biopsychosocial factors in injury: from an artist's perspective
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Biopsychosocial Factors in Injury:
From an Artist’s Perspective
Brittany N. Keefe
LEAP Senior Study
Biopsychosocial Factors in Dance Injury
Table of Contents
Abstract…………………………………………….3Preface……………………………………………...3Introduction………………………………………...4
Methods…………………………………………….5Results……………………………………………...7Discussion…………………………………………18References…………………………………………20
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Biopsychosocial Factors in Dance Injury
Abstract
A study was created using a survey and interviews to discern the impact of
biopsychosocial factors on the incidence and rehabilitation of dance injuries. The survey
had ninety-two, respondents reporting an injury affecting their participation in class or
rehearsal for ten days or more. Of those, representing multiple dance genres from a
national scope, the foot/ankle was the most prevalent site of injury. Using questions from
established work-stress questionnaires, only 62% of the respondents reported feeling
motivated at work, while 43% reported the need to hide their feelings while working. The
results of the study pointed to perfectionist tendencies, lack of or underinsured healthcare
access, and economic struggles being the primary sources of negative stress. When asked
about income, 75% of the respondents reported wages low enough to qualify them at or
below poverty level. The most conclusive finding from the survey was 73.4% of
respondents stated troubles coping with their injury. Even with support, education, and
assistance going through the process of injury, the majority of dancers struggle coping
with being sidelined. Dance at an elite level is an all-encompassing experience; it is more
than a job. As such, the entire institution of dance needs to support the role of the artist
both physically and psychologically.
Preface
I am fortunate to have a limited history of injury from my 13 years as a
professional dancer, but the first injury that prevented me from performing definitely had
contributing psychological factors. This injury occurred when I joined a new ballet
company, and was dealing with a new environment, colleagues, and direction. We were
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building up to a performance and after the morning rehearsals, my right calf felt tight and
stringy. The afternoon rehearsal brought an opportunity to dance the lead role in front of
the entire company. I desired to prove that, although I was new, I deserved this role. At
the end of the first dance, I felt my calf cramp. I still finished the dance, but I couldn’t
flex my foot. There were three more dances to do, so thinking it was just a cramp, I
continued. I survived the run of the ballet, but couldn’t stand or walk after. The next
morning, I still couldn’t walk and went to the doctor to discover that I had torn my calf. I
was afraid to tell anyone important, fearing it would prove that I wasn’t capable of the
role or would be replaced. In addition to the physical demands of the form, dancers
commonly put many psychological stresses on their bodies, which contribute to the
prominence of injuries.
As I have continued in the field, I have been privy to witnessing many dance
injuries. I have also personally known the people to whom these injuries happen, and, in
many cases, have thought there must be some correlation between the stresses imposed
by the job on the individual and the occurrence of the injury.
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Biopsychosocial Factors in Dance Injury
Introduction
There are many epidemiological studies and research on the cost, occurrence, and
contributing factors to sports and performing arts injuries (Garrick & Requa, 2005;
Liederbach & Compagno, 2001; Thomas & Tarr, 2009). Unfortunately, the point where
athleticism and art meet, that being dance, has a sparse database of research. Dance has
fewer financial resources, but to keep the art form moving forward, there is a great need
to support the study of psychological stresses on injuries. This research would serve to
support better training and treatment for dancers and could potentially extend an artist’s
career.
Injury is an inevitable factor of a career in dance. Dance injuries stem from both
intrinsic and extrinsic factors, such as: over training, repetition of similar movements,
poor anatomical technique, fatigue, costumes, and slippery or hard surfaces. Injury can
result in the loss of performances, career ascendance and income. Being injured can
cause the dancer to feel worthless, depressed, or isolated (Hamilton, 2008; Mainwaring,
Kerr, & Krasnow, 1993). Conversely, what if being sidelined from injury brings relief
from competition? Perhaps the artist may desire an interruption in the constant
perfectionist tendencies or a physical break from the rigors of training and performing.
