2012;16(4):139-53.

(8.) Stein CJ, Tyson KD, Johnson VM, et al. Injuries in Irishdance. J Dance Med Sci. 2013 Dec;17(4):159-64.

(9.) Noon M, Hoch AZ, McNamara L, Schimke J. Injury patterns infemale Irish dancers. PM R. 2010 Nov;2(11):1030-4.

(10.) Cumming J, Duda JL. Profiles of perfectionism, body-relatedconcerns, and indicators of psychological health in vocational dancestudents: an investigation of the 2x2 model of perfectionism. PsycholSport Exerc. 2012;13(6):729-38.

(11.) Russell JA. Preventing dance injuries: current perspectives.Open Access J Sports Med. 2013 Sep 30;4:199-210.

(12.) Noh YE, Morris T, Andersen MB. Psychosocial factors andballet injuries. Int Rev Sport Exerc Psychol. 2005;3(1):79-90.

(13.) Noh Y-E, Morris T, Andersen MB. Psychological interventionprograms for reduction of injury in ballet dancers. Res Sports Med. 2007JanMar;15(1):13-32.

(14.) Hamilton LH, Hamilton WG, Meltzer JD, et al. Personality,stress, and injuries in professional ballet dancers. Am J Sports Med.1989 Mar-Apr;17(2):263-7.

(15.) Koutedakis Y, Stavropoulos-Kalinoglou A, Metsios G. Thesignificance of muscular strength in dance. J Dance Med Sci.2005;9(1):29-34.

(16.) Angioi M, Metsios GS, Koutedakis Y, et al. Physical fitnessand severity of injuries in contemporary dance. Med Probl Perform Art.2009;24(1):26-9.

(17.) Ruemper A, Watkins K. correlations between general jointhypermobility and joint hypermobility syndrome and injury incontemporary dance students. J Dance Med Sci. 2012;16(4):161-6.

(18.) Cimelli SN, Curran SA. Influence of turnout on foot postureand its relationship to overuse musculoskeletal injury in professionalcontemporary dancers: a preliminary investigation. J Am Podiatr MedAssoc. 2012;102(1):25-33.

(19.) Tschudi-Madsen H, Kjeldsberg M, Natvig B, et al. A strongassociation between non-musculoskeletal symptoms and musculoskeletalpain symptoms: results from a population study. BMC MusculoskeletDisord. 2011 Dec 18;12:285.

(20.) Brinson P, Dick F. Fit to dance: The Report of the NationalInquiry into Dancer' Health and Injury. London: Calouste GulbenkianFoundation, 1996.

(21.) Auvinen JP, Tammelin TH, Taimela SP, et al. Is insufficientquantity and quality of sleep a risk factor for neck, shoulder and lowback pain? A longitudinal study among adolescents. Eur Spine J. 2010Apr;19(4):641-9.

(22.) Rosenstiel AK, Keefe FJ. The use of coping strategies inchronic low back pain patients: relationship to patient characteristicsand current adjustment. Pain. 1983 Sep;17(1):33-44.

(23.) McNair D, Lorr M, Droppleman L. Profile of Mood State Manual.San Diego: Educational and Industrial Testing Service, 1971.

(24.) Lovibond PF, Lovibond SH. The structure of negative emotionalstates: Comparison of the Depression Anxiety Stress Scales (DASS) withthe Beck Depression and Anxiety Inventories. Behav Res Ther. 1995Mar;33(3):335-43.

(25.) Smith RE, Schutz RW, Smoll FL, Ptacek J. Development andvalidation of a multidimensional measure of sport-specific psychologicalskills: The Athletic Coping Skills Inventory-28. J Sport Exerc Psychol.1995;17:379-98.

(26.) Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire:assessment of a new screening tool for eating disorders. BMJ. 1999Dec;319(7223):1467-8.

