Managing injury in the Australian Ballet
It takes a large medical and health team to keep MEAA’s members at The Australian Ballet in top physical condition. Sue Mayes reports.
THE Australian Ballet (TAB) has formulated an ‘Injury Management and Prevention Program’ aimed at protecting the health of dancers, prolonging their careers and preventing injuries that may affect their quality of life after dance.
The Australian Ballet is committed to the health (physical and psychological) and safety of its most precious asset, the dancers. This commitment stems from the board and extends to all levels of the company. The Australian Ballet has facilitated a change in behaviour over the years, which has directly influenced the culture from one that poses a high risk to health to one that embodies health and wellbeing. This has resulted in fewer injuries, faster recovery for the dancers and an increase in morale.
Ballet is a physically and emotionally demanding art form, classified as a high risk occupation. The dancers of TAB also endure the pressure of a hectic national and international touring schedule.
TAB has adopted a broad multidisciplinary medical approach by employing a medical team of dance medicine specialists providing their services onsite. This approach has proven to be extremely beneficial in a wide range of applications, from resolving minor complaints to complete resolution of injuries.
The team’s in-house and external members have worked in consultation with each other to refine the principles and notions of dance medicine at TAB. The concepts and practices of the medical team are now at a stage where dancers and the company are realising the benefits of this extremely effective program. High injury trends have been successfully reversed with a profound reduction in injuries to high-risk areas such as the ankle, back and hip.
The medical team’s planning, training, research and development have evolved into a documented ‘Injury Management and Prevention Program’, so that the benefits TAB has experienced can now be shared with other ballet companies across the world.
The Multidisciplinary Approach
From its inception, TAB had a degree of medical support through minimal part-time in-house specialists. When on tour, the dancers were referred to various health professionals in whatever city they were performing; thus treatment was mostly external, difficult to track, of varying quality and not at all centralised.
In 1984, a sports physician, keen to apply a multidisciplinary sports medicine approach to TAB, commenced with the company. The multidisciplinary model, which previously had been applied predominantly to the sporting community, was very appropriate to a ballet company made up of ‘artistic’ athletes. Hence there was a shift towards establishing full-time, centralised, multidisciplinary care, with an emphasis on both care and prevention, as well as increasing communication between medical and artistic Staff.
A significant move was the appointment of a full-time in-house physiotherapist in 1997. This was then extended into a fully-fledged risk management program following the appointment of the current artistic director in 2001 and a second full-time physiotherapist in 2002.
Today, TAB has a highly skilled in-house medical team specialising in dance medicine, and leads the world in dance medicine and injury rehabilitation. The physiotherapists and myotherapist travel with the company throughout the year to ensure dancers are provided with easily accessible, consistent medical care. In addition, certain members of the team are former ballet dancers and bring with them experience that is invaluable.
The medical team’s role is to support the health and wellbeing of the dancers and to optimise their performance. Recently Orchestra Victoria have joined The Australian Ballet and the medical team have extended their support to the musicians. Currently, the musicians are offered physiotherapy, Pilates and body conditioning by our team as well as free gym memberships. The aim is to gradually introduce a similarly successful centralised, onsite, multidisciplinary approach to support the health and wellbeing of the musicians.
The medical team comprises:
Medical team manager & principal physiotherapist
The medical group is headed by the medical team manager & principal physiotherapist, who is responsible for the day-to-day operational management of the Medical Team. The medical team manager & principal physiotherapist is currently developing an injury prevention and management program for Orchestra Victoria.
A team of physiotherapists work on-site and tour with the company. They are the primary contact for injured dancers offering detailed assessment, treatment and advice with ongoing management. They liaise closely with the medical team and artistic staff to ensure the exercise programs and workload of the dancer are monitored closely to allow full recovery from injury and optimal performance.
Sports and exercise physician
A sports and exercise physician works on-site in Melbourne and in Sydney to provide injured dancers with the required centralised medical assessment, review and/or recovery advice. They monitor the health and progress of injured dancers, liaise with the medical team about any medical issues, potential surgery, treatment regimes, rehabilitation and return-to-work planning. The physician also has an innate knowledge and understanding of dance medicine, including the constant physical and psychological demands placed on dancers. Their liaison with the medical team facilitates a forum for open communication and informed decision making.
