HEALTH-RELATED QUALITY OF LIFE (HRQOL) MEASURES USED IN DANCE: A SYSTEMATIC REVIEW

Abstract

Background:

Dancers are aesthetic athletes who engage in rigorous physical activity. Researchers have noted that 50-85% of dancers are injured annually. Therefore, clinicians have begun providing healthcare for dancers. As part of standard care, clinicians often use health-related quality of life (HRQoL) measures to examine their patient's physical, mental, and social health. While clinicians have previously used several measures to examine athletes’ HRQoL, which measures are used to examine dancers’ HRQoL remains unclear. This lack of information may make it difficult for clinicians working with dancers to understand their patients’ overall wellbeing and impede their ability to devise appropriate treatment plans.

Purpose:

Review existing literature on HRQoL instruments used to measure dancers’ health and wellbeing.

Design:

Systematic Review

Methods:

Three databases were searched (EBSCO Host, Web of Science, and ProQuest Performing Arts) through March 2019 to identify studies that used HRQoL measures to study dancers. Four studies qualified based on the eligibility criteria. Two reviewers independently scored the studies using (1) the modified Downs and Black Quality Index Tool (mDB) yielding a percentage out of 28 possible points scoring methodological rigor; (2) Strength of Recommendation Taxonomy (SORT) tool (i.e. A, B, or C); and (3) Level of Evidence(i.e. Level 1, 2, or 3). Any disagreement was resolved by discussion and a third reviewer (JPA) was available when consensus could not be reached.

Results:

All four studies ranged from 46.4-60.7% of mDB scores, B or C strength of recommendations, and Level 2 evidence. Eight different HRQoL instruments were used across the four studies. Although no two HRQoL measures were the same across studies, several measures had variations of similar overlapping constructs, and all measured some mental health construct.

Conclusions:

Overall, eight different measures were used to examine dancers’ HRQoL. All measures examine some construct of mental health. This finding is important considering the mental aspect of dance. Additional research is needed to examine which measures are suitable to study dancers’ HRQoL. Clinicians can use this information to track their dancers’ overall wellbeing by noting how HRQoL fluctuates over a season, after injury, and over a dancer's career – overall reducing their dancers’ injury risk and enhancing performance.

Levels of Evidence:

Level 1a

INTRODUCTION

Dance is a unique combination of art and sport that requires athletic activity with a lack of specificity and periodicity in training, movement in extreme ranges of motion, artistic expression, and musicality.^1-5 Due to these high mental and physical demands, dancers have an increased risk of injury.^5-7 Dancers have an injury prevalence of 50-85% and incidence rate of 4.44 injuries/1000 hours during a single season – higher than prior reports in other athletes.^5,8-12 High levels of stress and low social support may put dancers at higher risk of injury.¹³ Dance injuries can result in 30.2 hours/1000 hours of dance time-loss.⁵ Time-loss of this magnitude can equate to loss of roles, ability to fulfill educational, employment or program obligations, or career advancement – all of which can negatively impact a dancers’ overall health-related quality of life (HRQoL).^14-19

Recently, clinicians (e.g. physical therapists, athletic trainers, physicians) have begun providing healthcare for dancers.²⁰ As part of standard care, clinicians often use HRQoL to examine their patient's wellbeing (physical, social, and mental).^15,21-23 Dance medicine clinicians have adopted measures used in traditional sports medicine to understand physiometric and psychometric constructs in dancers.^15,16,24-27

Although it may initially seem convenient to use existing measures to study dancers’ HRQoL, it is important to understand that oftentimes these tools were developed and validated within a specific context (i.e. population, setting, intended use, etc.) that may be different than how they are being used in dancers.^25,26,28,29 While some of these measures are used to make inferences about physical or mental performance, patterns, propensity, or limitations, these normative values and interpretations may not be equally applicable across different populations.^16,22,30 For example, the Short-Form 36 (SF-36) questionnaire has been used to examine HRQoL in both the general and athletic population (i.e. collegiate, adolescent). However, the normative values developed for the general population may not completely describe or serve as a baseline function of the athletic population.³⁰ Additionally, using normative values for the collegiate population may not completely describe the adolescent athletic population.^29,30 If findings are not transferable across disciplines, this can result in inappropriate interpretations and clinical decisions.²⁸ As a result, a dancer's career trajectory could be impacted by implications and decisions that are highly dependent on interpretations from measures validated across other non-dance populations. For example, after a typical performance season, many dancers do not take enough time off and continue to perform at various festivals and competitions.³¹ Thus, they may begin to show signs of burnout and psychological fatigue, which may be overlooked if not properly examined, and affect their career. Disruption of one's career may not be caused by one specific situation or physical injury, but rather by the effect of the situation on the various dimensions of an individual's wellness.³²

Overall, despite high injury rates in dance, and health care providers often caring for dancers, it is unclear how HRQoL is being measured and how HRQoL measures are being translated to outcomes for dancers. Therefore, the purpose of this systematic review was to examine what instruments are currently being used to measure HRQoL in dancers and discern which instruments are best suited for the dance population.