(27.) Van Mechelen W, Hlobil H, Kemper H. Incidence, severity,aetiology and prevention of sports injuries. A review of concepts.Sports Med. 1992 Aug;14(2):82-99.

(28.) Dickinson C, Campion K, Foster A, et al. Questionnairedevelopment: an examination of the Nordic Musculoskeletal questionnaire.Appl Ergon. 1992 Jun;23(3):197-201.

(29.) Dunn KM, Croft PR. Classification of low back pain in primarycare: using "bothersomeness" to identify the most severecases. Spine (Phila Pa 1976). 2005 Aug 15;30(16):1887-92.

(30.) Ljung T, Holm G, Friberg P, et al. The activity of thehypothalamicpituitary-adrenal axis and the sympathetic nervous system inrelation to waist/hip circumference ratio in men. Obes Rese. 2000Oct;8(7):48795.

(31.) Charlesworth SJ, Johansen SM. Navicular Drop Test: User Guideand Manual. Available from: kennisbank. hva.nl/document/225653. AccessedOctober 11, 2013.

(32.) Hertel J, Braham RA, Hale SA, Ol msted-Kramer LC. Simplifyingthe star excursion balance test: analyses of subjects with and withoutchronic ankle instability. J Orthop Sports Phys Trier. 2006Mar;36(3):131-7.

(33.) Gribble PA, Hertel J. Considerations for normalizing measuresof the Star Excursion Balance Test. Meas Phys Educ Exerc Sci.2003;7(2):89-100.

(34.) Beighton PH, Grahame R, Bird H. Hypermobility of Joints (vol4). Cape-town, South Africa: Springer, 2012.

(35.) Topend Sports. 30 Second Endurance Jump. Available from: www.topendsports.com/testing/tests/ endurance-jump-30sec.htm. AccessedNovember 10, 2013.

(36.) Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heartrate revisited. J Am Coll Cardiol. 2001 Jan;37(1):153-6.

(37.) Cook G. Athletic Body in Balance. Champaign, IL: HumanKinetics, 2003.

(38.) Wikstrom EA, Tillman MD, Chmielewski TL, et al. Dynamicpostural stability deficits in subjects with self-reported ankleinstability. Med Sci Sports Exerc. 2007 Mar;39(3):397-402.

(39.) Shega JW, Ersek M, Herr K, et al. The multidimensionalexperience of noncancer pain: does cognitive status matter? Pain Med.2010 Nov;11(11):1680-7.

(40.) Damush TM, Wu J, Bair MJ, et al. Self-management practicesamong primary care patients with musculoskeletal pain and depression. JBehav Med. 2008 Aug;31(4):301-7.

(41.) Byhring S, B0 K. Musculoskeletal injuries in the NorwegianNational Ballet: a prospective cohort study. Scand J Med Sci Sports.2002 Dec;12(6):365-70.

(42.) Thomas H, Tarr J. Dancers' perceptions of pain andinjury: positive and negative effects. J Dance Med Sci. 2009;13(2):51-9.

(43.) Hurley N, John D. Low back & lower extremity injuries indance: prevalence, causes, treatment & prevention. Journal ofKinesiology and Nutrition Student Research. 2013;1(1).

(44.) Hincapie CA, Morton EJ, Cassidy JD. Musculoskeletal injuriesand pain in dancers: a systematic review. Arch Phys Med Rehabil. 2008Sep;89(9):1819-29.

(45.) WHO. Obesity: Preventing and Managing the Global Epidemic:Report ofa WHO Consultation. Geneva: World Health Organization, 2000,pp. 894.

(46.) Mistiaen W, Roussel NA, Vissers D, et al. Effects of aerobicendurance, muscle strength, and motor control exercise on physicalfitness and musculoskeletal injury rate in preprofessional dancers: anuncontrolled trial. J Manipulative Physiol Ther. 2012 Jun;35(5):381-9.