Some of the stresses and life circumstances present in a dancer’s life are unique to
the field. These specific demands include the pressure of success for an upcoming
performance, the attainment of better roles, the relationship to a teacher or choreographer,
economic uncertainties in a fragile arts industry potentially leading to job loss, and
maintaining an ideal aesthetic. The current study was created in an effort to deduce what
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Biopsychosocial Factors in Dance Injury
biopsychosocial factors may be present for a dancer, and if those factors could influence
their potential for injury. Biopsychosocial is defined as the social, biological, and
psychological aspects of illness in contrast with the biomedical aspects (Liederbach,
2010; Waddell, 2006). This study is administered from an artist’s perspective, versus a
clinical one, in hopes that the artists would be more forthcoming in their response.
Methods
A nationwide survey was distributed to discern whether or not stresses of
perfectionism, economic pressure, relationship troubles, and other psychological stresses
contributed to injury. In conjunction, a study from the Harkness Center for Dance Injuries
(Liederbach & Compagno, 2001) theorizes that stressors affect the preponderance of
injury by disrupting attention, increasing muscular tension, and reducing motor
coordination. The present study was retrospective, and relied on the participant’s memory
of a particular injury over an undetermined time frame. The working definition of injury
was any affliction keeping the dancer from full participation in class or rehearsal for ten
days or more.
The survey was administered through the Survey Monkey website for a period of
two-and-a-half weeks. The link to the survey was marketed through: personal email
contacts, personal healthcare relationships, a dance community newsletter based in
Minneapolis, MN, a link on the DanceNYC website, word of mouth, and the social
networking tool Facebook.
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Results
Of the 113 completed responses, ninety-two respondents were determined to have
an injury fitting the working definition. Of those ninety-two completed responses, 85.9%
considered themselves professional dancers, 6.5% were college students, 3.3% were
student dancers 18 years or younger, and 4.3% had another affiliation with dance.
The participants were asked what were their primary genres of dance and 76.1%
responded ballet, 32.6% responded modern, 9.8% responded musical theater and jazz,
2.2% responded folk/ethnic, and 9.8% responded with other forms (see figure 1).
Although the diversity of forms in the survey was not broad, the demographics
demonstrated a response coast-to-coast and represented over 27 states.
Figure 1- Primary dance genres.
In accordance with other studies (Liederbach, 2010), the foot/ankle was reported
in the survey to be the highest occurring injury. A total of 75 % of the dancers reported
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having a significant injury to this region. Subsequently, the back at 47.8%, the knee at
38%, the shoulder and the lower leg received 17.4%, and the neck totaled 16.3% of
reported injuries (see figure 2). Respondents submitted other injuries, not in the multiple-
choice options: broken rib, strained intercostals muscle, pulled hamstring, groin, hand,
and concussion.
Figure 2- Site of Injuries by Occurrence.
Numerous questions were created to determine the level of trust and
empowerment the dancer felt over his/her career at the time of injury. The employment
questions were adapted from the General Nordic (Kristensen, Hannerz, Hogh, & Borg,
2005) and Copenhagen PSychOsocial (Lindstrom et al., 2000) standard questionnaires
for work-related stresses. The former aimed at assessing psychosocial risks, and the latter
determined areas of work-related stresses. These questions discerned whether or not the
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dancers felt they had control over their working/dancing environment. Ergonomic
researcher Deeney & O’Sullivan (2009) observed, “There is growing evidence that
psychological risk factors exacerbate the effects of physical risk factors thereby
increasing the risk and severity of musculoskeletal disorders ” (p. 245). Questioning the
dancers’ feelings about their work could provide insight into their psychological state,
which potentially affects physical injury risk.
When asked to reflect about their working environment at the time of injury, only
62% of the dancers reported feeling motivated in their work. For such a short-lived, yet,
time and energy-consuming career, one would hope the degree of motivation would be
higher. Young dancers rarely consider the option of pursuing activities other than
dancing. Often this becomes a sacrifice of growing up without normal developmental
milestones such as graduation ceremonies, prom, football games, and parties with friends.
While these sacrifices for training may be true of any elite athlete, dance provides little
monetary compensation, so the trade-off is imbalanced.