METHODS

Protocol and Registration

This review was registered on the Center for Reviews and Dissemination PROSPERO register (CRD42018093754) and was conducted according to the Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) guidelines.³³

Search Methods

Three databases (i.e. EBSCO Host, Web of Science, and ProQuest Performing Arts) were systematically searched for studies using the search terms shown in Table 1. Titles and abstracts were screened for inclusion based on eligibility criteria. Inclusion and exclusion criteria are shown in Table 2.

Table 1.

Keywords and Search Terms Used.

Step	Search Terms	Boolean Operator	EBSCO Host	Web of Science	ProQuest Performing Arts
1	health-related quality of life		73,669	29,294	9
2	adolescent, high school, adult, colleg*, preprofessional, amateur, preparatory, professional, competitive, universit*, young, youth	OR	16,693,715	2,837,822	79,021
3	danc*	OR	116,439	50,684	32,367
4	1, 2, 3	OR	3,635,102	2,855,469	88,679
5	1, 2	AND	58,030	11,171	9
6	1, 3	AND	105	18	7
7	1, 2, 3	AND	85 (71 exported, may include duplicates)	6	7

^*Duplicates in EBSCO Host

Table 2.

Inclusion and Exclusion Criteria.

Inclusion Criteria	Exclusion Criteria
Studies comparing HRQoL outcomes in dancers and nondancers or in injured dancers or those with a history of injury and uninjured dancers or those without a history of injury	Studies that included only retired dancers
Participants in 1 or more groups were described as current dancers	Studies that limited participants to those with chronic diseases (e.g. asthma)
Uninjured dancers or dancers without a history of injury were defined as medically cleared for participation	Studies that used only region-specific or dimension-specific instruments (e.g. IKDC, FAAM, DASH)
Injured participants were defined as having a self-reported recent injury or having a history of musculoskeletal injury or concussion	Studies that described the development of an instrument to assess HRQOL
Studies using generic self-reported instruments (e.g. SF-36, PODCI) as the primary outcome measure	Case studies, conference proceedings, or review articles
Studies published in English
Studies published in peer-reviewed journals

Scoring Methods

Two independent reviewers (ECN, VNF.) assessed the methodological quality of the studies using the modified Downs and Black Quality Index Tool (mDB), yielding a percentage score out of 28 possible points.³⁴ This valid and reliable tool has been classified to examine the methodological rigor of both randomized and non-randomized studies (i.e. observational, epidemiological).³⁴ Studies scoring < 60% were deemed low quality, between 60-74.9% indicate moderate quality, and > 75% suggests high quality of methodological rigor.³⁴

The strength of recommendations made by included studies were determined using the Strength of Recommendation Taxonomy (SORT) tool, which includes A, B, and C grades.³⁵ Grade A is considered consistent, good-quality patient-oriented evidence.³⁵ Grade B recommendations are inconsistent, limited-quality patient-oriented evidence.³⁵ Grade C is considered consensus or case series for studies of diagnosis, treatment, prevention, or screening.³⁵

The Level of Evidence (LOE) ³⁵ was determined for the included studies. Level 1 represents good-quality patient-oriented evidence, Level 2 represents limited-quality patient-oriented evidence, and Level 3 represents other evidence.³⁵ Any disagreement was resolved by discussion and a third reviewer (JPA) was available when consensus could not be reached. The following data were extracted from the included studies: study design, study objective, sample size, and HRQoL measure(s) used (Table 3).

Table 3.

Characteristics of Included Studies.