(47.) Weiss DS, Shah S, Burchette RJ. A profile of the demographicsand training characteristics of professional modern dancers. J Dance MedSci. 2008;12(2):41-6.

(48.) Fabunmi AA, Akaraiwe CA. Hamstring flexibility: relationshipbetween straight leg-raise and backsaver sit and reach tests. Presentedat the Fourth International Council for Health, Physical Education,Recreation, Sport and Dance (ICHPER-SD). October 14-17, 2008. Gaborne,Botswana.

(49.) Khan K, Roberts P, Nattrass C, et al. Hip and ankle range ofmotion in elite classical ballet dancers and controls. Clin J Sport Med.1997 Jul;7(3):174-9.

(50.) Walker IJ, Nordin-Bates SM, Redding E. Characteristics oftalented dancers and age group differences: findings from the UK Centresfor Advanced Training. High Ability Studies. 2011;22(1):43-60.

(51.) DiGiovanni CW, Justin Greisberg M. Foot and Ankle: CoreKnowledge in Orthopaedics: St. Louis: C.V. Mosby, 2007.

(52.) Malliaras P, Cook JL, Kent P. Reduced ankle dorsiflexionrange may increase the risk of patellar tendon injury among volleyballplayers. J Sci Med Sport. 2006 Aug;9(4):304-9.

(53.) Tabrizi P, McIntyre W, Quesnel M, Howard A. Limiteddorsiflexion predisposes to injuries of the ankle in children. J BoneJoint Surg Br. 2000 Nov;82(8):1103-6.

(54.) Wiesler ER, Hunter DM, Martin DF, et al. Ankle flexibilityand injury patterns in dancers. Am J Sports Med. 1996Nov-Dec;24(6):754-7.

(55.) Gamboa JM, Roberts LA, Maring J, Fergus A. Injury patterns inelite preprofessional ballet dancers and the utility of screeningprograms to identify risk characteristics. J Orthop Sport Phys Ther.2008 Mar;38(3):126-36.

(56.) Nowacki RM, Air ME, Rietveld A. Hyperpronation in dancers:incidence and relation to calcaneal angle. J Dance Med Sci.2012;16(3):126-32.

(57.) Loudon J, Jenkins W, Loudon K. The relationship betweenstatic posture and ACL injury in female athletes. J Orthop Sports PhysTher. 1996 Aug;24(2):91-7.

(58.) Ambegaonkar JP, Caswell SV, Winchester JB, et al. Balancecomparisons between female dancers and active nondancers. Res Q ExercSport. 2013 Mar;84(1):24-9.

(59.) Day H, Koutedakis Y, Wyon M. Hypermobility and dance: areview. Int J Sports Med. 2011 Jul;32(7):485-9.

(60.) Gannon L, Bird H. The quantification of joint laxity indancers and gymnasts. J Sports Sci. 1999 Sep;17(9):743-50.

(61.) Ylinen J. Pressure algometry. Aust J Physiother.2007;53(3):207.

(62.) Garcia E, Godoy-Izquierdo D, Godoy JF, et al. Genderdifferences in pressure pain threshold in a repeated measuresassessment. Psychol Health Med. 2007 Oct;12(5):567-79.

(63.) Rafferty S. Considerations for integrating fitness into dancetraining. J Dance Med Sci. 2010;14(2):45-9.

(64.) Alexandre D, da Silva CD, Hill Haas S, et al. Heart ratemonitoring in soccer: interest and limits during competitive match playand training, practical application. J Strength Cond Res. 2012Oct;26(10):2890-906.

(65.) Wyon M, Allen N, Angioi M, Nevill. Anthropometric factorsaffecting vertical jump height in ballet dancers. J Dance Med Sci.2006;10(3-4):3-4.

(66.) Adam MU, Brassington GS, Steiner H, Matheson GO.Psychological factors associated with performance-limiting injuries inprofessional ballet dancers. J Dance Med Sci. 2004;8(2):43-6.