Working part-time in-house, the General Practitioner’s role is to enhance the general health and wellbeing of the dancers, including their nutritional and psychological health.
The myotherapist provides in-house remedial massage and myotherapy for dancers’ injuries, working alongside the physiotherapists and body conditioning specialist.
Body conditioning specialists
The body conditioning specialists develop, teach, assist, and monitor conditioning programs, including providing instruction in correct use of equipment, specific to the needs of individual dancers.
An Environment, Health and Safety (EHS)/WorkCover co-ordinator is responsible for running the company's health and safety management system and managing WorkCover claims.
These include General Practitioners, surgeons, rheumatologists, podiatrists and dieticians, although all areas of medical expertise may be required depending on the medical condition involved.
Psychologists work with the dancers off and on-site and run workshops. The psychological aspects of being a dancer can often be overlooked, with respect to the high expectation of performing perfectly in front of hundreds of people. Performance anxiety is not uncommon for dancers in addition to the constant lifelong fitness and production demands.
The artistic team
The artistic team acts as a ‘branch’ of the medical team within the ‘Injury Management and Prevention Program’. Without the support and involvement of the artistic team, the program cannot work. Being former dancers themselves, they understand the particular needs, difficulties and rewards of a dance career. The artistic team comprises:
The artistic director is closely involved with the program and actively supports it. Regular communication with the medical team informs the artistic director's decision-making about a wide variety of issues, from repertoire and scheduling to weekly management of dancers’ workloads. The artistic director upholds the notion of workload modification as a means of preventing serious or prolonged injury and allowing effective rehabilitation when an injury occurs.
The artistic staff teach company class and repertoire, and coach individual dancers as required. Being responsible for planning and teaching class each week and warm-up barre during the performance season, they have an active and essential role in implementing the prevention programs devised by the medical team. Their daily contact with dancers allows them to monitor the progress of each dancer and report back to the medical team.
The rehabilitation facilitator works one-on-one with dancers or in small groups who are experiencing discomfort, have sustained an injury or require specific coaching for their technique. The rehabilitation facilitator acts as the interface between the artistic and medical teams.
The success of TAB's ‘Injury Management and Prevention Program’ relies on the commitment and involvement of the dancers. Though The Australian Ballet has demonstrated full support to the dancers in maximising their wellbeing, it is expected that the dancers also take responsibility for ensuring they are physically fit to perform optimally.
A culture for success
A reporting culture
The Australian Ballet has successfully facilitated a shift in culture to early reporting of all complaints. A key to injury prevention is early attention to minor musculoskeletal dysfunction such as cramp, fatigue, stiffness or low grade discomfort. Early intervention into these minor complaints or symptoms has proven to reduce incident frequency rates.
The early reporting practice is taught to dancers at TAB School (eight to 17 years), the importance of which is further reinforced at The Australian Ballet during the annual Induction process, which is compulsory for all dancers. Early reporting is encouraged and supported by the artistic and medical teams. Early intervention is the primary means to preventing injury and/or minimising time off work.
A consultative culture
Consultation between members of the medical team, artistic team and dancers is frequent and open, and it takes various forms:
• Often a dancer receives treatment from multiple practitioners, in which case all practitioners liaise with each other about the future treatment and progress of the dancer. The dancer is consulted at each stage throughout the preventative and treatment regimes. While the dancers’ contracts allow for discussion between various members of staff, high standards of confidentiality are maintained.
• All participants in the injury prevention program, including the dancers, are consulted on policy matters that relate directly to their health, safety and wellbeing.
• The dancers have a forum for consultation about general health and safety matters, other than those specifically related to dance, via their EHS Representatives.
A just culture
The Australian Ballet fosters a culture that is supportive of the dancers’ physical and mental needs. Support, nurture and complete rehabilitation of injured dancers by the artistic and medical teams stems from their understanding of a dancer’s concerns and needs.
