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When choreographer George Balanchine of the New York City Ballet growled
at his dancers ‘I want to see bone’, he was aiming for the highest artistic
standards. Choreographers and audiences expect ballerinas to be long limbed
and almost impossibly slight. But for years, graceful movements and serene
smiles have masked pain and injury to dancers’ bodies.

Professional dance training demands superhuman performance from sometimes
wraith-like bodies and too often the bodies can’t keep up. Recent work has
revealed that dancers suffer a shocking level of injury. A survey by Ann
Bowling at St Bartholomew’s Hospital, London found that almost half of all
professional dancers have a chronic injury. Questionnaires were sent to
46 per cent of all classical ballet and modern dancers, male and female,
working in Britain in 1989. Two out of five had suffered an injury in the
previous six months severe enough to affect their dancing. Figures from
an Australian study are even more disturbing. There the Safe Dance Project
questioned dancers of all disciplines, and reported in 1990 that 65 per
cent of dancers had a low-grade chronic injury.

Injury is the dancer’s nightmare. In the short term it robs them of
prized roles and hits their income, while more serious strains and fractures
can end careers and lead to permanent disability. Little is known about
the extent of injury in previous decades, but many in the dance world believe
it is much higher now. Modern choreography demands more athleticism from
dancers and training methods have failed to keep up.

But if dedicated dance professionals get their way, things are about
to change. Every aspect of dancers’ health and welfare is being examined,
from pensions and theatre design to psychological problems, training methods
and diets. One of the first moves is the launch of the Healthier Dancer
project, an education programme for dancers covering body awareness and
injury prevention that began in October. Dance UK, the national forum for
dance responsible for the project, hopes the scheme is only the first step
on the way to a specialised national health and welfare service for dancers.

Similar schemes already exist in other countries. OzDance, the Australian
equivalent of Dance UK, for example, started looking at ways of improving
dancers’ health a few years ago. Tony Geeves, a pioneer of OzDance and lecturer
in dance at the Academy of Arts, Queensland University of Technology, says
training was one of the first areas to be examined.

Ballet dancers go through long and demanding daily classes, rehearsals
and performances, and this has been thought sufficient training. But Geeves
believes it may not be enough to get the heart pumping, and build cardiovascular
endurance. ‘Dancers say how hard they train and how fit they are,’ he says.
‘They are fit in that they have flexibility, coordination, power and strength,
but they’re often not fit in the cardiovascular sense. Dancers usually get
injured at 4 o’clock in the afternoon, when they’re tired and might stumble
and make mistakes.’

Ballet dancers need to do the sort of exercise recommended for the rest
of the population, he says. He recommends swimming or cycling three times
a week to, take the heart rate up to 120 beats a minute and keep it there
for 20 minutes.

The idea of supplementary training is not new in sport. Boxers skip
and runners use weights. But dancers don’t expect to need general fitness
training. Geeves is monitoring the introduction of cardiovascular endurance
training over five years to see whether it will reduce injury. He believes
it will.

Strong hold

A study already completed in Britain concentrated on improving the upper
body strength of male ballet dancers. Yiannis Koutedakis, senior lecturer
in health sciences at University of Wolverhampton, set up a strength training
programme at Birmingham Royal Ballet. It included 14 male dancers who had
trained in classical ballet since they were 12 years old. One group continued
with the dancing timetable as usual, while the others added a strength training
programme to their regime.

The programme included up to three weight training sessions per week,
each lasting up to 90 minutes. After 11 weeks, those who used weights showed
a significant drop in their percentage of body fat. They showed a 14 per
cent increase in upper body strength, improved grip strength, and almost
all said it was easier to lift their female partners.

Koutedakis’s programme for male dancers aimed to increase strength and
power in the upper body. Training focused on developing fast muscle fibres
– humans also have slow muscle fibres and intermediate muscle fibre, which
is a mixture of fast and slow. Fast muscles develop if the training encourages
anaerobic metabolism, for example weight training. The programme’s dancers
used free weights and machines in the gymnasium set at high resistance for
a low number of repetitions. They were also encouraged to do exercises that
develop slow muscle fibres. These develop when aerobic metabolism is taking
place in the muscles, for example during sports such as cycling or long-distance
running.

Koutedakis stresses that after his programme, dancers felt their physical
appearance had improved. During the weight training programme the dancers
were encouraged to lift weights that were lighter than the maximum their
bodies could tolerate. This prevented too great a build-up of fast muscle
fibres, which can eventually lead to the bulky appearance characteristic
of weightlifters.

Light weight

Some choreographers initially expressed doubts about the outcome of
Koutedakis’ weight training programme. This meant the project was restricted
to male dancers. But the results have convinced choreographers that their
sugarplum fairies are not going to turn into Ms Universe overnight, so Koutedakis
is planning to extend the programme to include women.

Geoffrey Goldspink, professor of anatomy at London’s Royal Free Hospital,
says fears about bulky muscles may be unfounded, especially for women.
The initial effect of training is to consolidate muscle rather than to increase
its size. Muscle fibres grow at the expense of the fluid-filled spaces that
surround them. The muscle becomes better defined and shows through the skin.
Beyond this stage, muscle growth appears to depend on the level of testosterone.

The Healthier Dancer programme is also emphasising the importance of
the body awareness taught in the Alexander and Pilates exercise techniques.
Both these aim to work muscles that are often neglected. Susanne Lahusen,
a Pilates teacher at London’s Laban Centre for movement and dance, says
the technique is about balancing the body. In dancers, muscles like the
trapeziuses, which rotate the shoulder blades, may stay permanently contracted
because the dancers are under constant pressure to pull their shoulders
back. However, this position may not be best for the dancers’ posture.