(67.) McEwen K, Young K. Ballet and pain: reflections on arisk-dance culture. Qualitative Research in Sport, Exercise and Health.2011;3(2):152-73.

(68.) Air ME. Psychological distress among dancers seekingoutpatient treatment for musculoskeletal injury. J Dance Med Sci. 2013Sep;17(3):115-25.

(69.) Rip B, Fortin S, Vallerand RJ. The relationship betweenpassion and injury in dance students. J Dance Med Sci. 2006;10(1-2):1-2.

(70.) Anderson R, Hanrahan SJ. Dancing in pain: pain appraisal andcoping in dancers. J Dance Med Sci. 2008;12(1):9-16.

(71.) van Hecke O, Torrance N, Smith BH. Chronic painepidemiology--where do lifestyle factors fit in? Brit J Pain.2013;7(4):209-17.

(72.) Etherton J, Lawson M, Graham R. Individual and genderdifferences in subjective and objective indices of pain: gender, fear ofpain, pain catastrophizing and cardiovascular reactivity. ApplPsychophysiol Bio feedback. 2014 Jun;39(2):89-97.

(73.) Popescu A, LeResche L, Truelove EL, Drangsholt MT. Genderdifferences in pain modulation by diffuse nox ious inhibitory controls:a systematic review. Pain. 2010 Aug;150(2):309-18.

(74.) Shah S, Weiss DS, Burchette RJ. Injuries in professionalmodern dancers: incidence, risk factors, and management. J Dance MedSci. 2012 Mar;16(1):17-25.

(75.) Allen N, Nevill A, Brooks J, et al. Ballet injuries: injuryincidence and severity over 1 year. J Orthop Sports Phys Ther. 2012Sep;42(9):781-90.

(76.) Motta-Valencia K. Dance-related injury. Phys Med Rehabil ClinN Am. 2006 Aug;17(3):697-723.

(77.) Ojofeitimi S, Bronner S, Woo H. Injury incidence in hip hopdance. Scand J Med Sci Sports. 2012 Jun;22(3):347-55.

(78.) Malliou P, Rokka S, Beneka A, et al. Reducing risk of injurydue to warm up and cool down in dance aerobic instructors. J BackMusculoskelet Rehabil. 2007;20(1):29-35.

(79.) Galambos SA, Terry PC, Moyle GM. Incidence of injury,psychological correlates, and injury prevention strategies for elitesport. Presented at the 2006 Joint Conference of the AustralianPsychological Society and the New Zealand Psychological Society,September 26-30, 2006, Auckland, New Zealand.

(80.) Hamilton LH, Solomon R, Solomon J. A proposal forstandardized psychological screening of dancers. J Dance Med Sci.2006;10(1-2):40-5.

(81.) Clark T, Williamon A, Redding E. The value of healthscreening in music schools and conservatoires. Clin Rheumatol. 2013Apr;32(4):497-500.

Roisin Cahalan, Ph.D., Helen Purtill, Ph.D., Peter O'Sullivan,Ph.D., and Kieran O'Sullivan, Ph.D.

Roisin Cahalan, Ph.D., and Kieran O'Sullivan, Ph.D.,Department of Clinical Therapies, University of Limerick, Limerick,Ireland. Helen Purtill, Ph.D., Department of Mathematics &Statistics, University of Limerick, Limerick, Ireland. PeterO'Sullivan, Ph.D., School of Physiotherapy, Curtin University ofTechnology, Perth, Australia.

Correspondence: Roisin Cahalan, Ph.D., Department of ClinicalTherapies, University of Limerick, Ireland; [emailprotected].

