Healthcare Considerations for Elite Dancers;Sport and Exercise Physicians’ Perspectives

Abstract

Introduction: Previous research on dancers’ perceptions of healthcare providers and access to healthcare has found lower utilization of physicians for dance-related injuries, with the perception that dancers do not have the same access to specialized healthcare as athletes. This study is the first to examine sports and exercise medicine physicians’ perspectives on similarities and differences in clinical care between dancers and athletes, specifically at the elite level. Methods: An international panel of 14 sports and exercise medicine physicians with dance medicine expertise was recruited. A four-round, ranking-type Delphi study explored consensus on perceived clinical similarities and differences between elite dancers and athletes. Results: 28 perceived similarities and 32 differences were grouped into six categories: physicality, health and wellness, injury, socioeconomic factors, training approaches, and personality traits. 20 perceived similarities and 12 perceived differences reached consensus status. Consensual perceived similarities were highest (n = 5) within the personality traits category, including traits such as highly motivated, highly determined, highly driven, perfectionistic, and highly committed. The highest number of consensual perceived differences was found in the physicality category (n = 4), including greater ranges of motion and the importance of aesthetic and choreographic demands in elite dance. Within the socioeconomic category, the panel concurred that elite dancers experience greater financial instability and less access to healthcare providers. Conclusion: The panel of sport and exercise physicians agreed there are more perceived similarities than differences between elite dancers and athletes, especially in personality traits. The unique aesthetic focus in dance distinguishes it from conventional sports and may contribute to a dance-specific injury profile. This study’s findings may help healthcare providers unfamiliar with dance medicine improve clinical care and healthcare accessibility when seeing elite dancers.

Key Points

Sport and exercise physicians (and other healthcare providers) who do not routinely see elite dancers should consider the following as part of their clinical approach:

• Elite dancers and elite athletes may share similar personality traits, including high motivation, determination, drive, commitment, and perfectionism.

• Elite dance differs from other sports due to its aesthetic focus and choreographic demands, which may predispose elite dancers to dance-specific injuries.

• Socioeconomic factors, such as financial pressure, may pose barriers to healthcare access for elite dancers; therefore, plans should be individualized, offering treatment options while weighing up costs versus benefits.

Introduction

The myriad forms of dance are enjoyed worldwide as a pastime, a social activity, and a profession. For an elite dancer, dance can be a love, a passion, and central to their identity. ¹ Ill health, including injury, is a common reason that dancers are unable to participate in dance. ² The utilization of physicians by professional and pre-professional dancers has been found in some studies to be lower than that of therapists and, at times, of non-healthcare providers such as dance teachers.^{2 -5}. Most of the elite dancers surveyed in the study by Shah et al ⁶ did not consult any physicians for their dance-related injuries, and more than half of the cohort studied by Alimena et al ⁵ did not receive any medical examination over a 12-month period. This has led to the observation that dancers may have less access to specialized healthcare providers than athletes. ² The complex interplay among dancer employment arrangements, healthcare infrastructure, and the dancer-doctor relationship has been postulated to affect elite dancers’ access to healthcare.^{3,7 -9}

The operational definition of dance medicine, being the application of sport and exercise medicine in dance, is a growing clinical discipline that has established health benefits for dancing populations. ² The availability of dance medicine services for dancers and dancers’ perceptions of their treating clinicians^{3 -7,10} vary worldwide. ¹¹ For example, most of the French dancers from the Alimena and Air ⁸ study had less than moderate confidence in their physicians’ ability to treat dance-related injuries. In contrast, professional and pre-professional Dutch dancers seen at the Medical Centre for Dancers and Musicians in The Hague reported that the majority first sought treatment from a medical doctor or physiotherapist, were satisfied with physician consultations, and were confident in their full recovery. ⁷ It appears that health-seeking behaviors may be influenced by existing referral pathways and word-of-mouth recommendations to specific healthcare professionals, ⁴ as well as by the availability of dancer-centric healthcare services, all of which affect dancers’ confidence and treatment outcomes.

Many studies have focused on dancers’ perceptions of healthcare providers and healthcare access;^{3 -7,10} few papers have examined healthcare professionals’ perceptions of this artistic cohort. ¹² Surveying healthcare professionals with expertise in dance medicine regarding their perceptions of caring for elite dancers ¹³ may provide insight into this cohort and help improve access to healthcare for dancers.