Diet is another crucial area that both the British and the Australian
prog-rammes are tackling. Geeves says the Australian study found women dancers
ate two meals a day on average and then supplemented these with snacks,
typically chocolate, for energy. ‘There’s a massive amount of misinformation,’
he says. ‘We need to re-educate dancers and get them to establish good nutritional
habits. They should be eating carbohydrate and eating every three hours.
We want the dancers to be slim, but with healthy, strong muscle tone so
that they can resist injury.’

In dancers who are not aerobically fit and who eat a snack-based, high
fat diet, appearances can be deceptive. Although they are slim, they carry
a surprisingly high proportion of body fat. Underdeveloped muscles may
leave space for a substantial layer of fat within a slight body.

The British survey found two-thirds of women dancers were underweight
with a body mass index – a figure that gives weight adjusted for height
– of less than 20. The normal range is 20 to 25, which is equivalent to
a body weight of between 60 and 75 kilograms for a woman who is 1.73 metres
tall. One in three female dancers had a BMI of less than 18. And one in
ten of the men had a BMI of less than 20.

Ballet dancers have a notoriously high incidence of anorexia and bulimia
– eating disorders in which dieting becomes an obsession. Even when dancers
do not have one of these recognised problems, they pay a price for constantly
restricting calorific intake. Low body weight coupled with intense training
can disturb menstruation. One in three ballet dancers has less than six
menstrual periods a year. The problem is common to other female athletes,
particularly long-distance runners and lightweight oars-women. Work with
these groups suggests the women may be at increased risk of osteo-porosis
– thinning of the bones – because reduced levels of body fat pro-duce less
oestradiol.

Jane Wilson, medical registrar at the British Olympic Medical Centre,
says that within five minutes of loading a bone, changes that would increase
bone density are visible at a cellular level. But these changes only occur
if there is a normal hormonal and metabolic background. ‘If you change the
level of calcium or sex hormones, the cellular response of the bone doesn’t
seem to occur,’ says Wilson.

Wilson says that dancers will start to lose bone density as soon as
their periods stop. Whether this will lead to an increased incidence of
osteoporosis in later life is still the subject of long-term studies. But
osteoporotic fractures can occur in young people, says Wilson. ‘We have
reported a true osteoporotic fracture in a 30-year-old. She hadn’t had periods
for eight years and had a proven low bone density. So it does happen.’

Even for those dancers who do not have osteoporosis, fractures and sprains
seem to come with the job. Floors in rehearsal studios and theatres are
often uneven and not properly sprung, increasing the risk of slips, strained
ankles and stress fractures. Victor Cross, doctor for the Birmingham Royal
Ballet, is looking at ways of tackling this kind of occupational hazard.
His work includes research into the design of ballet shoes, and improvements
in diagnostic techniques that would provide doctors and dancers with a greater
understanding of injuries.

Meanwhile in Australia, Geeves is investigating the origin of chronic
injury. He intends to survey adolescent dancers. ‘Our first report found
dancers had chronic injuries before they went into companies,’ he says.
‘They must have got them from somewhere. We want to know where they were
and what they were doing. Then we want to do something about it.’

The psychological stress of being a dancer in today’s world of tough
competition and constantly changing rehearsal schedules is another area
under scrutiny. Dancers lead unstable and unpredictable lives and often
need emotional and psy-chological support.

Psychotherapist Julia Buckroyd says ballet dancers are vulnerable because
of the close association between their body and their art. Any criticism
of body shape in class is a hurtful challenge to the dancer as a person.
Artists, musicians, and writers can put down their instruments and more
easily distance themselves from their job. But dancers use only their bodies.
If someone tells a dancer she is the wrong shape, too big, too fat, her
belly sticks out, or she has bad feet, it is very difficult for her to take
this as a criticism of her art form rather than of herself. ‘Learning to
dance is an extremely vulnerable activity,’ she says. ‘Dancers must think
about this and learn to treat themselves with respect.’

Ballet teaching methods need examining, says Buckroyd. The attitude
that the teacher knows everything and the dancer knows nothing leads to
an unsatisfactory exchange. The class becomes infantile. ‘Dancers are not
sufficiently conscious of their own power,’ she says. If young dancers could
mobilise their own intelligence and take responsibility for their own learning,
it would strengthen their confidence, she says.

Buckroyd also criticises the lack of solidarity between dancers that
has led to disgraceful pay and conditions for professional dancers. Actors
and musicians are not well paid, but they are a lot better off than dancers
and treated with more respect. Dancers lack self-esteem and fail to value
themselves. They often wait around for hours when rehearsals are rescheduled
or cancelled. They have allowed themselves to be bullied and misused, and
it will take collectivism and solidarity to change this, she says. ‘It’s
no use waiting around for somebody to say sorry. That won’t happen. It’s
up to practising dancers to take this up for themselves.’

This sentiment is at the heart of the drive to improve the lot of dancers.
Dance UK has sent out 3000 questionnaires to gather information about dancers’
physical and psychological health. The organisation hopes to use the information
in its campaign for better health facilities for dancers.

Improving the lot of the dancer will mean chipping away at a long established
culture. But Cross says the determination to see change is in place. ‘Everybody
is positively motivated to see as few injuries as possible. It will take
time, but we could see a real difference over the next thirty years.’

Helen Saul is a freelance writer specialising in health and medical
issues.