Table 1 Differences between Dance Groups andDescriptive Statistics as Means [+ or -] SD,%, or Median (Interquartile Range) Professional Student (N = 36) (N = 28)%Female to %Male 50/50 85.7/14.3Age (a,b) 23 (21, 27.5) 20 (19,22) (N = 34) (N = 29)Years Dancing (a,b) 17.51 [+ or -] 5.61 13.75 [+ or -] 5.31 Competitive p Value (N = 40)%Female to %Male 80/20 0.002 *Age (a,b) 20 (18.5, 20) <0.001 ([dagger]) (N = 39)Years Dancing (a,b) 13.00 [+ or -] 3.79 <0.001 ([double dagger])[chi square] test; ([dagger]) Kruskal-WallisTest; ([double dagger]) ANOVA; (a) significantbetween professional and competitivegroups; (b) significant between professionaland student groups.Table 2 Test Elements of Physical Screening ProtocolTest Element Outcome Measure ProcedureAnthropometric Body Mass Index Height and weight Measures (BMI) (kg/[m.sup.2]) and waist and hip Waist:Hip Ratio measures were taken to calculate BMI and waist:hip ratios, respectively. (30)Tissue Sensitivity Pain Pressure Upper trapezius Threshold (lbs) (UTr) and tibialis anterior (TA) muscles tested bilaterally using a calibrated handheld digital algometer (J-Tech Commander). An overall PPT score was calculated from the mean value of the four locations.Gastrocnemius Active ankle Measured with knee flexibility dorsiflexion extended using a ([degrees]) handheld goniometer. The mean value of two trials was recorded.Hamstring Active hip flexion Measured with a flexibility ([degrees]) Speedflexer[TM] device. Subjects required to actively sustain a maximal straight leg raise for 3 seconds bilaterally while supine with the contralateral hip and knee flexed. The mean value of two trials was recorded.Subtalar pronation Navicular drop (mm) The distance between the floor and the navicular tuberosity was compared in a seated, unloaded foot position and a loaded, standing foot position using an index card demarcated in millimeters. (31)Balance Star excursion The mean of three balance test (SEBT) trials was posteromedial recorded with axis (32) results normalized to leg length measured in standing from the iliac crest to the medial malleolus. (33)General joint Beighton The 9-point BHS- hypermobility Hypermobility scores of four or (GJH) Score (BHS) more are considered to indicate GJH. (34)Cardiovascular Speed, Power, Dancers were fitness and Agility, Reaction required to jump endurance and Quickness repeatedly for 30 (SPARQ) rating seconds over a system. (35) 12-inch soft hurdle Percentage of maximum with both feet and heart rate (%HRmax) land on both feet on the other side of the hurdle. Number of jumps, resting heart rate, heart rate immediately following the test and 30 seconds following the test were recorded using a finger pulse-oximeter (Nonin Onyx [TM]). %HRmax was calculated based on 208-(subject age *0.7). (36)Functional tests Functional Movement Deep squat and Screen (FMS) bilateral in-line lunge test elements of the FMS were used to identify any lower limb range limitations and side-to-side movement asymmetries. (37) The best attempt of three trials was recorded. A maximal score of three was attainable in each test (range 0-9).Lower limb power Vertical leap (cm) The difference between the maximum height reached