Author	Objective	Sample Size	HRQoL Measure(s)	HRQoL Domain (s)
Nicholson et al25	Determine whether current child dancers with JHS/EDS-HT experience the same severity & bodily extent of pain as nondancers Examine physical, functional, & psychosocial differences between those who currently dance & those who do not	102 children with JHS/EDS-HT (22 dancers, 80 non-dancers)	Pediatric Quality of Life Inventory (PedsQL) Pediatric Pain Questionnaire; PedsQL 4.0 Generic Core Scales; PedsQL Multidimensional Fatigue Scale	Physical, social, & emotional
Quested and Duda36	Examine relationship between perceptions of motivational climate, need satisfaction (autonomy, competence, & relatedness) & indicators of well-being (i.e. positive affect) & ill-being (i.e. negative affect & emotional & physical exhaustion) among hip hop dancers. The mediating role of need satisfaction in relationship between the perceived motivational climate & dancers' psychological and emotional health	59 hip hop dancers	Perceived Motivational Climate in Sport Questionnaire-2 (PMCSQ-2); Perceived Competence subscale of Intrinsic Motivation Inventory; Acceptance subscale of Need for Relatedness Scale Positive and Negative Affect Scale (PANAS); Athlete Burnout Questionnaire	Satisfaction of the need for relatedness Emotional & physical exhaustion
Schmidt et al.26	Determine the prevalence of GJH in elite-level adolescent ballet dancers, TeamGym gymnasts, & team handball players Investigate whether GJH is associated with self-reported pain, functional ability, HRQoL, injury frequency, postural sway, & motor performance	132 adolescents (22 ballet dancers, 57 TeamGym gymnasts, 53 team handball players)	Rheumatoid and Arthritis Outcome Score for Children (RAOS-Child) Version LK1.0	Pain, other symptoms, function in daily living, function in sport & recreation, & leg-specific QOL
White et al16	Examine internal consistency of mDPA in group of college dance students Examine HRQoL in university dance students using this instrument	31 collegiate female dancers	modified Disablement in the Physically Active Scale (mDPA)	Impairments, functional limitations, disability, psychosocial well-being

*All studies were cross-sectional

Abbreviations: HRQoL – health-related quality of life; JHS – joint hypermobility syndrome; EDS-HT – Ehlers-Danlos syndrome-hypermobility type; GJH – generalized joint hypermobility; & - and

RESULTS

The initial search retrieved 84 articles (Figure 1). Following the initial screening, 53 articles were discarded by either their title and/or abstract. Of the 24 remaining articles, four studies met the eligibility criteria. The mean mDB score of the four studies was 51.78% ± 0.11, which is deemed low methodological rigor (Table 4). On the mDB, all four studies received a ‘no’ on items relating to reporting, internal validity – bias, and internal validity – confounding (selection bias). These questions addressed the importance of reporting adverse effects, blinding of assessors and study subjects, and randomization. The four studies ranged in B or C strength of recommendations and Level 2 evidence. Eight different measures were used across the four studies.

Figure 1.

Search Strategy

Table 4.

Methodological Quality of Included Studies.

First Author	Year	mDB	SORT	LOE	Outcome Measure(s) Used
Nicholson et al.25	2017	46.4%	B	2	PedsQL 4.0
Quested and Duda36	2009	39.3%	C	2	PMCSQ-2, Intrinsic Motivation Inventory, Need for Relatedness, PANAS, Athlete Burnout Questionnaire
Schmidt et al.26	2017	60.7%	B	2	RAOS-Child
White et al.16	2018	60.7%	NA	2	mDPA

Abbreviations: mDB- Modified Downs and Black Quality Index Tool; SQRT - Strength of Recommendation Taxonomy; LEO - Level of Evidence; PedsQL - Pediatric Quality of Life Inventory; PMCSQ-2 Perecived Motivational Climate in Sport Questionnaire: PANAS - Positive and Negative Affect Schedule: ROAS-Child - Rheumatoid and Arthritis Outcome Score, child version; mDPA - Modified Disablement in the Physically Active Scale

DISCUSSION

Dancing is both physically and mentally demanding, as dancers need to perform rigorous choreography and still maintain pleasing aesthetics. Therefore, the various demands on dancers can be represented by many different constructs. Clinicians working with dancers should consider their patients’ overall HRQoL to optimize their healthcare. The current review found that across the four articles included, none of the researchers administered the same HRQoL instrument, indicating the lack of uniformity in HRQoL measurement in dance. Still, while the eight HRQoL measures used and multiple questions asked to study dancers’ HRQoL were different, all measures examined some construct of mental health.

