Training Ballet Dancers

I've been looking back throuh some of my archives and I'm going to start posting up some of my old Q&A's. These are not available anywhere else (due to the fact that the building that held the servers for my very first website burnt down!).

First up we have an interesting Q&A with Nick Allen. Nick runs the rehab for one of the UK's premier ballet companies. In his interview he shares with us how he has transitioned from the world of professional rugby to working with professional dancers.

NG: Thank you for the interview. Why don't you start by telling us a little bit about your current commitments?

NA: Thanks for the invite. At the moment I am the Clinical director of the Jerwood Centre. For those who are not familiar with it, it is a quarter of a million rehabilitation centre specifically designed for elite level dancers and athletes. I have also continued my work with England Hockey and sit on a register available to other National Bodies who require clinicians with international or elite level experience.

NG: Nick, you've been around a bit!! Can you tell the reader your educational or previous career background and how you ended moving from professional rugby to work with Birmingham Royal Ballet.

NA: I have had a very fortunate career so far. I hold an honours degree in Physiotherapy and a Masters in Sports Medicine. I am currently working on my expression of interest for my PhD. I have amongst others, worked as a Clinical Specialist in Sports and Musculo-skeletal Medicine in the NHS, been part of the RFU's Regional England Academy set-up as well as Head of Medical Services for a Premiership rugby club. The decision to give up a top Premiership job wasn't easy. What challenges me professionally are the cases that despite extensive intervention they still have problems- whether they be a persistent injury or just a catalogue of different injuries- this post gives me the opportunity to take the time to focus on those individuals, often working with their own medical teams to provide a solution.

NG: What have you taken from your work in elite sport and implemented into the Ballet. How have they taken to it? What matters are you still banging your head against a brick wall about?

NA: I feel strongly about manipulating all variables that contribute to optimal performance. One of the main omissions that I noted, was the dancers are happy to push themselves to the utmost limit, but failed to take on effective recovery strategies to take full advantage of all their good work. The other issue is a combination of determining fitness needs and nutrition requirements. We are still working hard to determine the true physiological demands of their discipline so we can provide effective programmes both to enhance fitness and provide the fuel needed while maintaining optimum body mass (an all to common scenario in the sports world!). In regard to banging ones head up against the wall, we, like in sports medicine come across the usual "we didn't have any of this in my day and worked flat out 17 hours a day and never got injured" coupled with some dancers who still don't see what they do as any relation to sport so are reluctant to do anything else but dance. That said I work for what must be one of the most progressive companies in the business that gives me fantastic support for my work.

NG: I guess the flip side of that is what could coaches and physios working with sports people learn from the performing arts?

NA: I always describe myself as a cultural heathen. Prior to taking this post my only venture into the arts world was taking my wife to see the Lion King as a gift (not much has changed since, having been with the company for 18 months I have only been to one ballet, another gift for the wife!) So when I originally watched the dancers jump and lift I figured they must have a pretty comprehensive Olympic lifting programme, nothing could be further from the truth. I have come to realise that what makes the dancers so exceptional is their skill and technique. Their ability to repeat a movement technically correct time after time gives them an efficiency I have not seen in any other sporting discipline. Second is the issue of core stability.

NG: What in your opinion are the essential skills needed to be a successful physio working in a high performance environment.

NA: I think the clinical side is a given, a more important factor is the clinical reasoning. But I think the key is to understand that an injury may not be just an injury. Appreciating what an elite competitor has gone through to get to that stage in their career gives an insight as to the impact it may have on their training and ultimately their career. Simon Barnes of The Times when describing David Beckhams metatarsal fracture indicated pain is the staple diet of sport and anyone who participates in it! I think this summarises the ethos of elite performance- they are simply prepared to push past the point at which the likes of Joe Average would say "no more". As a clinician working with elite performers you need to be aware of that. A decision to continue competing should be based on whether the injury would get worse as a result, or that the convalescent time is extended as a result rather than necessarily pain. It really is a balance between seeing performers as both patients and athletes. Favour the patient side and you could inadvertently hinder the progression of an athletes career, favour the athlete side and you could prematurely end an athletes career. Some might argue not an enviable position to be in!

NG: What are your typical clients and personal achievements as a physio?

NA: I am not sure I have typical clients, actually it tends to be the opposite- I generally see the atypical patients. From an achievement point of view I have been very fortunate to be part of a team that won the end of season Championship, the Cup and finished the season 11 points clear at the top of the table, only European glory eluded us. I also count as my personal achievements working 1:1 with a number of international athletes with potentially career threatening injuries and seeing them return back to competition. It's a good feeling.

NG: Can you describe a typical day at Birmingham Royal Ballet?

NA: It does depend on what day it is. Monday I start the day with a meeting my physician where we discuss all current cases to ensure we are constantly exploring all options to help speed up the healing process. It's normally followed with his treatment session (He won bronze at the World Triathlon Championships in Hawaii last year). I have a similar meeting with rest of the Jerwood Centre team where we discuss at length each case programme. The rest of my time is committed to clinic sessions with some time allocated for our research project (I am currently drawing correlations from our musculo-skeletal and physiological profiling with an injury audit to develop an effective tool for predicting injury).

NG: What does a day in the life of a dancer look like?

NA: This varies a little depending on whether they are in rehearsal or performance periods. Generally there is class at 10.30 for one and a quarter hours. This can be followed by up to 5 hours of rehearsal calls, then during performance periods this may be followed by a show from 7.30 -10.30. It becomes a bit of a nightmare trying to fit in things like complimentary training aspects, let alone nutrition and recovery.