during a double-footed countermovement jump and standing reach height. (38) Standing reach was measured with subjects' preferred arm extended against a wall- mounted tape measure with feet flat on the ground. The best score of three trials was recorded.Table 3 Group Comparisons of Physical Variables by Sex; DescriptiveStatistics as Means [+ or -] SD or Median (Interquartile Range) Female (N = 66) Male (N = 18)Body Mass Index 22.03 [+ or -] 2.37 21.60 [+ or -] 2.53 (kg/[m.sup.2])Waist:Hip Ratio 0.76 (0.73, 0.80) 0.81 (0.80, 0.85)Pain Pressure 32.27 (25.4, 40.3) 40.23 (30.6, 52.1) Threshold (lbs)Navicular Drop (mm) 6.5 (4.5, 8.5) 8.0 (3.5, 10.0)Functional Movement 7 (6, 8) 8 (7, 8) Screen TotalHamstring Flexibility 93.51 [+ or -] 9.23 83.88 [+ or -] 9.01 ([degrees])Gastrocnemius 14.70 [+ or -] 4.02 14.74 [+ or -] 3.46 Flexibility ([degrees]) *Balance (%LL) 90.80 [+ or -] 8.4 92.67 [+ or -] 8.67Vertical Leap 34.83 [+ or -] 8.69 41.72 [+ or -] 10.93 (cm) ([dagger])Beighton Hypermobility 2.63 [+ or -] 1.99 1.67 [+ or -] 1.81 Scale ([dagger])Number of Jumps 38.42 [+ or -] 9.18 47.59 [+ or -] 9.79 ([double dagger])Percentage Max 77.98 [+ or -] 6.19 76.55 [+ or -] 7.76 Heart Rate ([section])%LL = percentage of leg length; * female = 65, male = 17;([dagger]) female = 65, male = 18; ([double dagger]) female= 62, male = 17; ([section]) female = 58, male = 16.Table 4 Group Comparisons of Subjective Variables bySex; Descriptive Statistics as Means [+ or -] SD orMedian (Interquartile Range); Categorical Data alsoShownDescriptive Data Female (N = 74)Age 20 (19, 22)Years dancing 14.74 [+ or -] 4.77Number of 4 (2, 7) subjective health complaintsNumber of 1 (0, 2) psychological complaintsCross training 4 (2, 6) per week (hours)Number of body 3 (2, 4) parts affectedCatastrophizing 6 (2, 12)Stress 8 (4, 14)Profile of Anger-Hostility 2 (0, 5) Moods Scale Tension-Anxiety 5.5 (3, 9) Confusion-Bewilderment 2 (1, 5)Athletic Coping Coping with adversity 5.73 [+ or -] 2.71 Skills Coachability 9.86 [+ or -] 2.20 Inventory 28 ([double dagger]) Concentration 6.99 [+ or -] 2.55 Confidence and 7.01 [+ or -] 2.44 achievement motivation Goal setting and 5.85 [+ or -] 2.84 mental preparation Peaking under 4.76 [+ or -] 2.63 pressure Freedom from worry 5.82 [+ or -] 2.96Alcohol Units 5 (4, 8) ([section])Categorical Data CountWarm Up Always 36 Not Always 38Smoking Yes 10 Previously, not now 5 No 59SCOFF At risk 13 Not at risk 61Sleep quality Insufficient 37 Moderate 36 Sufficient 1Previous injury Yes 25 No 41Dance in pain Less severe 46 Severe 28General Less severe 38 everyday pain Severe 36Bothersomeness Less severe 36 of pain Severe 37General health Very Good/Good 59 Neither/Poor/Very Poor 15Energy Very much/Quite a lot 54 Some/Little/none 20Descriptive Data Male (N = 30)Age 22.5 (20, 25)Years dancing 14.69 [+ or -] 6.33 *Number of 3 (1, 6) subjective health complaintsNumber of 1 (0, 2) psychological complaintsCross training 5 (2, 7) per week (hours)Number of body 3 (1, 4) ([dagger]) parts affectedCatastrophizing 4 (2, 10)Stress 8 (4, 14)Profile of Anger-Hostility 2 (1, 5) Moods Scale Tension-Anxiety 3.5 (1, 6) Confusion-Bewilderment 1.5 (0, 4)Athletic Coping Coping with adversity 