Generalizability Across Measures

Each of the instruments included in this study were created for a specialized population, which threatens generalizability of the results across the different HRQoL measures. Nicholson et al.²⁵ examined HRQoL in pediatric dancers and nondancers (aged 6 to 16 years) diagnosed with Joint Hypermobility Syndrome/Ehlers-Danlos Syndrome-hypermobility type (JHS/EDS-HT). While Schmidt et al.²⁶ investigated HRQoL in elite-level adolescent athletes (aged 13 to 16 years) who participated in ballet, TeamGym gymnastics, or team handball and may or may not have been diagnosed with Generalized Joint Hypermobility (GJH). The studies found differing results despite similar populations. Nicholson et al. found that their pediatric dancers’ HRQoL were impacted by JHS/EDS-HT similarly to those with other chronic diseases such as cancer.²⁵ Alternatively, Schmidt et al. found no significant difference in lower extremity HRQoL between the adolescent participants with and without GJH.²⁶ Despite similar populations, the results might have differed because the RAOS-Child focuses only on the physical component of HRQoL and does not encompass the various other constructs. Both studies might have had seen similar results in their studies if the measures were holistic in their evaluation.

The populations measured in the included studies also differed. For example, Quested and Duda³⁶ examined facets of mental health in professional hip hop dancers, while White et al.¹⁶ examined HRQoL in university dance students. Although both groups were ‘dancers’ – one group was professionally employed, while the other group was learning dance as an academic career. The level of expertise and demands on both groups would therefore be different. Thus, it is somewhat difficult to synthesize the findings of these two studies as the actual aspects of HRQoL being measured – and resulting outcomes differ between these dancers. Specifically, Quested and Duda found that the relationship between motivational perceptions (i.e. task- and ego-involving feature) in the hip hop climate and dancers’ reporting of well/ill-being (i.e. positive and negative affect) are fully resolved by satisfaction of the need for competence.³⁶ Alternatively, White et al. suggested that pain, impaired motion, and stress had the greatest contribution to the decrease in the physical and mental domains of HRQoL in their population.¹⁶ Thus, while all the studies examine some context of mental health – the viewpoints, background, and implications cannot be directly generalized across the studies.

Appropriateness of HRQoL Measures

The current review also noted differences in the content included in the differing HRQoL instruments. For example, both the Pediatric Quality of Life Inventory (PedsQL) Scale and Rheumatoid and Arthritis Outcome Score for Children (RAOS-Child) specifically examine HRQoL in children.^25,26 The PedsQL Scale examines the physical, social, and emotional components of a child's well-being.^25,37 The PedsQL was appropriate for the study population, as the authors wanted to examine the influence of JHS/EDS-HT on overall HRQoL and the three domains (physical, social, mental).²⁵

Alternatively, the RAOS-Child focuses on the physical component of one's wellbeing.²⁶ The RAOS-Child was used to examine whether GJH was associated with HRQoL and injury prevalence.²⁶ This instrument may not have been appropriately used, as pain and the physical component of HRQoL are not the only factors that affect one's overall HRQoL.³⁸ Although the participants’ physical domain may not have been affected by GJH, it is unknown if their psychological or social domains were affected. Adolescents dealing with GJH may deal with psychological distress as joint pain and musculoskeletal injuries are suggested consequences of the condition.²⁶ Thus, they may feel some sort of anxiety during participation in physical activity. As a result, pertinent information may have been missed on how individuals’ HRQoL may be affected by GJH. This observation highlights the need to carefully consider which HRQoL instrument should be used to answer specific question(s) in specific population(s).

Quested and Duda³⁶ administered five instruments to measure facets of mental health in hip hop dancers (i.e. perceived motivation, intrinsic motivation, need for relatedness, positive and negative affect, and athlete burnout). These findings may not be generalizable to all dancers in other genres because it is unknown how the physical and mental demands of hip-hop dance are similar or different compared to other types of dance. Prior research has found that the three basic psychological needs (i.e. autonomy, competence, and relatedness) and different types of motivation are significant indicators of global burnout among athletes.³⁹ Although dancers in different genres might deal with these specific constructs, the level of impact might differ between the genres.

For example, ballet is a traditional and technically challenging western dance form that include precise positions that generally exceed anatomical limitations, large leaps, jumps, and turns set to mostly even-tempo, classical music.^3,40,41 Additionally, ballet may focus more on the aesthetic and lines of the dancer so that it is pleasurable for the audience to watch. Thus, ballet dancers may put more pressure on themselves to maintain an unrealistically low body weight, which may produce psychological stress.²³ In contrast, hip hop dance is a technically challenging form of street-style dance that incorporates some anatomically challenging, structured and unstructured movements (i.e. spins, handstands, tumbling) set to hip hop music.^3,42,43 Hip-hop dancers may not be as focused on their body image as ballet dancers, because this factor is not a large priority in the hip hop dance genre. As a result of the varying physical and psychological demands in each genre, hip hop dancers and ballet dancers may differ in these constructs. Thus, it is important to take these factors into account when measuring wellness in different dance genres.

