Inspired by Blackmon & Elson 2020.
Last week the topic was Parkinson’s disease (PD), and this week I have selected a paper on acupuncture for dancers, so I thought I would just check the PD literature, as I recalled that dancing was being used therapeutically in this condition. Sure enough there is a substantial literature on the effects of dance in improving motor control in PD.[2–5]
This paper by Blackmon & Elson is a general review that focuses on the role of therapeutic needling in dancers. I should make it clear that this paper focusses more on the professional dancer than patients with PD using dance as a therapy.
As soon as I saw this paper I thought of sending it to the only BMAS colleague I know who herself was a professional dancer, and she replied with such a thorough review of the paper, I thought I should put it up here, and invite her to lead the subsequent webinar.
This is Fiona’s reply…
I finally got around to reading the paper. I must admit I haven’t had much interest in reading papers since finishing that diploma this summer. It’s nice to get back into it again.
I think it was a really good paper. I also did a little reading up on both authors, Lauren Elson appears to work out of the greater Boston area and she herself has 15 years of dancing experience as well as a Harvard affiliation. Amanda Blackmon was trained in Atlanta and is lead physio for The Atlanta Ballet Company. Both have excellent experience in the field of dance which always helps.
The acupuncture intro was really nice and concise, getting the point across without being too science-heavy. I actually didn’t realise there was a significant temperature difference between needle tip and handle in situ. They made a nice point toward the end of page 2 describing acupuncture as a technique that “may not be able to ‘fix’ pathologies…” I think it was a truthful, realistic approach to convey. Always a good idea to make patients understand this early on, regardless of them being a dancer or not.
There was a very valid point made down the end of the acupuncture section (page 3) how it can assist with stress and anxiety management in the dancer cohort. As dancers depend so heavily on their physical state for a livelihood it can be devastating to have injury impact or threaten this in anyway. I experienced it all too many times with our own troupe on tours over the years. Being sent home from a tour prematurely to heal a fracture for example and knowing someone else has replaced you literally overnight can be a lot to process. Financially it can be very straining. Certainly, having more experience with my acupuncture now allows me to look at the patient/dancer/athlete as a whole as opposed to zoning in on the injury alone. I thought this translated very well in the paper.
I never knew that more than 90% of the traditional 360 acupuncture points in fact correspond with MTrP’s! I found I rarely applied the vigorous dry needling approach as our dancers were performing 8 shows 6 days per week, so we couldn’t afford for the dancer not to perform (post treatment) due to lack of excess pool of dancers, especially on a long 6-9-month tour. This may be easier to accomplish on a larger tour/show with a greater number of reserve dancers or a ‘home theatre’ such as the ROH where a dep or a substitute may be drafted and ready on standby.
I used to get bothered about identifying and having to aim to treat only active TrPs. Now, I treat both and if I am unable to elicit or reproduce familiar symptoms I don’t get worked up. In fact, sometimes for the anxious/nervous patient it is a nice ‘intro’ to treat latent points. It gives them a ’taster’ for what is to come! The point they made of TrPs developing 2 years into repetitive low-load muscle activity is classic in the dancer/performing artist cohort. Long hours of rehearsals, especially when the dancer is fatigued and overworked – it isn’t at all surprising that TrPs may develop.
A lot of the injuries mentioned under the subgroup ‘Clinical conditions’ would be very typical in a classical ballet setting especially. I would have treated predominantly Irish dancers revealing mostly lower extremity injuries. There were just a small group of Russian ballet dancers in our show (who typically remained very very healthy compared to our lot!) I guess it was due to more vigorous training and a better knowledge and experience in professional dance productions. Our’s was such a new phenomenon, and it bore a professional Irish dancing scene literally overnight. The contrast in both discipline and education with the Russian troupe for example with the Irish group was tremendous. In Russia, training starts at a very young age and they learn about the physiology and anatomy of the human body as well as actual dance techniques. Albeit strict and very strenuous, I think there is a lot to be said for good solid training.
Coming back to the point of Irish dancing versus ballet, the style of dance very much dictates the movement and thus the region of injury. In Irish dancing, one is disqualified (at a high-level competition) to land from a jump on a flexed knee. They must keep the leg entirely straight and en pointe (hence the overdeveloped gastrocnemius complex). Classical ballet tends to be more forgiving in this manner, allowing knee flexion on landing, hence the larger quadriceps/hamstring region. My understanding is a larger amount of body weight is absorbed more distally in the Irish dancer and more proximally for all other styles. So, for example the mention of plantar fasciitis, metatarsal stress fractures and to a lesser extent anterior hip pain, would be very typical for the Irish dancer. An upper limb injury would also be less common in the Irish group due to the nature of the dance style. The likes of hip hop, ballet, contemporary and jazz I expect would have a higher incidence of upper extremity injuries (as mentioned in the paper: whiplash, concussion, discogenic spinal conditions and lower back pain etc) possibly down to the nature of the choreography and the particular style of the genre of dance.
