Taboo Topics
Pain Theory, Weight on Screenings, and High School Dance
On this week’s episode of The Dance Docs Dr. Davenport and I sat down to discuss some popular but unpopular topics such as when to use pain theories when treating patients, why are we still taking weight on screening tools, and is it worth the risk for a dancer with a history of injuries to attend a performing arts high school? We thought it was important to start answering some of these harder topics for you that historically avoided or pushed off to the side. I hope you enjoy our conversation.
Pain Theory
Hi Dance Docs, I am reaching out because I recently had an injury that took me out of dance for an extended period of time. I had pain that was progressively getting worse over the course of a few months. I was being seen by another healthcare provider who explained that the pain I was feeling was not actually what I was feeling. I felt very lost knowing that my pain was getting worse but wanting to trust my healthcare team. When should I be trusting my instincts vs trusting my healthcare provider?
I want to point out that all clinicians have a different approach to treating the individual in front of them, we are all human and sometimes miss a diagnosis, and when you miss something it sticks out in your mind.
This is where having a mentor, a team, multidisciplinary approach can be so valuable
Want to find a clinician who is the right fit for you, whether its a PT, MD, acupuncturist ect
As clinicians we should try our best not be offended by it
Find a clinician who is going to treat you in a way that you feel comfortable with
Don’t want to shop around too much that you are overwhelmed by all of the differing opinions
As a patient always trust your own instinct, and be your own biggest advocate
For Dr. Kat this question clinically break down into two parts:
Clinical diagnostic skills
When do we use pain neurobiology theories
Neurobiology of pain
Great Ted Talk by Lorimer Mosley on neurobiology of pain https://www.youtube.com/watch?v=gwd-wLdIHjs
These say that pain is a 100% a construct of your mind and is not related to a tissue
Pain is the end result- it’s an output of the brain to help protect you
Someone who has been in pain for an extended period of time- continue to run the neuron in the brain that produce the sensation of pain the amount of stimuli needed to elicit a response is much less
These networks become so sensitized and turned on all the time that the area of pain becomes much bigger, spreads out
Clinically when do Dr. Kat and Dr. Davenport use pain theory
Start by asking questions:
How long has the pain been going on- longer lasting pain may be an indication of needing more pain theory ideas
Is this something that comes and goes?
Do you have any history of injury to the area?
Many times when clinicians begin to address pain theory the patients get very upset or turned off
In someone with a major injury such as a ACL tear or a serious herniated disc beginning with immediate sports psychology to reframe the thinking around the injury could lead to improved long term outcomes and future pain responses
Gaol as a clinician can be to improve overall brain body connection early in the rehab process, so the pain response does not become over stimulates and over responsive to future pain in the area, or when in a similar situation
As a clinician also need to make sure that your patient feels heard
It is also our responsibility to use good clinical reasoning, and evaluation skills
What are your tissue specific test and measures
Are you able to reproduce this dancer’s pain through your tests and measures?
Are you testing and re-testing every session
As a PT are your interventions teaching your patient to move in pain free ways?
Dig into your tool bag to offload the tissues and help show your patient that they can move in pain free ways and then slowly add in the resistance
Even though the mind body connection is important, you cannot deny a tissue specific injury, and you need to correct any underlying tissue impairment before the brain will calm down
Have a threshold for when you refer out to your team, or reach out to your mentor
If someone was not showing improvements in 2-3 weeks, I would refer out for medical consult for further work up
2005 Study on Clinical Diagnosis Accuracy
This study from 2005 looked at Orthopedic surgeons, PT’s and Non Operative practitioners, and their proper diagnosis rate as confirmed my MRI’s for MSI
OS- 80.8%
PT-74.5%
NOP- 35.4%
The findings from this study further support the basic premise that PTs are not only capable of making good clinical judgments regarding the ordering of diagnostic imaging studies and the diagnosis of musculoskeletal conditions, but that these decisions can be made independent from physician referral.
When in doubt listen to your patient
If pain is always in the same spot it is structural until proven otherwise
If pain is moving, or in different locations that is usually a good sign
Steps that you can take as a clinician to make sure your patient is feeling heard
Repeat what your patient told you back to them to confirm
As a PT it is important to look at the whole picture for the patient
Is this patient improving, same the same, or getting worse
Was the patient improving and now we have hit a road block
Have a rapport with a physician, so that you can pick up the phone and say “hey, I think it’s time for some imaging, or the next steps with the patient.”
Not uncommon to miss early stages of stress injuries in dancers due to their historic high pain tolerances
If the dancer is reporting that something just feels off, you need to listen to them and refer out sooner rather than later
Dancers and doctors/PT’s need to trust their instincts, and be their own biggest advocate
Weight during screenings
Dear Dance Docs, I know that both of you have been involved with DanceUSA, our company has us complete a yearly screening, part of the screening is taking down a dancers weight, I am concerned that the company may be using weight in determining our role eligibility.
Weight is an issue in many female athletic sports
Why was weight initially added to the screening
Major company in the US who had a dancer with a severe eating disorder who ended up passing away from a cardiac event
Weight is on the screen so that if a dancer loses 10% of their body weight in a season it’s a red flag for the medical team, and can be addressed immediately
Dancer should be stepping on the scale backwards and not actually see their weight
This information is only supposed to be seen and used by the medical team, it is not supposed to be released to the artistic staff
Screening information is protected under HIPPA, a medical professional would need consent from the dancer to share any of the information
If a workers compensation claim is opened for an injury the medical professional can speak to artistic staff as necessary on that specific injury
they cannot just release all medical information for you
Dancer can specify what information that they want shared
Dancer may want to request to be present for communications between artistic and PT staff, or dancer could speak directly to artistic staff instead of PT speaking with artistic staff
Overall weight is not a very important part of the screen, it’s not what we want you as a dancer to focus on, and that is why it is taken backwards
A dancer can opt out of any test/measure that they do not feel comfortable completing
The screen really looks at overall health measures to paint a picture of your overall health, and how you move. Not designed as a tool for a company to use against you
Also know that weight is a number on the scale, it does not really tell us about your overall health
You can weigh more and be leaner than at a lower weight on the scale
Sadly dance is very much about having the right look
Looks matter differently to different people
The look of a company may change if a new artistic director comes in
The most important thing to do is be the best dancer that you can be
Most important thing is to adapt your body to be the healthiest, most fit version of you instead of just trying to fit someone else’s vision
Performing Arts High School’s
My child was admitted to a performing arts school. They are recovering from an injury and I am worried that dancing at their studio and the school will be too much dancing. Should I let them go to the school?
You have to look at the dancers overall load
National Pediatric associations guidelines are no more hours of specialized sport than the child’s age
14 year old should not be dancing more than 14 hours a week
If the child is currently dancing 14 hours a week and is dealing with stress injuries should we add 2 hrs/day of dancing on?
Dr. Kat’s thought process
What were the injuries
Were these injuries from a lack of conditioning
Can we add in some cross conditioning to improve strength and avoid future stress injuries
Or is the dancer already at their max load and their system can handle more load
If the dancer does want to attend the school, it may be a good idea to drop some of the hours danced at an outside studio to allow for the overall load to remain the same
This may just need to be an initial drop at the studio and a slow ramp back up
We can use a 10% rule for increasing overall load
10% per week in terms of class time
Example: Dancer currently dancing 14 hours a week can add ~1.4 hrs of class at the same difficulty level
Also consider what is the dancer’s goal:
Do they want to be a professional dancer?
Do they want to go into a college program?
Do they want to go to a school with their friends?
Do they want to dance through high school and then just enjoy dancing for the joy of it?