Author: Stephanie De’Ath on behalf of the IADMS Education Committee 

What is screening?
Screening is often used for pre-entry to a school or company to highlight any concerns with regards to health, injury risk or mental and physical capabilities. Although research suggests that protocols should, where possible, be carried out by a physiotherapist or dance science professional there are some protocols that can be adopted by schools or companies with limited resources to at least complete some of the tests for educative purposes. Although not widely used as an educative tool, screening provides a great opportunity for dancers to learn more about their bodies, optimise performance and identify injury risk¹. By addressing the weaknesses or concerns which arise as a result of the screen, a programme of activity can be developed to compliment training and reduce the likelihood of injury. As a member of Trinity Laban's screening team for the past four years, in this post I will explore how screening can contribute to injury prevention from an educational perspective. 

What is involved in screening?
As highlighted by Liederbach et al², screening often involves collating information on many components including medical history, skeletal structure, alignment, range of motion, strength, cardio-respiratory response, motor skills, stability and mobility, self esteem, motivation and nutrition amongst others. From personal experience, the benefits for using screening as an educative tool, rather than pre-entry or for research, is that the methods can be adaptive to reflect the student needs, the current staff's knowledge/experience and developments in research. This can however make it somewhat difficult to use the data for research, which is why changes in protocols should be considered carefully 

In the UK National Institute of Dance Medicine and Science (NIDMS) screening program, we explore a number of different areas which include: health and injury history, current training exposure, anthropometrics, hypermobility/flexibility, strength, a functional musculoskeletal screen and an aerobic fitness test. Once the assessments have been completed, individuals are invited for feedback to go through each test result: looking at comparable means and discussing how their results can impact their training. 

How can screening contribute to injury reduction?
There are many benefits and outcomes of screening, however the following are the five testing protocols that I typically find to be most helpful in educating dancers on injury reduction. These protocols can easily be adopted by individuals, especially those with limited resources. 

1. Health and injury history
As we already know, results from injury history, menstrual status and nutritional status can be combined to “red flag” symptoms of Female Athlete Triad³. A red flag for each area would be:

• Frequent bone related injuries (more than 2) in the last 12 months e.g. Fractures, bone bruising, etc and/or already diagnosed osteoporosis and/or a known low bone mineral density.
• Amenorrhea, or no menstrual cycle, for more than three months.
• And disclosure of, or indicators of, an eating disorder or disordered eating. There are of course many other areas which may arise as a concern from completing the health and injury questionnaire. For example a low BMI or sleep disturbances, however what is important in this instance is that any red flags for Female Athlete Triad or any other issues are dealt with appropriately. Therefore, if you do not have the provision in your school/ company to provide nutritional advice, have a reliable contact who you can refer your dancers to. 

2. Single jump height Single jump height measures how high an individual can jump. This result is important information for dancers, however what I find more interesting as an observer of the test is the biomechanics of an individual's jump technique. By looking out for the following we can use the screen itself to optimise the performance of the jump and reduce injury:

• Are they rolling in or out of the ankles during take-off/landing?
• Turning in/out of the feet, looking to see if one is more turned out than the other.
• Are they able to maintain the 90 degree angle at the knees during take-off and landing, as specified in the test protocol.
• If/when fatigued, are they able to maintain technique e.g. feet pointed during jump, land in parallel, maintain height, maintain speed, etc By breaking the jump down and giving this feedback to the dancers I find this to be more helpful than informing them how high/powerful their jump is (of course they will still be interested in this!) as you may point something out to them that hasn’t been identified before. 

3. Turnout/turn in
There are a number of different ways to test turnout/ turn in, however I find active standing turnout to be one of the most useful for educative screening, as it is most representational of the dancer in the studio. The dancer will stand on two rotational discs (therefore removing the friction from the floor) and starting in parallel they will turnout or in. The distance of each measurement will be recorded in degrees and repeated three times for accuracy, as they can be rather wobbly if you haven't used them before! In literature it is suggested that dancers should be achieving 70 degrees of turnout⁴, which may be true for ballet dancers, however for other dance genres this requirement may not be as necessary. What I find that we are actually looking for here is bilateral balance between the right and left side, with no more than 10 degrees difference between the right and left score. An inability to achieve bilateral balance may be an indicator of muscle weakness or tightness in the internal or external rotators or simply a lack of proprioception. I particularly like this test because the dancers are unable to "cheat" due to there being no resistance from the floor - but make sure their knees stay over the toes to ensure no cheating!
USEFUL VIDEO HERE. 