A very valid point was made later in the paper about anxiety owing a huge amount to the well-being of the dancer and, indirectly, the outcome of injury. Maintaining physical well-being is extremely tough, not to mention the impact of that strain and pressure has on emotional and mental well-being. The performing arts is undoubtedly so competitive. The mention of eating disorders was something that cropped up in Lauren Elson’s biography. I think it may be something she gives talks on. Eating disorders and dysmorphia were sadly ’trendy’ amongst some of the young female dancers in the Irish dance troupe. Again, the pressure to ‘look the part’ was ever prominent. Contracts were scarce as was full-time work. Promotions were often dangled with unfortunately little chance of realistic promotion. Body dysmorphia is a whole other level and certainly something I am not read up upon enough but it is rampant amongst professional dancers, globally. Perhaps acupuncture has an even larger role here in the future amongst this cohort. Wouldn’t it be nice to establish an acupuncture clinic solely for elite and professional dancers!
Safety issues were well covered at the end of the piece. I tried to read the paper by the Irish authors (Brady et al) but there was no access even to the abstract. I didn’t pursue it any further! Nevertheless, a reassuring statistic of <0.4% was published back in 2014 for the incidence of significant adverse reactions amongst patients receiving dry needling performed by physiotherapists.
Thanks for giving me the opportunity to review the article. It was good discipline and refocus on my acupuncture world – much enjoyed.
I hope all is well.
My thanks to Fiona for such a thorough review with interesting insights into life as a dancer, and the important differences between styles.
I thought I had better have a good read of the paper myself before the Wednesday evening webinar and check out some of the authors’ statements and references. One that caught my eye was the suggestion that needling was superior to injection, so I checked the reference and discovered a rather sneaky form of dual publication. The same lead author published 3 very similar papers in the same year. All 3 were parallel arm RCTs, and I guess they all came from the same 3 arm trial that was sliced 3 ways so that the data from each arm was duplicated but all 3 papers were different.[7–9]
1 Blackmon AM, Elson L. Dry Needling and Acupuncture in Treatment of Dance-Related Injuries, MD, and PT Perspectives. Phys Med Rehabil Clin N Am 2021;32:169–83. doi:10.1016/j.pmr.2020.08.005
2 Kalyani HH., Sullivan K, Moyle G, et al. Effects of Dance on Gait, Cognition, and Dual-Tasking in Parkinson’s Disease: A Systematic Review and Meta-Analysis. J Parkinsons Dis 2019;9:335–49. doi:10.3233/JPD-181516
3 Bek J, Arakaki AI, Lawrence A, et al. Dance and Parkinson’s: A review and exploration of the role of cognitive representations of action. Neurosci Biobehav Rev 2020;109:16–28. doi:10.1016/j.neubiorev.2019.12.023
4 de Almeida HS, Porto F, Porretti M, et al. Effect of Dance on Postural Control in People with Parkinson’s Disease: A Meta-Analysis Review. J Aging Phys Act 2020;:1–11. doi:10.1123/japa.2019-0255
5 Carapellotti AM, Stevenson R, Doumas M. The efficacy of dance for improving motor impairments, non-motor symptoms, and quality of life in Parkinson’s disease: A systematic review and meta-analysis. PLoS One 2020;15:e0236820. doi:10.1371/journal.pone.0236820
6 Brady S, McEvoy J, Dommerholt J, et al. Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. J Man Manip Ther 2014;22:134–40. doi:10.1179/2042618613Y.0000000044
7 Ga H, Choi J-H, Park C-H, et al. Dry Needling of Trigger Points with and Without Paraspinal Needling in Myofascial Pain Syndromes in Elderly Patients. J Altern Complement Med 2007;13:617–24. doi:10.1089/acm.2006.6371
8 Ga H, Choi J-H, Park C-H, et al. Acupuncture Needling versus Lidocaine Injection of Trigger Points in Myofascial Pain Syndrome in Elderly Patients – a Randomised Trial. Acupunct Med 2007;25:130–6. doi:10.1136/aim.25.4.130
9 Ga H, Koh H, Choi J, et al. Intramuscular and nerve root stimulation vs lidocaine injection to trigger points in myofascial pain syndrome. J Rehabil Med 2007;39:374–8. doi:10.2340/16501977-0058