This is the first study to gather the perceptions of a cohort of sports and exercise medicine physicians with expertise in dance medicine regarding similarities and differences in the care of elite dancers compared with that of conventional elite athletes. Several definitions of the elite athlete exist, including an individual who competes nationally or internationally, or someone with greater performance ability than peers in the same sport. ¹⁴ The operational definition of an elite dancer in this paper refers to a dancer who has embarked on a career in dance and is paid, either by salary or contract, by a professional dance company.

Methods

The Delphi methodology has been widely utilized in health and medical research^15,16 and is well-regarded for its ability to investigate expert opinion. ¹⁷ The original Delphi method aimed to obtain the most reliable group consensus regarding a specific topic.^18,19 A variation known as the ranking-type Delphi has been developed by researchers to brainstorm important issues, narrow the list to the most important items, and rank them according to their level of importance.^20,21 Previous literature has recommended that a Delphi study involve at least three iterations for consensus development.^13,22 A cohort size of 10 to 15 experts with homogeneous backgrounds has been deemed sufficient to achieve consensus using the Delphi methodology.^14,15

This study involved four rounds of web-based surveys (Qualtrics Research Suite, Qualtrics, Provo, Utah, USA) with a target panel of 10 to 15 sports and exercise medicine physicians, and was approved by the research ethics committee of Edith Cowan University, Western Australia.

Expert Panel

As the success of the Delphi study critically depends on the selection of knowledgeable experts^13,23 with special interests related to the target questions, the inclusion criteria for panellists in this study were sports and exercise medicine physicians with expertise in the care of elite dancers. Training in sports and exercise medicine varies worldwide. In the United States and Canada, doctors had to be board-certified in their primary specialty and hold additional certification in sports medicine. In the UK, Europe, Australia, and New Zealand, sports and exercise medicine is a stand-alone specialty training program. To be considered eligible for this study, sports and exercise medicine physicians had to meet region-specific training requirements and be fully qualified in their field.

The researcher reviewed the individuals’ online academic biographies to ensure they met the inclusion criteria. The aim was to include as many international experts in the field as possible; however, individuals whose biographies were not written in English were excluded from the study. The primary researcher identified 48 sport and exercise medicine physicians from a range of sources, including personal networks, ²⁰ online searches of doctors involved in the care of dance companies internationally, authors involved in dance research and three databases of international performing arts medicine and sports medicine organizations. A physician who indirectly oversaw the project was excluded, bringing the final number to 47. Fourteen physicians responded to the invitation email, meeting the target of 10 to 15.

Procedure

Questionnaires were designed in Qualtrics (Qualtrics Research Suite, Qualtrics, Provo, Utah, USA) to collect demographic information and panellist responses. Pilot tests were conducted with three sports and exercise medicine physicians who were not involved in the study, and the questionnaires were edited based on feedback. The initial invitation email included information on the aims of the research project and the procedure. ²⁴ The Delphi method included a minimum of three rounds of surveys^13,22 released approximately two weeks apart, ¹⁴ with the stopping rule of achieving consensus or stability of the answers, ²⁵ whilst maintaining anonymity between panellists.^23,26,27

The first round gathered demographic information from panellists and asked two open-ended questions: 1) What do you perceive are the primary similarities in the care of elite dancers and elite conventional athletes? 2) What do you perceive are the primary differences in the care of elite dancers and elite conventional athletes? Each question required six responses, each accompanied by a short description, to uncover the important issues for each participant during brainstorming. ²⁸ Each panellist was contacted for clarification of answers. Duplicate items were eliminated, and responses for questions one and two were consolidated into randomized order. ²⁸

Consolidated lists were given as feedback to the panellists in round two, who were asked to rate agreement from one (highly disagree) to five (highly agree) on a Likert Scale. ²¹ The definition of consensus-percentage agreement ²⁵ was adopted, with a threshold of 70% or higher. ²⁹ Responses with agreement ratings of four or five by more than 70% of the panellists were considered to have reached a consensus.

Round three reiterated the agreement rating process from round two, using the same lists of items for questions one and two as a repeatability assessment before the ranking process. ²⁸ Responses from each round were provided to panellists as feedback before proceeding to the next round. Items that met the consensus threshold in both rounds two and three were ranked in order of importance by the panellists^20,21 in round four.