When asked about emotional involvement in their place of work, 81.5% reported
positively stating they were emotionally involved. However, it seems that this
involvement is not completely transparent, because 43.5% of the dancers reported the
need to hide their feelings at work. This shows a majority of the dancers have an
emotional connection to their work, but are not always able to express themselves.
Certainly, in any group endeavor, there is some degree of compromise. But, this finding
suggests a need for greater empowerment of the artists through open communication
channels and strong leadership. In accordance, the survey also showed the majority of the
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respondents (46.7%) felt that “only sometimes” they had a large degree of influence over
their work.
The lack of influence dancers feel over their work may be based in the
hierarchical and dogmatic approach with which dance is taught. Students are first taught
the basic positions and movements of dance through emulation. Eventually, as the student
becomes more skilled, the dancer moves and is ‘corrected’ in their experience. This
correction is a criticism and carries the expectation that the movement will then be
‘fixed’. In a sort of reverse psychology, the dancer anticipates and craves the attention of
the correction. This criticism becomes an important aim in assessing progress. In an
interview with professional dancer Michelle deFemery, she supposes, “Dance can be so
negative….we see corrections/criticisms as compliments and spend so much time picking
things apart in a mirror” (M. deFemery, personal communication, December 29, 2010). If
the instructing and leading of dance work instilled a higher degree of empowerment in its
dancers, the dancers could see their degree of influence over the artistic product more
clearly.
The dancer’s quest to maintain peak physical condition and performance is a
given stress of the art, but obviously dancers experience other daily struggles, which may
influence their susceptibility of injury. A study through the Stanford University (Adam,
Brassington, Steiner, & Matheson, 2004) assessed stress and self-esteem over an eight-
month period in thirty-nine female university students. At the end of the study, there was
a strong correlation between the psychological stresses and total injury duration. There
was also a distinction found between the influences of positive stress and negative stress.
Negative events connected with longer injury duration, whereas positive events shortened
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the length of rehabilitation. These results paralleled other sports studies on the influence
of psychological factors on injury. Specifically, Astrid Junge (2000) reported, “it can be
supposed that psychological stressors modify the emotional state, especially
characteristics such as vigor, concentration, or attention” (p. S-14). Dance requires all of
these attributes for peak performance.
Performance-decreasing external stressors can stem from both unique job
demands and struggles for survival. Some of the sources reported in the present dancer
survey included low income, feelings of inadequacy, lack of insurance, new job, and
struggles with a boss. The American College of Sports Medicine recently made a public
statement to various coaches and trainers stating stressed-out athletes are at least twice as
susceptible to injury than their non-stressed peers (Hamilton, 2008, p 138.).
Low income is a known issue for those pursuing a career in dance. Income is
rarely steady and may include periods of unemployment. In the current survey the
primary average monthly income was between $1000-$2000 for 28.3% of the dancers.
The next highest percentage from respondents was 25% reported earnings in excess of
$2000 per month; the next total being 22.8% of dancers earning $0-$250 per month (see
figure 3). While the survey was limited in its ability to decipher earnings in excess of
$2000 per month, even without the highest category, it demonstrated 75% of the
respondents are living at or below the poverty level. The survey was conducted in the
fall, a typically more lucrative season, so it should be noted that the results might be
affected. The summer and late winter are times of more unemployment or fewer jobs.
Still, these statistics demonstrate the reality of low income when considering that 85.9%
of the respondents considered themselves professional dancers.
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Figure 3- Average monthly income.
The economic circumstances affect both the organizations and individuals
contributing to dance. It is often difficult for small organizations to afford insurance for
their dancers, let alone prevention or treatment programs. A study of 100 dance
companies in the bay area (Garrick & Requa, 2005) of San Francisco, California, found
that less than half of the 192 dancers included were covered by workers compensation.
When the largest ballet company was excluded from the study, less than 10.2% of the
dancers had any access to regular health insurance coverage (p. 81). The costs of
healthcare then fall onto the individual dancer, most of who are already living and
working just above the poverty level. In this study, 25% of the respondents reported that
not having insurance or being under-insured, was a stress in their lifestyle.
