Abstract
Background:
Updated rates and patterns associated with patients with dance-related injuries reporting to US emergency departments (EDs) is needed.
Hypothesis:
Between the years 2014 and 2018, there will be an observed rise of patients with dance-related injuries seen within US EDs.
Study Design:
Retrospective analysis.
Level of Evidence:
Level 4.
Methods:
Utilizing the National Electronic Injury Surveillance System (NEISS) database, data were abstracted for all structured dance-related injuries for all people who presented to a NEISS participating hospital from January 1, 2014, to December 31, 2018. Data were abstracted on age, sex, race, disposition, location on the body where the injury happened, and free text box regarding the mechanism and nature of the injury. Each patient case was associated with a weight to provide national incidence rate (per 100,000) estimates. Descriptive statistics were used to summarize counts, percentages, and rates across patient cases.
Results:
Between years 2014 and 2018, 4152 patients reported to the NEISS EDs with a dance-related injury. Most injuries occurred in female patients (83.3%; n = 3459) and among those who were 10 to 18 years old (76.2%; n = 3164). The most common injuries were ankle sprain/strain (12.7%; n = 527) and knee sprain/strain (10.4%; n = 431). Almost all patients were treated and released (97.1%; n = 4033). These data yielded population-weighted estimates of 125,618 injuries for the study period, with an increasing trend over time (19.2% increase over 5 years). Incidence rates were over 4 times higher for female (12.4) than for male patients (3.0) and highest in the 10- to 18-year-old age group (incidence rate = 46.4).
Conclusion:
Patients with dance-related injuries reporting to EDs increased over a 5-year period from 2014 to 2018. The majority of dancers in the study were female patients, between the ages of 10 and 18 years, nearly half of the patients reported to the ED with a sprain/strain, and almost all patients were treated and released.
Clinical Relevance:
An increase in access to proper injury prevention medical services and education should be provided to female dancers between the ages of 10 and 18 years.
Strength of Recommendation Taxonomy:
B.
Keywords: dance, epidemiology, emergency department, injury prevention
Structured dance provides suitable requirements to fulfill global health benefit recommendations on the amount of moderate-to-vigorous intensity physical activity (MVPA) humans should obtain within multiple age groups.24 Structured dance includes any various style of dance taught by a dance teacher or a dance piece performed in front of an audience. As a fun and creative way of satisfying MVPA, dance is enjoyed by many. Dedicated high-volume and high-intensity dance training starts at a relatively young age for those seeking careers in dance.13 The high physical demand of dance training places the human body at increased risk of injury, with injuries occurring most commonly as a result of systematic overload involving the lower extremity.23 While these injuries may cause pain or discomfort, they tend to be ignored by dancers due to the development of high pain tolerances and the familiarity of performing in pain, without taking into consideration potential consequences for the dancer’s future well-being.20,21
In an effort to standardize dance epidemiology, the International Association of Dance Medicine and Sciences released a position statement in 2012 that standardized measures across dance research to incorporate both a medical diagnosis and a definition of injury as being full time-loss from dance for 1 or more days beyond onset.12 Since then, high-quality dance epidemiology studies have been conducted similar to sport epidemiology research.8 For example, recent studies among professional ballet dancers reported 1.06 for injuries in male dancers and 1.46 for injuries in female dancers per 1000 dance hours.19 Furthermore, compared with other genres of dance, ballet is associated with a higher ratio of overuse to acute injuries.3,4,6,7,23 While these findings provide insight into dance injuries that are managed by on-site health care providers (eg, athletic trainers, physical therapists), little is known about those injuries occurring at sites without a health care provider.
One way to gain a better understanding of dance-related injuries not managed by on-site health care providers is to investigate injury data reported by emergency departments (EDs). For example, from 2000 to 2013, it was reported that approximately 17,000 dance-related injuries presented to EDs in the United States every year.22 While the total number of dance-related injuries was comparatively lower than those associated with contact sports (eg, basketball, football, soccer), an increase of 33.4% for total number of dance-related injuries from 2000 to 2013 suggests that they are becoming a frequently managed injury in EDs.22 Although these findings provide initial insight to patients with dance-related injuries reporting to EDs in the United States, data have not been updated since 2013. Thus, the purpose of this study is to describe the rates and patterns associated with patients with dance-related injuries reporting to EDs between 2014 and 2018.