6.27 [+ or -] 2.84 Skills Coachability 8.70 [+ or -] 2.89 Inventory 28 Concentration 7.47 [+ or -] 2.33 Confidence and 7.80 [+ or -] 2.67 achievement motivation Goal setting and 6.47 [+ or -] 2.84 mental preparation Peaking under 6.07 [+ or -] 3.35 pressure Freedom from worry 4.43 [+ or -] 2.79Alcohol Units 10 (4, 20) ([parallel])Categorical Data CountWarm Up Always 16 Not Always 14Smoking Yes 4 Previously, not now 1 No 24SCOFF At risk 4 Not at risk 25Sleep quality Insufficient 6 Moderate 23 Sufficient 1Previous injury Yes 8 No 19Dance in pain Less severe 24 Severe 6General Less severe 11 everyday pain Severe 19Bothersomeness Less severe 19 of pain Severe 11General health Very Good/Good 29 Neither/Poor/Very Poor 1Energy Very much/Quite a lot 23 Some/Little/none 7* N = 27; ([dagger]) N = 29; ([double dagger]) N = 73;([section]) N = 46; ([parallel]) N = 22; ([paragraph]) female = 66,male = 27; # female = 73, male = 30.Table 5 Anatomical Location of All Pain and InjuriesSustained over the Previous 5 Years with Diagnosis ifKnown: Troublesome Bodily Areas over the Previous YearSelf-ReportedAnatomicLocation ofPain or Injury(5 years)(N = 80)Foot or ankle 48.8%Calf or shin 11.3%Knee 10.8%Hip or thigh 9.4%Lower back 6.4%Head or neck 4.3%Elbow, wrist, 2.5% or handGroin 2.0%Ribs 2.0%Coccyx 1.0%Pelvis 0.5%Abdomen 0.5%Upper back 0.5%Diagnosis ofPain orInjury(5 years)(N = 80)Unaware of diagnosis 19.2%Muscle strain 17.2%Joint sprain 12.6%Fracture 10.2%Ligament 9.6%Tendonitis 6.0%Stress fracture 6.0%Joint trauma 6.0%Unspecified bony injury 1.2%Cartilage 1.2%Other * 10.6%Self-ReportedAnatomic Locationof TroublesomeComplaints(1 year)(N = 337)Foot or ankle 23.1%Calf or shin 19.0%Lower back 14.2%Knee 12.5%Hip or thigh 11.0%Head or neck 9.2%Shoulder 4.7%Upper back 4.5%Elbow, wrist, or hand 1.8%* Other: nerve injury, laceration, infection,chronic instability, avulsion, bone spur.Table 6 Group Comparisons of Subjective Variables:Descriptive Statistics as Means [+ or -] SD orMedian (InterquartileRange); Categorical Statistics also ShownDescriptive Data SI (N = 33)Age 20 (19, 22)Years dancing 14.53 [+ or -] 4.74Number of 7 (4, 9) subjective health complaintsNumber of 1 (0, 3) psychological complaintsCross training 4 (2, 6) per week (hrs)Number of body 4 (3, 6) parts affectedCatastrophizing 9 (3, 13)Profile of 13 (7, 20) Moods Scale Anger-Hostility 3 (1, 7) Tension-Anxiety 6 (4, 9) Confusion-Bewilderment 3 (1, 7)Stress 10 (6, 14)Athletic Coping Coping with adversity 5.58 [+ or -] 2.41 Skills Coachability 9.82 [+ or -] 2.54 Inventory 28 Concentration 7.45 [+ or -] 2.03 Confidence and 6.82 [+ or -] 2.16 achievement motivation Goal setting and 5.42 [+ or -] 2.87 mental preparation Peaking under 5.00 [+ or -] 2.70 pressure Freedom from worry 5.45 [+ or -] 2.80Alcohol units 5(4, 9) ([section])Categorical Data CountGender Female 28 Male 5Warm Up Always 10 Not Always 23Smoking Yes 6 Previously, 4 not now No 23SCOFF At risk 8 Not at risk 25Sleep quality Insufficient 18 Moderate 15 Sufficient 0Previous injury: Yes 12 most No 20 troublesome body partDance in pain Less severe 5 Severe 28General Less severe 0 everyday pain Severe 33Bothersomeness Less severe 5 of pain Severe 28General