4. Plank
Like all of the other tests, the plank is more than just achieving a number, it can be indicative of a number of different physical aspects. However from past experiences we usually see dancers achieving roughly around the 2-3min mark. Whilst the dancer is completing the plank (feet hip width apart and resting on forearm) you can also look out for the following:

• Feet: are they rolling in/ out or can they maintain a true parallel?
• Hips: are they even? Or does one side dip more than the other?
• Alignment: can they ensure that the head, hips and feet sit in one straight line.
• Shoulder blades: do they "wing" off the back? 

5. Dance Aerobic Fitness Test (DAFT)
Over the past 10 years schools and companies have been able to use Dance Specific Fitness Tests (DSFT)^5,6,7. One of the most frequently used DSFT by schools and companies is the contemporary Dance Aerobic Fitness Test (DAFT). This fitness test has a number of advantages beyond the data produced i.e. heart rate and rate of perceived exertion (RPE). Observers can also make notes on the individual’s technique over the five stages, each of which is four minutes and progressively increases in intensity. An observer might look out for: arm placement, landing from the jumps, extension of movements, focus, musicality, coordination, etc. The DAFT stage three is representative of the effort levels required for a technique class and stage five is representative of performance intensity. Therefore, the individual can track the changes in their heart rate and RPE over a time period, to see if their training is providing any positive adaptation in their aerobic fitness levels and resistance to fatigue, which allow them to perform set movement at a lower relative intensity. There is currently no published data available on the norms or averages for each stage of the DAFT, however Redding et al will be presenting this information for the first time at the 25th Annual meeting in Pittsburgh…so watch this space! 

So…what do we do with all this information?
Well, as you can see from the above information, the outcomes are primarily indicators of an area of weakness. To allow this information to contribute to injury reduction we need to ensure that we apply these findings back into training. Therefore, I would recommend that your feedback time is highlighted as one of the most important features of your educative screening session. These indicators cannot be actioned if dancers do not understand the importance and relevance of the results, and furthermore, how to implement this into their training. Ensure you are confident with the official protocols for each test and most importantly, develop a network of dance specialist professionals who you trust for onward referral. 

Stephanie De’Ath, MSc, SRMT, is a Lecturer in Dance Science at UK Higher Education Institutions and is a Sports and Remedial Massage Therapist at London Contemporary Dance School and Central School of Ballet.
Email: stephaniedeath1@gmail.com 

References/ recommended resources

1. Wilson, M., & Deckert, J. L. (2009). A screening program for dancers administered by dancers. Journal of Dance Medicine & Science, 13(3), 67-72.

2. Liederbach, M., Hagins, M., Gamboa, J. M., & Welsh, T. M. (2012). Assessing and reporting dancer capacities, risk factors, and injuries: recommendations from the IADMS standard measures consensus initiative. Journal of Dance Medicine & Science, 16(4).

3. Torstveit, M. K., & Sundgot-Borgen, J. (2005). The female athlete triad: are elite athletes at increased risk?. Medicine & Science in Sports & Exercise, 37(2), 184-193.

4. Howse, J., & McCormack, M. (2009). Anatomy, Dance Technique and Injury Prevention. A&C Black.

5. Wyon, M., Redding, E., Abt, G., Head, A., & Sharp, N. C. C. (2003). Development, reliability, and validity of a multistage dance specific aerobic fitness test (DAFT). Journal of Dance Medicine & Science, 7(3), 80-84.

6. Redding, E., Weller, P., Ehrenberg, S., Irvine, S., Quin, E., Rafferty, S., Wyon, M. & Cox, C. (2009). The development of a high intensity dance performance fitness test. Journal of Dance Medicine & Science, 13(1), 3-9.

7. Twitchett, E., Nevill, A., Angioi, M., Koutedakis, Y., & Wyon, M. (2011). Development, validity, and reliability of a ballet-specific aerobic fitness test. Journal of Dance Medicine & Science, 15(3), 123-127.