Methods
Instrumentation
This study was a retrospective analysis of de-identified data extracted from the National Electronic Injury Surveillance System (NEISS). The NEISS is operated by the Consumer Product Safety Commission and is publicly accessible at the following web URL: https://www.cpsc.gov/cgibin/NEISSQuery/home.aspx. This data set contains all patient injuries presenting to EDs from a group of approximately 100 purposely sampled hospitals across the United States. Previous studies have used the NEISS database to describe social health issues and provide preventative health measures for targeted populations. Data from the NEISS have been shown to be accurate and reliable for description of nonfatal injuries in the United States.16,18
Procedures
In October of 2019, data were abstracted from the NEISS, which consists of de-identified, publicly available, nationally representative patient data collected from a probability sample of 100 EDs located in the United States. All data were entered by hospital staff and reviewed by a facility NEISS coordinator at each hospital. The NEISS coordinator abstracted pertinent data from selected ED records and transcribed them in coded form onto a NEISS coding sheet using rules described in the NEISS Coding Manual.15
Variables
Data were abstracted for all structured dance-related injuries (product code 3278) for all people who presented to a NEISS participating hospital from January 1, 2014, to December 31, 2018. Data were abstracted on age, sex, race, disposition (outcome of presentation), location on the body where the injury happened, and free text box regarding the mechanism and nature of the injury. Only injuries that occurred during structured events (eg, dance class, dance competition, dance school, dance practice) or injuries that mentioned specific dance terminology (eg, style of dance, dance motion, dance clothing, dance equipment) were included. Injuries occurring during unstructured events (eg, dancing at a wedding) were excluded.
Statistical Analysis
Each patient case was associated with a weight to provide national estimates. Descriptive statistics (frequencies, percentages) were used to summarize counts, percentages, and rates across patient cases. For incidence rate (IR) calculations, US population estimates for male and female patients were abstracted from the US Census Bureau for the period 2014 to 2018 by age group. IRs were calculated as the number of cases per 100,000 people.
Results
Between the years 2014 and 2018, 4152 patients reported to the NEISS EDs with a dance-related injury. Injury demographics are summarized in Table 1. Most injuries occurred in girls (83.3%; n = 3459) and among those who were 10 to 18 years old (76.2%; n = 3164). The injuries occurred most commonly at the knee (22.5%; n = 935), ankle (15.7%; n = 650), and foot (10.2%; n = 424) and were diagnosed as sprain/strain (42.6%; n = 1767), fracture (10.3%; n = 428), and contusion (8.1%; n = 336). When considering diagnosis by body area, the most common injuries were ankle sprain/strain (12.7%; n = 527), knee sprain/strain (10.4%; n = 431), and knee dislocation (4.3%; n = 179). Cross-tabulating diagnosis with sex, similar percentages of diagnosis were found among both sexes, except male patients had more fractures (13.6%, n = 94) than female patients (9.7%; n = 33.4), and male patients had fewer sprain/strains (34.9%; n = 242) than their female counterparts (44.1%; n = 1525) as seen in Table 2. Almost all patients were treated and released (97.1%; n = 4033), and a small percentage were admitted to the hospital (1.6%; n = 67) or left the ED before being seen by a health care provider (1.0%; n = 41). These data yielded population-weighted estimates of 125,618 injuries for the study period, with an increasing trend over time (19.2% increase over 5 years) as seen in Figure 1. Incidence rates were over 4 times higher for female (12.4) than for male patients (3.0), and highest in the 10- to 18-year-old age group (IR = 46.4). IRs in the other age groups were as follows: 19-30 years = 7.4, 31-60 years = 2.1, and 61+ years = 1.7.
Table 1.
