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Leading the Way in Dance Healthcare Management – the Science Behind the Art

The concept of a dancer as ‘artistic athlete’ comes of age, writes Head of Industry and Artist Support and the National Institute of Dance Medicine and Science Helen Laws

Dancer in The Royal Ballet’s Healthcare Suite, photo Andrej Uspenski

For those of us who have been striving to promote dancers’ health and fitness with the aim of reducing risk of injury and improving performance and career longevity since before the first ‘Healthier Dancer Conference’ in 1990 and the first national survey of dancers’ health and injury (Fit to Dance?, Brinson and Dick, 1996), it seems that we are now reaching a crucial time.

When the concept of an ‘athletic artist’ was gaining momentum in the nineties and 2000s, we relied on limited dance-specific evidence and borrowed from sports medicine and sports science. Now, we find ourselves at a tipping point in how the health and fitness of dancers is supported as several leading companies and training institutions begin to truly embrace a more scientific, evidence-based approach to helping dancers stay at the top of their game.

I spoke to Greg Retter, Clinical Director at The Royal Ballet, and Karen Sheriff, Healthcare Manager at The Royal Ballet School, to gain insight into the recent developments in the way they now jointly approach the healthcare management of the dancers across the School and Company.

Impetus for change
Retter joined The Royal Ballet in the new role of Clinical Director in 2013, following a review of healthcare services. Together, they wanted to implement a more streamlined and meaningful delivery of healthcare services for dancers with better integration across diverse provisions.

The impetus for this review was in part a recognition by leadership that the field of sports/dance science had an important role to play in reducing and managing injuries. The board, Chief Executive, and Artistic Director, Kevin O’Hare, recognised their duty of care to provide excellent healthcare to the dancers, who use their bodies as their instrument.

Having embedded a comprehensive multidisciplinary team (MDT) at the Company, it was clear there was also a need for more support at the School and Artistic Director Christopher Powney was keen to integrate a Healthcare Manager at The Royal Ballet School. Since September 2017, the School has built a healthcare team consisting of 21 members of staff operating across White Lodge and the Upper School.

Working separately, practitioners can individually provide good rehabilitation, but working together results in an excellent rehabilitation. Greg Retter, Clinical Director, The Royal Ballet

The key to the change has been the new leadership at both the School and Company coming from a viewpoint and understanding that supporting the dancers to be the best they can be requires investment.

Dancer in The Royal Ballet’s Healthcare Suite, photo Andrej Uspenski

What does The Royal Ballet’s healthcare and sports/dance science integration look like?
The stronger link between Company and School began when the Company tendered for a sports science service to complement and work alongside their existing healthcare team. St Mary’s University, Twickenham, was successful and began by sharing strength and conditioning services across the Company and School in September 2016.

Karen Sheriff manages the White Lodge and Upper School healthcare teams which at each site consist of:

  • 2 Physiotherapists
  • Strength and Conditioning Coach
  • Sports and Exercise Medicine (SEM) Consultant (1/2 day a week)
  • Pilates Instructor
  • Counsellor (P/T)
  • Nurse (F/T)
  • Nutritionist (1 day at each site – contracted through the English Institute of Sport and therefore buying into their wider organisational knowledge. The School is the first non-Olympic sport to be taken on by the EIS and it is working well so far.)
  • Rehabilitation Ballet Instructor at Upper School (mirroring the Company)

What are the priorities?
The priority for the company is to manage injuries effectively; ensuring that all the dancers are exposed to the best model of practice as evidenced in the EIS model for Olympic Sport, with a Head of Performance Services (or Clinical Director) having oversight of all the disciplines within the MDT to provide an effective interdisciplinary service.

The school’s key objectives are to optimise bone health, tendon health, wellness and resilience – and they are initiating research projects to inform these.

The School is also aiming to develop dancers who think of themselves as athletic artists, the difference being that they see it modelled around them and are given the tools to achieve it. Sheriff gives the example that at White Lodge they are starting to break down a skill acquisition syllabus for years 7-11, identifying technical skills for development and growth, and setting sports science goals alongside them. A big change next year will be for each student to have 50 minutes out of a ballet class each week to dedicate towards tailored strength and conditioning work. Artistic management has been supportive of the change.

They join others such as ArtEz in the Netherlands, who are shifting from traditional dance training methods to try out a more ‘periodised’ approach, using and adding to the growing sports/dance science evidence-base. The change is a calculated one, based on evidence, and necessary if training and prevention of injury is to improve and evolve to meet the current demands of the profession.