Health Very Good/Good 23 Neither/Poor/ 10 Very PoorEnergy Very much/ 22 Quite a lot Some/Little/None 11Descriptive Data NSI (N = 71)Age 20 (19, 24)Years dancing 14.82 [+ or -] 5.44 ([dagger])Number of 3 (2, 6) subjective health complaintsNumber of 1 (0, 2) psychological complaintsCross training 4 (2, 6) per week (hrs)Number of body 3 (1, 4) parts affectedCatastrophizing 4 (2, 10)Profile of 7 (4, 15) Moods Scale Anger-Hostility 1 (0, 5) Tension-Anxiety 4 (2, 8) Confusion-Bewilderment 1 (0, 4)Stress 8 (4, 14)Athletic Coping Coping with adversity 6.03 [+ or -] 2.89 Skills Coachability 9.39 [+ or -] 2.43 Inventory 28 Concentration 6.97 [+ or -] 2.37 ([double dagger]) Confidence and 7.44 [+ or -] 2.66 achievement motivation Goal setting and 6.31 [+ or -] 2.80 mental preparation Peaking under 5.20 [+ or -] 3.01 pressure Freedom from worry 5.41 [+ or -] 3.06Alcohol units 6(4, 10) ([parallel])Categorical Data CountGender Female 46 Male 25Warm Up Always 42 Not Always 29Smoking Yes 8 Previously, 2 not now No 60SCOFF At risk 9 Not at risk 61Sleep quality Insufficient 25 Moderate 44 Sufficient 2Previous injury: Yes 21 most No 40 troublesome body partDance in pain Less severe 65 Severe 6General Less severe 55 everyday pain Severe 16Bothersomeness Less severe 50 of pain Severe 20General Health Very Good/Good 65 Neither/Poor/ 6 Very PoorEnergy Very much/ 55 Quite a lot Some/Little/None 16Descriptive Data p ValueAge 0.474Years dancing 0.792Number of 0.001 * subjective health complaintsNumber of 0.036 * psychological complaintsCross training 0.969 per week (hrs)Number of body <0.001 * parts affectedCatastrophizing 0.047 *Profile of 0.010 * Moods Scale Anger-Hostility 0.122 Tension-Anxiety 0.019* Confusion-Bewilderment 0.040*Stress 0.442Athletic Coping Coping with adversity 0.437 Skills Coachability 0.409 Inventory 28 Concentration 0.315 Confidence and 0.246 achievement motivation Goal setting and 0.140 mental preparation Peaking under 0.749 pressure Freedom from worry 0.942Alcohol units 0.937Categorical Data p ValueGender Female 0.036 * MaleWarm Up Always 0.006 * Not AlwaysSmoking Yes n/a Previously, not now NoSCOFF At risk 0.146 Not at riskSleep quality Insufficient n/a Moderate SufficientPrevious injury: Yes 0.769 most No troublesome body partDance in pain Less severe <0.001 * SevereGeneral Less severe <0.001 * everyday pain SevereBothersomeness Less severe <0.001 * of pain SevereGeneral Health Very Good/Good 0.004 * Neither/Poor/ Very PoorEnergy Very much/ 0.242 Quite a lot Some/Little/NoneSI: Significantly injured; NSI: Not significantlyinjured; * Statistically significant at p < 0.05;([dagger]) N = 68; ([double dagger]) N = 70;([section]) N = 17; ([parallel]) N = 51; SCOFF:Sick, Control, One stone, Fat, Food.Table 7 Odds Ratios: 95% CIs and p-Valuesfrom Logistic Regression Model Odds Ratio 95% CI p ValueSex (Female) 3.12 0.98-9.94 0.054Warm-Up (Not always) 2.69 1.05-6.92 0.040Higher number of 1.21 * 1.04-1.41 0.011 subjective health complaints* The odds ratio for a quantitative variable representsthe proportional increase in the odds of being in theSI group per one unit increase in theindependent variable.

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