National estimates of dance-related injuries presenting to US emergency departments, 2014-2018 (% of injuries)
| Injury demographic | n (%) |
|---|---|
| Sex | |
| Female | 3459 (83.3) |
| Male | 693 (16.7) |
| Age, y | |
| 10-18 | 3164 (76.2) |
| 19-30 | 532 (12.8) |
| 31-60 | 321 (7.7) |
| 61+ | 135 (3.3) |
| Disposition | |
| Treated and released | 4033 (97.1) |
| Treated and transferred | 6 (0.1) |
| Treated and admitted | 67 (1.6) |
| Left without being seen | 41 (1.0) |
Table 2.
Diagnosis and sex cross-tabulation of most common dance-related injuries presenting to emergency departments, 2014-2018 (% of injuries within sex)
| Diagnosis | Male | Female | Total |
|---|---|---|---|
| Strain, sprain | 242 (34.9) | 1525 (44.1) | 1767 (42.6) |
| Other/Not stated | 168 (24.2) | 882 (25.5) | 1050 (25.3) |
| Fracture | 94 (13.6) | 334 (9.7) | 428 (10.3) |
| Contusions | 53 (7.6) | 283 (8.2) | 336 (8.1) |
| Dislocations | 52 (7.5) | 174 (5.0) | 226 (5.4) |
| Internal organ injury | 26 (3.8) | 89 (2.6) | 115 (2.8) |
| Concussion | 13 (1.9) | 88 (2.5) | 101 (2.4) |
| Laceration | 33 (4.8) | 47 (1.4) | 80 (1.9) |
| Avulsion | 3 (0.4) | 9 (0.3) | 12 (0.3) |
| Nerve damage | 2 (0.3) | 8 (0.2) | 10 (0.2) |
| Foreign body | 1 (0.1) | 6 (0.2) | 7 (0.2) |
| Hematoma | 3 (0.4) | 4 (0.1) | 7 (0.2) |
| Dental injury | 2 (0.3) | 1 (0.0) | 3 (0.1) |
| Poisoning | 0 (0.0) | 3 (0.1) | 3 (0.1) |
| Hemorrhage | 1 (0.1) | 1 (0.0) | 2 (0.0) |
| Dermatitis, conjunctivitis | 0 (0.0) | 2 (0.1) | 2 (0.0) |
| Burns | 0 (0.0) | 1 (0.0) | 1 (0.0) |
| Puncture | 0 (0.0) | 1 (0.0) | 1 (0.0) |
| Anoxia | 0 (0.0) | 1 (0.0) | 1 (0.0) |
| Total | 693 (100) | 3459 (100) | 4152 (100) |
Figure 1.
Incidence rate of dance-related injuries presenting to emergency departments between 2014 and 2018.
Discussion
During the years 2014 to 2018, there was an overall increase in patients with dance-related injuries presenting to US EDs. A population-weighted estimate of 125,618 structured dance-related injuries reported to EDs during this study period, with an increasing trend over time (19.2% increase over 5 years). In conjunction with previous research, these findings suggest that over the past 20 years, there has been a somewhat constant rise of dance-related injuries seen within US EDs with no clear indication of a decline.22 It is known that there is a growth in the number of dance studios, and hence a growing population of dancers, but the 19.2% increase in injuries reporting to EDs during this study period surpasses the 3.1% growth of the dance studio industry seen between the years 2014 and 2019.5 With this increase in patients with dance-related injuries reporting to EDs, health care providers should become more aware of dance-related injuries. Specifically, those who work within EDs should be apprised of the most common types of these injuries reporting to EDs.