The data collection took place between September 2020 and May 2021. The surveys were distributed approximately every four weeks. Data from the four rounds of surveys were analyzed in Microsoft Excel (Microsoft, Seattle, WA, USA).

Results

Expert Panel Demographics

The 14 sports and exercise physicians recruited were based in North America, Europe, and Australia, and the majority identified as male. Fifty per cent of the panellists had more than 15 years of experience in the care of elite dancers. As the survey took place during the COVID-19 pandemic, the question specifically asked about physicians’ consultation rates pre-COVID-19, and more than 70% had weekly consultations with elite dancers. In addition to sports and exercise medicine, the most common sub-specialty was in rehabilitation medicine (29%), followed by orthopedic surgery (27%). Other sub-specialties included family medicine, internal medicine, and pediatrics (21% each). Table 1 details the demographic profiles and response rates across the rounds.

Table 1.

Demographics Participants and Response Rates Across Rounds 1-4.

Demographics	Round 1n = 14(n (%))	Round 2n = 12(n (%))	Round 3n = 8(n (%))	Round 4n = 9(n (%))
Gender
Female	5 (36)	4 (33)	2 (25)	2 (25)
Male	9 (64)	8 (67)	6 (75)	7 (77.7)
Continent
Australasia	3 (21)	2 (17)	2 (25)	2 (25)
Europe	4 (29)	3 (25)	3 (37.5)	3 (37.5)
North America	7 (50)	7 (58)	3 (37.5)	4 (44.4)
Medical speciality (other than sports and exercise medicine)
Family medicine	1 (7)	1 (8.3)	0	0
Internal medicine	1 (7)	1 (8.3)	0	0
Orthopedics	3 (21)	3 (25)	2 (25)	3 (33.3)
None other (sole specialization)	4 (29)	3 (25)	2 (25)	3 (33.3)
Pediatrics	1 (7)	1 (8.3)	0	1 (11.1)
Rehabilitation	4 (29)	3 (25)	4 (50)	2 (22.2)
Years of experience treating elite dancers
<5 years	2 (14)	1 (8.3)	0 (0)	0 (0)
5-9 years	3 (21)	2 (16.7)	1 (12.5)	1 (11.1)
10-14 years	2 (14)	2 (16.7)	2 (25)	2 (22.2)
>15 years	7 (50)	7 (58.3)	5 (62.5)	6 (66.7)
Frequency of consultation with elite dancers (pre Covid 19 pandemic)
Weekly	10 (71)	8 (66.7)	5 (62.5)	5 (55.6)
Fortnightly	2 (14)	2 (16.7)	2 (25)	2 (22.2)
Monthly	2 (14)	2 (16.7)	1 (12.5)	2 (22.2)
Every 3 months	0 (0)	0 (0)	0 (0)	0 (0)
Every 6 months or more	0 (0)	0 (0)	0 (0)	0 (0)

Abbreviations: n, number of participating panelists; %, % participation out of the initial 14.

Round 1

Fourteen panellists contributed 28 perceived similarities to question one and 32 differences to question two. These responses were organized into six categories: physicality, health and wellness, injury, socioeconomic factors, training approaches, and personality traits. The survey answers related to questions one and two are provided in Tables 2 and 3, respectively.

Table 2.

Results of Rounds Two and Three with Percentages of Agreement Regarding Responses to Question 1: What Are the Perceived Primary Similarities Between Elite Dancers and Elite Athletes?

Perceived similarities (N = 28)	Percentage of agreement
	Round two (n = 12)	Round three (n = 8)
1. Physicality
1.1 High levels of athleticism/physicality	82	100
1.2 High emphasis on body weight and physique	73	88
2. Health and wellness
2.1 Require highly individualized treatment plans	82	75
2.2 The need for wellness monitoring strategies	82	100
2.3 At risk of developing Relative Energy Deficiency Syndrome and female athlete triad syndrome	63	88
3. Injury
3.1 High level of awareness by the elite athlete or dancer towards injury recognition and management	27	88
3.2 At risk of overuse injuries	91	100
3.3 Fearfulness towards injuries	55	38
3.4 At risk of acute injuries	73	100
3.5 Tendency of training while injured	73	100
3.6 At risk of developing dance-specific and sport-specific injury profiles	73	88
4. Socioeconomic
4.1 Experience external pressures to perform at a high level	100	88
4.2 Short career span	55	63
4.3 The nature of elite dance and elite sport is all-consuming	91	88
4.4 Used to working in highly hierarchical environments	82	63
4.5 Elite dancers and athletes are professionals; their bodies are tools of their trade and sources of income	91	100
4.6 Requirements for local and international travel	27	50
5. Training approaches
5.1 Tendency for burnout	63	75
5.2 High levels of skill training and specialization	91	88
5.3 High levels of aerobic fitness and conditioning	55	100
5.4 Have unique nutritional requirements	73	100
5.5 High demands of training load.	91	100
5.6 Undergone rigorous dance or sport selection processes over the years	73	88
6. Personality traits
6.1 Highly committed	91	88
6.2 Highly motivated/driven	91	100
6.3 Highly disciplined	91	88
6.4 Highly determined	91	100
6.5 Perfectionistic	82	100