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One of the dancers from the survey reported their struggle with insurance and
how it directly related to the condition of their body. In an open-ended question the
participant responded, “I am currently still dealing with this injury. It has been very
frustrating and I have not had the extra money or health care benefits to really take care
of it. I have been dancing with pain for two months now. If I had insurance or savings I
would be making an appointment with a doctor.” While conventional wisdom would
suggest the dancer should rest to help to heal an injury, it is possible this dancer cannot
afford to stop dancing. Additionally, rest alone may not restore his/her function. In the
present study, inadequate healthcare affects 33.3% of respondents in their delay of
treatment paired with another 36% who saw money as an obstacle to seeking help.
Worker’s Compensation is another avenue for treatment of injuries for the
dancers contracted with larger dance companies. However, this is not without stress
either for the organization or the individual. The premiums of insurance are often
unrealistically high. Over the course of a five-year period the Boston Ballet generated a
study (Solomon, Solomon, Lyle, & McGray,1999) on its insurance premiums and the
potential savings that could be attained from supplementing care through other avenues.
The impetus of the study was a proposed Workers Compensation Insurance premium of
over $792,000. Through time and additional services, the premium was reduced to an
average of $389,262 per season for the 60+ dancers (p. 168). If they can even afford to
offer insurance, smaller organizations do not always have the resources to provide
alternative treatment nor can they afford to have an increase in their premiums. In this
survey, one dancer mentioned fighting with his/her employer to get Worker’s
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Compensation Insurance coverage for a ruptured ACL. It is likely this fight for care both
delayed treatment and prolonged the rehabilitation.
Fortunately, results from the survey demonstrated an expeditious path to
treatment and diagnosis. In fact, only 2.2% of respondents did not seek help. Half the
respondents did find medical assistance within the day of injury. Again this is in the
context of injuries, which are defined as something keeping a dancer from full
participation in class, rehearsal or performance. Additionally, 65% of injuries in dance
result from repetitive overuse, or micro trauma, that can eventually progress to chronic
injury (Liederbach, 2010). These types of injuries can often be prevented if caught early
on, if the dancer has access to treatment and is willing to seek help.
Physical Therapy Assistant Shannon Casati reports in her work with dancers there
are still many injuries dancers are afraid to acknowledge or treat. Mrs. Casati supposes,
“There is often fear associated with stopping and taking care of an injury in the first
place. Dancers don’t want to seem vulnerable to a colleague or a boss… Sometimes a
dancer will decide that their injury is healed because it is more convenient…” (S. Casati,
personal communication, December 28, 2010). It can be assumed these injuries are not
yet the type to fulfill the working definition of injury, but it is possible they can develop
into a more serious or chronic injury. The dancer’s dependency on how others view them
creates a plethora of psychosocial issues.
Perfectionism dominates the field of dance, which contributes constructively to a
dancer’s drive toward constant work and technical growth. But more often, perfectionism
may lead to a dancer’s decreased sense of self –worth or control over his/her abilities.
This can lead to eating disorders in an attempt to regain control over a career and the
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primary tool- the body (Hamilton, 2008). Especially within the path of classical ballet,
the ideal aesthetic is already prescribed. Dr. Linda Hamilton, the renowned dance
psychologist has done significant research on eating disorders. She asserts that some of
the stress stems from the reality that only 4% of the population naturally achieves the
ideal ballet body type, the rest need to work at it (L. Hamilton, personal communication,
November 13, 2010). That does not mean a stressful nor unhealthy end, but often the
dancer takes it upon his/herself to meet the perceived aesthetic body type without
knowing how to do so, or to whom to turn for help. From a study of a group of South
African ballet dancers (van Staden, Myburgh, & Poggenpoel, 2009), one professional
reported, “When I was younger, when I just came into the company, there were times that
I didn’t allow myself to eat anymore. I wanted to look like the others” (p. 22). It is not
wrong for a dancer to want to fit in, but the safe and healthy means must be established
for dancers to attain longevity and a life beyond dance.
Another maladaptive sense of perfectionism can result in a feeling of inadequacy
in their dancing. From the study of South African classical ballet dancers (van Staden,
Myburgh, & Poggenpoel, 2009), one of the principal dancers commented, “…Dancers
are their [own] worst enemies, because you get off stage and you could never be perfect.