In the past dancers were reluctant to report injuries so as not to jeopardise performance opportunities. TAB has demonstrated that reporting injuries does not disadvantage them in any way; on the contrary, everything is done to ensure that dancers are not restricted from their pre-injury status.
Injury prevention program
Dancers are exposed to multiple risks in every production. There are approximately nine productions and 180 performances per year, and about five months of national and international touring. Few other dance companies tour for as long, or travel as far as TAB. The company employs 70 dancers who range in age from 19 to 42 years.
Each production presents new roles and physical demands, with additional risks posed by the differing workplaces and performance conditions present at each venue.
The TAB’s comprehensive injury prevention program is designed to meet these challenges and prevent the risk of injury. Its key elements are: screening; risk analysis; prevention programs; communication and on-site facilities.
Following on from risk analysis is the development of site-specific, group-specific and repertoire-specific prevention programs designed to address particular issues.
Injury prevention exercise programs are devised by the Medical Team and instructed by the body conditioning specialist with the dancers at the beginning of the rehearsal period.
Other prevention programs include the annual graduated return-to-work program as well as post-performance, in-flight and post-flight recovery strategies.
Graduated return-to-work program
The graduated return-to-work program has been in effect for 14 years. It was initially devised by the medical team to address the high incidence of stress fractures originating at the beginning of each year due to the sudden onset of workload following the annual holiday break.
Before going on annual leave, the dancers are instructed in a home exercise program that has been developed for them by the therapists of the medical team. In the three days prior to the company’s first day back at work, optional conditioning classes are offered to all dancers. The first two weeks of the return-to-work period are then structured carefully to minimise the likelihood of injury.
By the end of the second week, dancers have gradually increased the hours and intensity of their workload to a full day of class and rehearsals.
Covering a variety of health topics, the education sessions are an important part of this program, aiming to increase dancers’ appreciation of the importance of injury prevention measures and understanding of current injury management strategies. Topics include nutrition, stress management, recovery strategies, cross-training and cardiovascular training.
The program has dramatically reduced the incidence of stress fractures, and also equips dancers with self-management techniques to improve their wellbeing.
Post-performance recovery strategies
Recovery from rehearsal and performance loads is an integral part of maximising performance. Both the mind and the body need to recover so many tools are utilised at The Australian Ballet including the use of spa and plunge pool, contrasting hot/cold showers, ice baths and compression garments. Dancers are trained in specific methods of flexibility recovery such as dynamic stretching. Relaxation and leisure pursuits are also encouraged.
Communication begins with daily liaison between the medical team, artistic staff and dancers and a weekly injury report, which becomes the basis for a weekly medical meeting between the medical team and artistic staff. The documented meetings are a forum for discussing the status of dancers and short-term treatment and prevention strategies, including workload modification.
The medical and artistic teams meet bi-annually to discuss injury data, incident trends, future prevention strategies as well as to monitor and evaluate the effectiveness of current preventative measures. The artistic director, executive director and director of operations are included in this meeting, which looks beyond the short-term and encourages innovative solutions to issues that have arisen in the previous six months.
The EHS Committee meets quarterly and discusses a range of issues, including hazards within the dancers’ working environment in the rehearsal room and on stage. They then develop safe working procedures, communicated to all relevant personnel. The vision for the company's health and safety management system is ‘Speaking Up For Safety’ and the EHS Committee is a key element in that line of communication.
The Australian Ballet has an ever-growing range of facilities used to promote fitness and prevent injuries including an in-house exercise studio, travelling exercise equipment and a variety of portable devices located in and around the rehearsal studios.
The development of The Australian Ballet’s Injury Management and Prevention Program has evolved over several years, involving all levels of the organisation. The success of the program extends both from the enthusiasm and commitment of all participants and the desire for continual improvement. The Medical Team regularly formulates innovative ideas and solutions to maintain the health and well-being of its dancers and thereby enhance the company as a whole.
This article originally appeared in the December edition of the MEAA Symphony Orchestra Musician Association magazine, SenzaSord, and was produced with the assistance of Sue Mayes, Principal Physiotherapist and Medical Team Manager at The Australian Ballet.