Items that achieved the consensual agreement threshold of 70% in both rounds two and three are in bold.

Abbreviations: N, number of perceived items; n, number of participants.

Table 3.

Results of Rounds Two and Three with Percentages of Agreement Regarding Responses to Question 2: What Are the Perceived Primary Differences Between Elite Dancers and Elite Athletes?

Perceived differences (N = 32)	Percentage of agreement
	Round two (n = 12)	Round three (n = 8)
1. Physicality
1.1 Elite dancers regard themselves primarily as performers, not as athletes	63	75
1.2 Elite dancers desire lower body fat and thinness, more than conventional elite athletes	63	100
1.3 Elite dancers are more likely to have and maintain higher range of motion	91	100
1.4 There are dance specific movements, which are not found in conventional sports	91	100
1.5 There is the importance of artistry and choreography in dance, which is not the case in conventional sports	91	100
1.6 There is higher aesthetic focus in elite dance compared to conventional elite sports	91	100
2. Health and wellness
2.1 Elite dancers are more likely to smoke than conventional elite athletes	73	75
2.2 Elite dancers are more prone to the consumption of alcohol and/or other recreational drugs than conventional elite athletes	18	25
2.3 Elite dancers tend to value ongoing physical maintenance care, more than conventional elite athletes	27	50
2.4 Elite dancers are at higher risk of adolescent growth-related injuries, than most conventional elite athletes, apart from gymnasts	27	50
2.5 Elite dancers tend to be less compliant with dietary guidelines, compared to conventional elite athletes	45	50
2.6 Elite dancers have a higher risk of developing Relative Energy Deficiency Syndrome than conventional elite athletes	73	63
3. Injury
3.1 Elite dancers are less likely to get contact injuries compared to conventional elite athletes	91	100
3.2 Elite dancers have dance-specific injury profile, which is different to conventional elite athletes	82	86
3.3 Elite dancers tend to be under less external pressure to train while injured, compared to conventional elite athletes	9	25
3.4 Elite dancers tend to modify their dance activities, and continue dancing while injured, whereas most conventional elite athletes would not	18	50
3.5 Elite dancers tend to self-manage their injuries, more than elite conventional athletes	55	50
4. Socioeconomic
4.1 Elite dancers tend to get less recognition for their skills, compared to conventional elite athletes	73	75
4.2 Elite dancers experience less financial stability compared to conventional elite athletes	73	100
4.3 Elite dancers have less access to healthcare professionals, than conventional elite athletes	73	75
4.4 Elite dancers have less recovery time than other elite athletes, as they must supplement their income with extra work	55	63
4.5 Elite dancers tend to be insufficiently insured compared to conventional elite athletes	73	50
5. Training approaches
5.1 Elite dancers tend to focus less on strength training and use lower load, than conventional elite athletes	82	86
5.2 Elite dancers have less recovery time than conventional elite athletes, due to their performance schedules and the lack of periodization in training	82	86
5.3 Elite dancers have a better understanding of anatomy compared to conventional elite athletes	36	50
5.4 Elite dancers utilize muscle memory in dance training and performance, more than most conventional elite athletes	36	50
5.5 Elite dancers tend to be less aware of overtraining than conventional elite athletes	45	25
5.6 Elite dancers are weaker in strength than conventional elite athletes	45	50
5.7 Elite dancers tend to have longer training hours than conventional elite athletes	45	38
5.8 Elite dancers tend to have lower cardiovascular fitness levels, than conventional elite athletes	55	63
6. Personality traits
6.1 Elite dancers tend to be more distrusting of medical professionals, compared to conventional elite athletes	55	63
6.2 Elite dancers work more independently and self-focused, whereas conventional elite athletes are more team orientated	63	63

Items that achieved the consensual agreement threshold of 70% in both rounds two and three are in bold.

