Date of Award


Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

First Advisor

Thomas Stewart, MD


Despite facing exceptionally high physical and psychological stressors, dancers in most parts of the world represent a marginalized and often neglected patient population. This study examined the physical, psychological, and health care access challenges of injured dancers in the Netherlands, a country which has remained grossly underrepresented in the performing arts medicine research literature, despite having a unique tetrad of universal health care access, a robust performing arts industry, leading clinical care in performing arts medicine, and tight-knit systems of networks and referrals between dance and medical institutions. The purpose was to determine the degree of psychological distress among injured dancers, and whether this distress represented an independent trait of dancers personalities or a state that was dependent on the physical injury. Therefore, the Brief Symptom Inventory (BSI)®, (1) a well-known, and highly validated tool was used to screen for psychopathology in 154 pre- and post-retirement age injured Dutch dancers and was used to identify clinical features of dancers who were at highest risk for elevated distress. In addition, a cross-sectional, descriptive survey and chart review were performed in this group to determine the physical outcomes of injured dancers in the Netherlands, their health care seeking behavior, and their perceptions of the medical industry when injured in order to control for these variables impact on dancers BSI scores. Dutch dancers sustained a low injury and surgery rate compared to available data from other countries, but the epidemiology of the injuries was similar. Dancers sustained an average of 1.5 injuries, most often to the knee or foot-ankle complex (30%, each). The surgery rate was 4% (6 of 154 dancers). Most injuries were chronic (M= 20.6 ± 25.3 months), overuse-type injuries, and 40% of dancers did not know where or how the injury occurred. Pain and artistic compromise emerged as distinct entities of the injury process, with artistic compromise representing a variable of greater magnitude and duration than somatic pain. Logistical and perceptual restrictions to health care were not reported by dancers in the study; only three younger (<35 years), foreign dancers lacked a primary care physician. No dancer reported monetary or insurance hindrances, or fear of going to the doctor. A small percentage of the younger group (18%), but none of the older dancers, reported that they felt the doctor would not understand them (χ2=2.2, df=1, p=0.14). Nevertheless, the majority of dancers were satisfied or very satisfied with their medical treatment prior to presenting to the dance medicine specialist (67% older dancers, 52% younger, χ2=1.19, df=1, p=0.2) as well as afterwards (100% older dancers, 93% younger dancers, χ2=1.46, df=1, p=0.2). In fact, dancers in both age groups most often sought first treatment from either a physiotherapist (36-40%) or a medical doctor (39-41%). The primary reason for not seeking treatment from a physician first was that dancers had already had access to a physiotherapist, and thought this treatment was sufficient. This attitude was in stark contrast to reports of dancers antagonistic perceptions of their medical providers reported elsewhere. In terms of psychological health, however, injured Dutch dancers performed poorly on the BSI: a high degree of persistent, elevated psychological distress was detected. Sixty percent of dancers scored high enough for referral to a psychiatrist for at least one psychological dimension, 80% scored above the average of the normative Dutch adult outpatient population (dimensional score 5, Z >1.0 S.D.), and 20% scored highly distressed on a global measurement of psychological well-being (GSI score 6 or 7, Z >2 S.D.). On average, referable dancers suffered in multiple clinical dimensions (M=4.00). These findings were independent of age, gender, dance style, anatomic injury, professional experience, pain, and perceived level of artistic compromise due to injury. Somatic, cognitive, interpersonal sensitivity, paranoid, and anxious symptoms were the grounds for most referrals. However, overall there was little change in the psychological profiles of dancers and number of clinically significant dimensions, despite injury resolution (3.9±4.0 vs. 4.0±2.9 dimensions, p=0.9). Clinical reduction in scores post-dance injury treatment was seen in phobic (50% reduction), somatic (44%), hostile (38%), and paranoid dimensions (38%); yet, on the level of individual dancers, the number who changed from referable to non-referable distress was equivalent to those who showed no change in distress level (n=7, 41% vs. n=6, 35%). Students emerged as a particular patient population with a particularly high level of persistent distress. Therefore, even in a country such as the Netherlands, where injured Dutch dancers displayed improved physical outcomes, health care seeking behavior, and doctor-dancer relationships than dancers in other parts of the world, their elevated level of psychological distress was an independent feature of the injury process. This supports the hypothesis that psychological disturbances are traits of dancers personalities, rather than states due to injury. In the Netherlands and abroad, physicians, dance institutions, instructors, and individual dancers should be aware of this problem and take measures to mitigate the distress including: increased education for patients and providers, increased support services at dance academies, and increased funding for research into the etiology of the distress.