Similar to previous dance epidemiology, most patients with dance-related injuries reporting to EDs were within the lower extremity and consisted of sprains/strains.23 It is unclear from the data whether these injuries were acute or chronic in nature. With the high prevalence of chronic injury seen within dance, this leads to instances of time loss from activity, affecting a dancer’s ability to rehearse or perform for an extended period.17,19 Chronic ankle instability, for example, creates concerns for a dancer who needs to go on demi-pointe or en pointe. Chronic ankle instability has been found to be present in 75.9% of a university dance population, which correlates with the most common injury of 12.7% ankle sprain/strains found in this study.17
In our findings, the vast majority of patients reporting to EDs with dance-related injuries were relatively young (10- to 18-year-olds = 76%) and were girls (83.3%). IRs rates suggest that female patients are over 4 times (12.4) more likely to suffer a dance-related injury than male patients (3.0). Previous dance epidemiology has indicated that the incidence of injury among amateur ballet dancers was 0.99 for male and 1.09 for female dance injuries per 1000 dance hours.19 Similar results have been reported for professional ballet dancers, with the incidence of injury 1.06 for male and 1.46 for female dancers.19 Thus, our reporting of higher incidence of injuries in female than male patients by a factor of 4 is greater than the almost 1:1 incidence of injury reported within the dance epidemiology literature. This indicates that there may be a potential reason as to why female dancers are 4 times more likely than their male dancer counterparts to seek health care from EDs. Studies have previously shown that women do utilize medical care services more than men.2 Within this study, this may potentially be due to differences in health perceptions and the reporting of symptoms and illnesses, or a greater likelihood that women seek help for prevention and illness compared with men.2
Almost all patients captured in this data abstraction were treated and released (97.1%), and only a small percentage were admitted to the hospital (1.6%) or left the ED before being seen by a health care provider (1.0%). With 97.1% of these injuries being treated with conservative care, this places a huge cost burden for these dancer patients. These injuries could have potentially been treated and managed by on-site health care practitioners such as athletic trainers reducing the burden these injuries might be placing on EDs, as well as providing more immediate and cost-effective treatments for dancers. Research indicates that athletes at secondary schools with medical teams, including athletic trainers, sustain lower incidences of injuries than athletes in schools without athletic trainers.11 The athletic health care teams recommend appropriate health care professionals (ie, athletic trainers, team physicians, consulting physicians, school nurses, physical therapists, emergency medical service personnel, dentists, and other allied health care professionals) to provide not only emergency care but also ongoing daily athletic health care.1 There has been an increase in athletic training services within the college, university, and professional dance programs, but it is unclear whether these services are being offered to preprofessional dance students.14 Since 10- to 18-year-olds are the major age group that reports to EDs, an increase in access to proper medical services such as athletic training and injury prevention education should be provided to preprofessional dance students.
Prevention and identification of risk factors for injury are key to avoiding injury within dance. Since the majority of dance-related injuries are chronic in nature and occur within the lower extremity, this places greater importance on not only identifying injury but also providing continued health care beyond an initial visit.19 Evidence suggests that dancers may dance through injury without seeking medical attention or may return to work before full recovery when still prone to reinjury.2 Research shows that treating smaller aches and pains minimizes chronic overuse injuries.3,9 A supervised therapeutic training regimen and a gradual increase in intensity have been shown to decrease dance injury.10
Limitations
Using a retrospective cross-sectional study design, there are inherent flaws and limitations to this study. One major limitation is the inability to analyze the exact behaviors or reasoning as to why these dancers decided to go to the ED as opposed to seeking alternate health care. These data do not indicate whether alternate health care services were available to the dancer or if these dancers first sought conservative care prior to the ED visit. Because of the lack of patient-reported outcomes or follow-up after the ED encounter, another limitation to this study is that we were not able to determine cause and effect based on the results of this study. In addition, we were not able to determine why dance-related injuries reporting to EDs increased between 2014 and 2018. Last, another limitation to this study design is that the population obtained is not guaranteed to be representative. Coding of the NEISS data was quality checked by an NEISS coordinator, but the inclusion and exclusion criteria of injuries related to true technical dance activities were not established by the NEISS coordinators. This may lead to a misrepresentation of this population if NEISS coordinators were unable to classify technical dance injuries, or if nontechnical dance injuries were not excluded from this study.
Conclusion
Our findings suggest that patients with dance-related injuries reporting to EDs increased over a 5-year period from 2014 to 2018. The majority of dancers were girls, between the ages of 10 and 18 years, nearly half of the patients reported to the ED with a sprain/strain, and almost all patients were treated and released. Future investigations should aim to better understand the role on-site health care providers (eg, athletic trainers, physical therapists) play in managing these patient cases within these specific populations to help address global health care concerns, including overall demands and costs.
Footnotes
The authors report no potential conflicts of interest in the development and publication of this article.
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