Abbreviations: N, number of perceived items; n, number of participating panelists.

Rounds 2 and 3

Twelve panellists (86%) responded in round two, and 8 (57%) in round three. With consensus for agreement defined as an agreement rating of 4 and 5 on the Likert scale by 70% or more, ²¹ 20 perceived similarities (71% of N) for question one and 12 perceived differences for question two (38 % of N) achieved consensus in both rounds, as shown in Tables 2 and 3. Items that did not reach the agreement threshold in both rounds were removed from the lists.

Consensual Relevant Similarities

Personality factors such as high motivation, determination, drive, commitment, and perfectionism towards their profession accounted for the most consensually agreed items regarding the similarities between elite dancers and athletes (N = 5). This was closely followed by the training approaches and injury categories (N = 4).

The perceived similarities in injury demonstrated the risks of acute and chronic injury, the dance- and sport-specific injury profiles, and the tendency for both groups to train while injured. The high levels of athleticism and the specific physique required for performance are reflected in the physicality category. The training category highlights the rigorous demands of training, including load, nutritional requirements, skill acquisition, sport specialization, and participation in rounds of selection processes.

Within the socioeconomic category, both groups are perceived as experiencing high pressures to perform at high levels, with their professions described as all-consuming. The panel agreed that elite dancers and athletes are professionals whose bodies are tools of their trade and sources of their income.

Consensual Relevant Differences

The physicality category had the highest number of consensually relevant differences (N = 4), in which the importance of dance-specific movements, greater ranges of motion, aesthetic focus, and artistic and choreographic demands were found to be uniquely different in dance compared to sport.

The next highest category was socioeconomic factors, which highlighted differences in societal recognition, financial gains, and access to healthcare for elite dancers compared to athletes (N = 3). The panel recognized that dancers are less likely suffer from contact injuries; focus on strength training and incorporate adequate recovery and periodization strategies. Elite dancers were also perceived as more likely to smoke than elite athletes. There were no differences in personality traits that were consensually relevant between the two cohorts.

Round 4

Nine panellists ranked consensually relevant responses derived from rounds two and three, from the most to least important. Tables 4 and 5 present the median scores, standard deviations, and interquartile ranges (IQRs) for responses to questions 1 and 2.

Table 4.

Consensually Relevant Similarities of Question 1 Ranked According to the Median Scores in Round 4.

Rank	Similarities (N = 20)	Category	Median	SD	IQR
1	Highly committed	Per	4	4.5	8
2	The nature of elite dance and elite sport is all-consuming	Soc	4.5	7.4	13
2	Elite dancers and athletes are professionals; their bodies are tools of their trade and sources of income	Soc	4.5	5.7	8
3	Highly disciplined	Per	7	5.1	9
4	At risk of developing dance-specific and sport-specific injury profiles	Inj	7.5	5.8	11
4	High levels of skill training and specialization.	Train	7.5	3.1	3
4	Highly motivated/driven	Per	7.5	4.4	7
5	At risk of overuse injuries	Inj	8	6.8	14
6	Require highly individualized treatment plans	Health	8.5	4.3	5
7	Undergone rigorous dance or sport selection processes over the years	Train	10	2.7	7
8	High emphasis on body weight and physique	Phys	11.5	5.9	10
8	High demands of training load	Train	11.5	5.1	6
9	Experience external pressures to perform at a high level	Soc	13	5.7	12
10	At risk of acute injuries	Inj	13.5	7.0	12
10	Tendency of training while injured	Inj	13.5	5.2	5
10	Highly determined	Per	13.5	4.5	10
11	Perfectionistic	Per	14	4.6	7
12	High levels of athleticism/physicality	Phys	16.5	7.5	11
13	The need for wellness monitoring strategies	Health	17	5.2	10
14	Have unique nutritional requirements	Health	18	4.1	7

Items with the same scores were allocated the same rank.