Sheriff recognises it is a risk for directors to change a fundamental element of how dancers have been trained for so many years, to significantly reduce the technique timetable and trust that they will still improve in ballet. Improvements are already showing but Karen is looking forward to seeing the long term impacts of her team’s work.

Retter stresses that from the Company’s perspective it is fantastic to have dancers coming from the School already cognisant of how to manage themselves effectively through the knowledge they’ve gained. The dancers arrive with a developed understanding of the additional physical, nutritional and psychological requirements needed, alongside dance technique,
to succeed.

The integration of sports and dance science in the dancers’ training and support sits absolutely comfortably and in synergy with artistic development and skill acquisition. Karen Sheriff, Healthcare Manager, The Royal Ballet School

Science and technology in dance healthcare management
In March 2014, The Royal Ballet Company began using a digital healthcare data management system to facilitate the MDT’s interdisciplinary working and monitor the effectiveness of their provision. Following a tendering process, Fusion Sport’s Smartabase offered the best solution for these reasons:

  • It works across different disciplines, so the MDT can share information in one space
  • It provides a user-friendly repository for clinical notes
  • There is flexibility to be able to change forms and add modules to make it dance specific
  • Dancers can interact with their profile and full medical notes (Company dancers only) using a smartphone app, enabling them to engage more positively and proactively with experiences in the Healthcare Suite

The Royal Ballet, as the first dance company to use the platform, has invested heavily in it to ensure the system is truly fit for dance purposes. Development of a bespoke scheduling module allows analysis of dancer workload alongside injury and health and fitness screening data to understand and mitigate against the most significant risk factors for injury. An appointment module allows dancers to make and access appointment information through the app, and tracks utilisation of services across the Healthcare Suite. Fusion Sport has been supportive of developing Smartabase for use in the dance sector and the Royal Ballet School (September 2016), Birmingham Royal Ballet (2015) and Queensland Ballet (November 2017) have also started to use it, with others interested.

The School is in a particularly good position to use the technology for education as well as healthcare management purposes. Since establishing their degree programme in 2017 the students take Healthy Dancer modules; in Year 1, they attend nutrition, musculoskeletal and injury management lectures and in Year 2 they study sport psychology and sports science. Students also track their wellness daily via the app, including measures of fatigue, hydration, sleep quality/quantity, general muscle soreness, sessional RPE (Rate of Perceived Exertion), and menstrual cycle. Acute chronic workloads are automatically calculated to identify when dancers need to pull back or do more.

A traffic light system is incorporated where ‘red alerts’ on wellness are flagged with the healthcare team and dancers are then called to have a check-in to ensure all is ok. The students have been embracing the science and technology at their disposal for education and healthcare support, linking this vital support and knowledge with dancing success. Some of the expertise is also being fed into the School’s Associate classes, which train dancers from 8-17 years-old once a week in centres across the country.

Digital ‘Dashboards’ are set up for the healthcare team to see key data at a glance, for example:

  • Profiling scores – showing the individual dancer as well as where they sit within a cohort
  • Relative Energy Deficiency in Sport (RED-S) – adverse effects on health and performance when nutritional intake doesn’t cover energy demands of both training and normal metabolic processes
  • Wellness – a student-facing dashboard upon which students have to write a weekly reflection and an essay

The dance sector is in a great position (compared with the competitive sports world) to benefit from using such a platform. Dance organisations using it are sharing their developments with each other, creating an international community where we will all be able to learn much more from each other. This includes the ability to look at the (anonymised) data across a range of different organisations collectively. The National Institute of Dance Medicine and Science (in which the Royal Ballet companies are partners) is hoping to be able to purchase a UK version of Smartabase so that medium and small-scale dance companies and schools can benefit from the technology and sharing of expertise too.

Measuring success
Success for Retter and Sheriff is measured in a number of ways. They work to manage needs better but also enhance understanding of training, reducing injury, improving performance availability, and increasing dancer satisfaction. Having the wider knowledge and support network to call upon in tricky situations is also important to both the dancers and the healthcare team.
It has been vital for the two institutions to work together for the benefit of students and the Company; utilising the expertise from both teams puts them in the strongest position. Working together on research projects and ongoing work and the strong link with St Mary’s University means they are managing dancers’ transitions into the profession much better and as Christopher Powney believes, “it is about creating the best dancers for the profession.” As Sheriff concludes, “there is still so much to discover but our teams are on it!”

 

Originally published in One, Issue 5 – Autumn 2018

NIDMS Royal National Orthopaedic Hospital