You will never ever be satisfied…never”, (p.21). This dissatisfaction with oneself can
create a negative psychological stress, which has been linked to affecting the onset of
injury (Mainwaring, Kerr, & Krasnow, 1993).
Perfectionism can also make a dancer fear showing vulnerability, or they often
perceive there is no time for injury. It can lead a dancer to continue pushing in rehearsal
or performance when their body is giving clear indications for the need of rest. A study
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published in the Journal of Dance Medicine (Liederbach & Compagno, 2001) detailed
how fatigue related to injury. In the study, 79% of injured dancers reported having
danced in excess of 5 hours prior to injury, (p. 118). Similarly, all of the qualified
healthcare professionals interviewed in this study cited stubborn dancers pushing beyond
their bodies’ warnings. Dr. Hamilton mentioned that sometimes teachers are also
responsible for forcing students to work beyond the body’s limits. She stressed the
importance of the student/teacher (or student/parent) relationship. She hypothesized
sometimes pleasing the teacher or parent is so strong that the early warning signs of
injury go unnoticed in pursuing the dream job or role. The dancer feels pressured to work
through pain and abuse, which is ultimately sabotaging (L. Hamilton, personal
communication, November 13, 2010).
While perfectionism is a known psychological stress for dancers, it is also a key
factor in the success of a dancer. However, an important determining factor of how likely
an injury will occur because of stress or perfectionism lies in how a dancer responds, or
what mechanisms they have to help cope. The most conclusive finding from the survey
was that 73.4% of respondents stated troubles coping with their injury. Even with
support, education, and assistance going through the process of injury, the majority of
dancers struggle coping with being sidelined. Assistance during rehabilitation was
primarily sought from family and friends, with 92% of the respondents citing outside aid.
Other sources included spirituality and meditation. Additionally, 62% of the dancers
reported that the injury negatively affected other aspects of their lives. Clearly,
preventative measures would be well warranted for helping dancers to deal with injury,
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but more pressing is the need for resources to aid an injured dancer to deal with the
implications of being injured.
During the interviews, it was repeatedly mentioned that subsequent injuries are
often easier psychologically than the first. Michelle deFemery utilized the knowledge she
had gained from her first injury as a coping mechanism to ease the fear and frustration of
the second injury. Senior Physical Therapist Faye Dilgen, PT, DPT of the Harkness
Center for Dance Injuries correlates, “Unfortunately, I think the dancers who deal best
with an injury have been injured before. They know what to expect, they know how to
rehab their injury and respect the time frame of healing. Dancers who have never been
injured may have expectations that are not realistic - the learning curve is much steeper”
(F. Dilgen, personal communication, December 13, 2010).
A pointed question was asked in all of the interviews about the creation of injury,
which couldn’t be shown through the survey. The question read: “Have you ever
considered that injury might be self-created or even an opportunity for psychological
healing?” None of the respondents thought that a dancer would knowingly injure
him/herself but they all noted the possibility of self-created injury. Things mentioned
included the opportunity for release from a stressful lifestyle, time-away from a negative
environment, an opportunity to focus on other aspects of life, and even physical time off.
Faye Dilgen replied, “There are dancers who prefer to have an injury – especially if they
are looking for attention and want to keep coming to PT as this is a person who listens to
them, touches them, and gives them undivided attention for a treatment session. This can
facilitate psychological healing, but I have rarely seen an instance when there was not
true injury…” (F. Dilgen, personal communication, December 13, 2010). One dancer
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agreed that while there may be some need for attention, not unlike an eating disorder, the
injury was probably already a potential; a chicken before the egg scenario (M. deFemery,
personal communication, December 29, 2010). The question leads back to the need for
attention and a high degree of care for a dancer to consistently achieve an elite level of
performance.
Discussion
Given that the study relied on the respondents recall, it can be questioned whether
the results are affected by the dancer’s current physical condition or state of mind. In
recording the artists psyche by recollection, this study may have positive bias. However,
the data correlates to existing research about types of injury sustained in the field, and it
further exposed the need for care of the artists. Perhaps also the results would prove
different if the format was more personal, such as an interview type format, versus an
online survey.