Abbreviations: N, number of consensually relevant items; SD, standard deviation; IQR, interquartile range; Soc, socioeconomic; Per, personality traits; Train, training approaches; Health, health and wellness; Inj, injury; Phy, physicality.

Table 5.

Consensually Relevant Differences of Question 2 Ranked According to the Median Scores in Round 4.

Rank	Differences (N = 12)	Category	Median	SD	IQR
1	Elite dancers tend to get less recognition for their skills compared to conventional elite athletes.	Soc	3	4.3	6
2	Elite dancers are more likely to smoke than conventional elite athletes.	Health	4	3.8	5
2	Elite dancers have less access to healthcare professionals, than conventional elite athletes.	Health	4	3.7	4
3	Elite dancers have dance-specific injury profile, which is different to conventional elite athletes.	Inj	5	3.0	6
4	Elite dancers tend to focus less on strength training and use lower load, than conventional elite athletes.	Train	5.5	3.4	6
5	There is the importance of artistry and choreography in dance, which is not the case in conventional sports.	Phy	6.5	2.7	3
5	There is higher aesthetic focus in elite dance compared to conventional elite sports.	Phy	6.5	3.3	5
6	Elite dancers have less recovery time than conventional elite athletes, due to their performance schedules and the lack of periodization in training.	Train	7	2.3	2
6	Elite dancers are more likely to have and maintain higher range of motion.	Phy	7	3.6	7
7	There are dance specific movements, which are not found in conventional sports.	Phy	7.5	3.9	7
8	Elite dancers experience less financial stability compared to conventional elite athletes.	Soc	9	2.3	2
9	Elite dancers are less likely to get contact injuries compared to conventional elite athletes.	Inj	11	1.4	3

Items with the same scores were allocated the same rank.

Abbreviations: N, number of consensually relevant items; SD, standard deviation; IQR, interquartile range; Soc, socioeconomic; Train, training approaches; Health, health and wellness; Inj, injury; Phy, physicality.

‘Highly committed’ of the personality trait category was ranked the most important consensually relevant similarity (Median 4, SD 4.5, IQR 8), whereas ‘Elite dancers tend to get less recognition for their skills compared to conventional elite athletes’ of the socioeconomic category was ranked the most consensually relevant difference (Median 3, SD 4.3 and IQR 6).

There was weak consensus for the rank order scaling for question one according to Kendall’s coefficient of concordance (W = 0.32, P < .001), and weak to very weak consensus for question two (W = 0.26, P < .001). ²⁸

Discussion (Findings and Clinical Implications by Categories)

Personality Traits

Given the similarity in personality factors between elite dancers and athletes, this highlights the dedication of these individuals to their profession. Medical professionals should be aware of the potential anxiety that elite dancers may bring to health consultations, particularly if medical treatment warrants non-participation in dance for a period. Educating the dancer about the benefits of compliance and the potential consequences of noncompliance with treatment is essential, ¹² as is establishing a streamlined communication pathway with the dance company, particularly with the artistic team and other healthcare providers involved, in the management plan.

The success of the consultation with an elite dancer may require the clinician to have not only a sound understanding of the injury profile and its management, but also an awareness of the cluster of personality traits and the potential anxiety levels associated with the injury. High levels of anxiety and depression would necessitate the involvement of an experienced mental health practitioner to provide psychological support for the dancer.

Socioeconomic Factors

The panel has agreed upon the definition of elite dancers and elite athletes as professionals whose bodies are tools of their trade and sources of their income; they perceive both groups as similarly involved in all-consuming, high-level performance, in which the body is indispensable.

Despite working in similar environments of performance pressure and demands, the panel thought that elite dancers received less recognition, income, and access to healthcare professionals than athletes, suggesting that lower access to healthcare may be in part due to financial constraints.

Clinicians may consider asking about the dancers’ medical insurance status, as the situation may vary depending on the size of the company, the dancer’s employment status as an employee or contractor, and whether insurance coverage covers only dance-related injuries and excludes other issues. A case-by-case approach, involving the dancer and the dance company in the shared decision-making process, will be necessary to select the best treatment options while weighing costs versus benefits.

Training Approaches, Health and Wellness

Elite dancers were perceived by the sports and exercise panel as having high training loads and training specialization, as reported by the athletes, but also as having a lower perceived focus on strength training, periodization, and recovery. The perceived lack of strength focuses in dance training may increase injury rates and prolong injury rehabilitation times, which can be counterproductive. Further research is necessary to determine the optimal strength measures for dance performance and injury risk reduction.