The modified Disablement in the Physically Active Scale (mDPA) that White et al. used was adapted from the original DPA scale and measures HRQoL in physically active individuals.^16,44 Although the mDPA analyzes mental health, it may not measure emotional health. Emotional health encompasses an individual's thoughts, feelings, and behavior internally and externally.⁴⁵ If emotional health is being negatively affected by a situation, it may affect the individual's overall mental health. Thus, practitioners could miss pertinent information about their patients’ comprehensive mental well-being. Overall, all the described instruments may not uniquely identify with the various physical and mental requirements of dance at the different performance levels (i.e. pre-professional, collegiate, professional).

Primacy of Examining Mental Health

Despite the differences in the included measures, each instrument includes examination of a mental health component. Mental health encompasses emotional and social well-being, and may be affected differently in the various performance levels.⁴⁶ For example, for collegiate dance students, mid- and end-semester times can be both physically and mentally exhausting as they prepare for examinations and/or rehearse hours for performances.⁴⁷ In addition, collegiate dance students may encounter mental stress resulting from the transition of high-school to college including changes in normal routines, academic and social relationships, responsibilities (i.e. finances, employment, etc.), and expectations.^48,49 Professional dancers, on the other hand may have to contend with the mental stress of deciding whether to report an injury in the fear of potential loss of roles/debuts and subsequent financial implications.^19,31,47,50 Prior evidence suggests that mental stress may lead to injury, increase once injury is sustained, and fluctuate throughout the rehabilitation process.^{19,23,31,52,53} Thus, professional dancers might sacrifice their wellness because their personal and professional lives may be significantly affected if they discontinue working. Collegiate dancers may believe that psychological stress is apart of the “collegiate” experience and wait to take care of their psychological health until the end of the semester.

Other factors that can increase mental stress include: unhealthy eating, fatigue, decreased concentration, exhaustive training schedules, challenging choreography, poor social support, perceived lack of autonomy and control, perfectionism, company competition and major life events (i.e. death, relationship dissolution, or career transition).^24,51 Additionally, Patterson et al. found that high levels of stress and low social support may put dancers at higher risk of injury.¹³ Taken as a whole, dance medicine clinicians need to consider their dancers’ mental health and its influence on their comprehensive well-being, as it is an integrally important component of overall health.

Clinical Relevance

The clinical relevance of this study includes that multiple measures have been used to examine dancers’ HRQoL and all measures examined mental health. The use of multiple instruments may decrease the generalizability and construct validity of study results, as each dance genre and population differ. The consideration of mental health by each measure indicates the importance of mental health in this setting. Thus, clinicians should recognize the role that the interaction of physical and mental health play toward a dancers’ overall wellbeing. Of the eight measures discussed in this review, the mDPA seems to be the most adequate tool in measuring HRQoL in dancers. However, the mDPA only has four questions pertaining to mental health and may miss valuable information about dancers’ mental health. Thus a single HrQoL tool cannot be recommended for dancers across populations. Overall, the findings indicate support for the creation of a tool that can be utilized across multiple populations of dancers to ease clinician assessment of patient wellness.

Limitations

Studies were not included if they examined the effect of dance as an intervention on HRQoL. Evidence exists that describe the therapeutic effects of dance on HRQoL in the general population or in individuals with chronic diseases such as Parkinson disease.^54-57 However, these studies would not be applicable to this population of dancers. As a result, limited information exists on HRQoL measurement in dancers which contributed to the inclusion of four articles and low quality of evidence.

CONCLUSIONS

In summary, the four studies included in this systematic review utilized eight different instruments to measure HRQoL in their dancers. Interestingly, despite differences in the HRQoL measures utilized, all measures examined some construct of mental health, highlighting the need to consider the importance of this construct in dance. Additional research is needed to examine which measures are suitable to study dancers’ HRQoL irrespective of genre. Clinicians would benefit from using a suitable measure to track their dancers’ comprehensive wellbeing by noting how HRQoL fluctuates over a season, post injury, and over a dancer's career – overall reducing their dancers’ injury risk, improving their performance, and enhancing their career longevity.