Regardless to the survey’s imperfections, it is clear dance at an elite level is an
all-encompassing experience; it is more than a job. When a dancer can’t do their job, they
often have troubles dealing with the rest of their life psychologically and financially. The
results of the survey demonstrated a strong link to coping strategies and injury. There is a
need for future studies to discern what programs best serve dancers coping with injury
and how the dancers find such resources. The repeated mention of subsequent injuries
being easier to cope with also demonstrates an avenue for future studies.
Dancers do not enter the field anticipating financial stability. But how can schools
or companies aide their artists with managing finances and dealing with lost income
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during injury? Similarly, what resources can be made available to dancers to be able to
afford and utilize healthcare? Without these resources dancers are less able to deal with
injury.
The entire institution of dance needs to support the role of the artist both
physically and psychologically. This support comes in the form of readily available heath
care resources, sympathetic directors and teachers, healthy schedules that maximize
exertion when the dancer is warm and not fatigued, and appropriate spaces and surfaces
for the dancers to safely train and perform. Until we empower and support the “whole
dancer,” injuries will continue to plague the artists more than necessary.
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References
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Byhring, S., Bo, K. (2002). Musculoskeletal injuries in the Norwegian National Ballet: a prospective cohort study. Scandinavian Journal of Medicine and Science in Sports, 12, 365-370.
Deeney, C., & O'Sulivan, L. (2009). Work related psychosocial risks and musculoskeletal disorders: potential factors, causation and evaluation methods. Scandinavian Journal of Work, Environment and Health, 239-248.
Garrick, J., & Requa, R. (2005). Do professional dancers have medical insurance? company-provided medical insurance for professional dancers. Journal of Dance Medicine and Science, 9(3&4), 81-83.
Hamilton, L., Hamilton, W., Meltzer, J., Marshall, P., Molnar, M. (1989) Personality, stress and injuries in professional ballet dancers. The American Journal of Sports Medicine, 17:2, 263-267.
Hamilton, L. (2008) The Dancer’s Way: The New York City Ballet Guide to Mind, Body and Nutrition. New York: St Martin’s Griffin.
Junge, A. (2000). The influence of psychological factors on sports injuries: review of literature. The American Journal of Sports Medicine, 28(5), S10-S15.
Kristensen, T., Hannerz, H., Hogh, A., & Borg, V. (2005). The copenhagen psychosocial questionnaire- a tool for the assessment and improvement of the psychosocial work environment. Scandinavian Journal of Work, Environment and Health, 31(6), 438-449.
Liederbach, M. (2010). Injuries in dance: biopsychosocial considerations. Power point presentation at the Harkness Center for Dance Injuries principles of dance CME course. July 15, 2010.
Liederbach, M., & Compagno, J. (2001). Psychological aspects of fatigue-related injuries in dancers. Journal of Dance Medicine and Science, 5(4), 116-120.
Lindstrom, K., Elo, A., Skoggard, A., Dallnee, M., Hattinen, F., Knardahl, S., Orhede, E. & Gamberale, F. (2000). User guide to qps nordic: general nordic questionnaire for psychological and social factors at work. Nordic Council of Ministers, 8(2), 239-248.
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Mainwaring, L., Kerr, G., & Krasnow, D. (1993). Psychological correlates of dance injuries. Medical Problems of Performing Artists, 3-6.
Solomon, R., Solomon, J., Lyle, J., & McGray, E. (1999). The "cost" of injuries in a professional ballet company. Medical Problems of Performing Artists, 164-170.
Thomas, H., Tarr, J. (2009). Dancer’s perceptions of pain and injury - positive and negative effects. Journal of Dance Medicine and Science, 13(2), 51-59.
Waddell, G. (2006). Preventing incapacity in people with musculoskeletal disorders. British Medical Bulletin, 77 & 78, 56- 69.
van Staden, A., Myburgh, C., & Poggenpoel, M. (2009). A psycho-educational model to enhance the self-development and mental health of classical dancers. Journal of Dance Medicine and Science, 13(1), 20-28.
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