For decades, the concepts of recovery and periodization, which have been employed in elite sport to achieve optimal performance, especially in a competitive setting, have been rarely utilized in dance. Elite dancers practice for long hours during rehearsal periods, and the workload may increase in the lead-up to in-season performances. ²⁹ Elite dancers are expected to be in optimal form for the first show of the season and throughout the season, ²⁹ potentially leading to acute, chronic, and dance-related injuries.

The study by Wyon et al ³⁰ demonstrated the benefits of implementing pre-performance tapering in a dance company setting for improving dancers’ mood states and reducing the potential effects of overtraining. There is a need for more such studies to be conducted, exploring the outcomes of pre-performance season tapering in relation to injury rates, so more dance company directors and stakeholders can utilize periodization concepts.

The panel also recognized the presence of individualized, dance and sport-specific treatment plans and wellness monitoring in dance and sport. As previously mentioned, effective verbal or written communication between healthcare practitioners, dancers and the artistic team, including artistic directors and choreographers, may improve treatment outcomes. ¹² This information may include risk factors for injury and illness, such as strength deficits, macro and micronutrient deficiencies and overtraining, which can impact the dancer’s well-being and performance.

Physicality and Injury

The expert panel identified that the highest number of primary differences between elite dancers and athletes was the physicality factors associated with dance performance; within these factors, aesthetic and artistry-related factors took precedence. Dance is an art form in which the aesthetics of the moving body are the means through which the art is expressed; it is often associated with high ranges of motion and dance-specific movements, driven by the choreographic intention of the performance. As identified by the panel, dancers were perceived as having similar needs to those of athletes, including athleticism, physicality, and a specific body type. These unique needs of dancers are directly related to the aesthetic and choreographic demands of any performance, and as a result, the panel recognized that dancers often present with a unique profile of dance-specific injuries.

Limitations

The ideal panel size has been a debated topic in Delphi studies, with no consensus on an optimal number. ¹⁷ Much of the literature cites a minimum of 10 participants to buffer for attrition. ²³ This study’s initial panel size of 14 met the literature’s recommendations; however, there was an unexpectedly high attrition rate of 36% by round four, ²⁶ which could have been due to the COVID-19 pandemic’s impact on participation among sports and exercise medicine physicians. The high attrition rate and the smaller panel size in subsequent rounds may have contributed to the variation in panel responses across items.

The presence or absence of clinicians’ affiliations with dance companies and referral pathways was not surveyed, which would have provided insight into the dancers’ access to these dance medicine specialists. Moreover, the expert panel was composed solely of sport and exercise physicians; therefore, these findings may not be applicable to other healthcare providers.

It should be noted that although several items achieved strong consensus through the Delphi methodology, others did not, with panel responses varying across many items, including opinions on dancers having a higher risk of relative energy deficiency than athletes. As in all areas of medicine, dance medicine practice requires critical, case-by-case evaluation and effective collaboration among healthcare providers to achieve optimal outcomes for the dancing patient.

Areas for Future Research

Further research opportunities include surveying the medical structures of different professional dance companies of varying sizes and genres, and the impact of streamlined medical referral pathways versus the lack of streamlined referral pathways on primary and specialized healthcare utilization rates, health and treatment outcomes of company dancers. Finally, replicating this study with participants across the different health sectors, such as other therapists involved in the care of elite dancers and elite athletes, would help assess the diversity of healthcare approaches among healthcare professionals with expertise in dance medicine.

Conclusion

The panel of sport and exercise physicians agreed there are more perceived similarities than differences between elite dancers and athletes, especially in personality traits. Dancers and athletes are similarly involved in all-consuming, elite-level performance, and their bodies are essential tools for athleticism and sources of income. Individualized dance- and sport-specific treatment plans and wellness monitoring are important in both management and prevention of injuries and illnesses.

The unique aesthetic focus in elite dance distinguishes it from conventional sports, where, in combination with a lower emphasis on strength focus and recovery strategies than athletes, it may contribute to a dance-specific injury profile. Financial barriers may contribute to inequities in healthcare access among elite dancers. Future research opportunities include examining relationship between medical structures and medical referral pathways in dance companies and healthcare utilization rates, health and injury management outcomes for dancers.