NG: How do you keep your dancers performing. I'm guessing you face similar issues to coaches trying to keep athletes healthy for a full season. What are your 3 top tips for keeping dancers out of the treatment room?

NA: I am a strong believer in fitness, more specifically aerobic base. We have a physiological lab here at the Jerwood Centre and perform VO2max testing on all dancers as part of our screening. I also believe you cannot get the best out of your body if you don't treat it with respect- we work hard on nutrition and recovery. But probably the most important focus is on symmetry. I can't often tell you how strong is strong enough but I can tell you is asymmetry exists- be it muscle imbalance, range of movement- there is a good chance some structure within the kinetic chain may sustain an injury.

NG: What's the one thing that really gets under your skin when it comes to sports physiotherapy?

NA: Insecurity. It's by no means across the board but some individuals tend to want ownership over their patients. I think they feel that they are exposing weakness by allowing other thoughts or specialities to become involved. It comes down to accountability. One of the lessons I learnt heading up a medical team for a professional club was that whatever the situation you have to find a solution. I do think you need to be absolutely certain and confident which sources you use and that they have a proven track record with elite level performers and work well with you own objectives but ultimately I don't care who gets my patients better, as long as they get back to playing

NG: What's your opinion of S&C, where does it fit in with physio?

NA: I was going to say hand-in-hand, but the mental picture it conjured up is disturbing me a little. I believe the greatest successes are born out of good working relationships between S&C and physios. Again it comes back to this issue of insecurity, but I think it is great to have some overlapping skills as it allows the bridge between clinical rehabilitation and functional rehabilitation. If you are secure in your skill set and want the best for your athlete, there shouldn't be a problem.

NG: Core stability - everyone does it but not many people understand what it really means!!! It's all recruit TVA and multifidus, fire through the core, co-contract - but are we missing the point? When we are talking about sporting performance (not a clinical pathology - low back pain etc) which is the most important - the ability for a healthy ahthlete to recruit deep muscles or the ability to use larger global muscles (RA, Obliques etc)?

NA: I suppose this is where I stick my head out a little bit. I don't believe in injury prevention! I believe in performance enhancement. The body has an optimal but finite amount of loading it can withstand, beyond which the structures will fail. Unfortunately, most of our athletes break down before this point. How we 'prevent' that is to manipulate all the variables that affect it, like fitness, strength, co-ordination, skill, nutrition and hydration, and yes I am afraid core strength muscles. A simple analogy would be if you and I had a one lap race of our rehab pool here at the Jerwood Centre (aprox. 8m) but I get to push off the wall at the start but you don't. Chances are I would win. Core stability muscles provide a stable platform from which larger global muscles can generate force. The more stable the platform the greater potential for force production. So I think the short answer is they are both important if we are considering optimal performance.

NG: In my experience, most physio's are pretty poor at programming (3 x 10 seems to be a favourite). What do you think?

NA: You mean 3x10 doesn't fit every scenario?? Sorry but I would tend to agree. I know from my own development both my postgraduate degree as well as working along side physiologists has improved my understanding as to applicable programming.

NG: I know you study the field a lot. Who do you go to for advice?

NA: In regards to S&C I have been fortunate to have worked with Mike Anthony from the New Zealand All Blacks, Rudi Meir from Australia and Ed Archer from South Africa (who is currently doing some great work at the moment trying to bridge the 'functional Rehabilitation' divide) and Dr Matt Wyon. They tend to be my first port of call.

NG: Who else in the field has influenced or helped you? What are the best tips you learned from them and can pass on to your readers?

NA: I used to work with a chap called Dr Wayne Diesel (Head of Medical Services at Charlton Athletic Football Club). I think sometimes we can tend to over complicate matters. Wayne always told me to keep it simple. Work with the basics and the solution is there.

NG: What tips could you add of your own?

NA: Listen to your body. It is telling you something. Our job is to find out what and to make sure it doesn't progress into something that will hinder training or performance. Be wary of asymmetries, they could become a cause for concern

NG: What are the most common injuries that you see in your clinic?

NA: The whole spectrum really. My particular areas of interest are the biomechanics and peripheral nerve entrapments. Those odd injuries that appear common enough, but where the mechanism of injury may not always fit the injury, or it doesn't seem to settle in the normal time frame. That's when we start to look at the whole kinetic chain and appreciate the various influencing factors.

NG: What do you think about some of the supplements on the market such as glucosamine, chondroitin etc. Do you think they work? What would you recommend.

NA: I think in regards to the supplements as a whole, my fear is that athletes tend to rely on them rather that just good fresh food. Short of endurance athletes (like some cyclists), generally most athletes can plan their nutrition around their training needs. That said there are times when the body needs more that n the usual and supplements can play a role. Glucosamine and Chondroitin have always been interesting. As a supplement rather than a drug had meant the major drug companies weren't as interested in researching it, as they couldn't hold a license for it. But some research has been trickling through and the results seem to be positive. Anecdotal evidence from some of my surgeon friends is also encouraging in support of its use.

NG: What are your goals as a physio?

NA: This is not to sound altruistic but providing support to elite athletes allowing them to achieve their goals allows me to fulfil mine.

NG: In a nutshell, what is your philosophy?

NA: Keep it simple.

NG: Anything else you'd like to mention?

NA: I suppose I would like to commend Birmingham Royal Ballet Company for the investment in the Jerwood Centre but also the work they are doing in the community. They are currently involved in a huge charity project that is brining the experience of the arts to disadvantaged communities. (See up coming series on Channel 4 in September including an interview with yours truly on the “3 minute wonder” series).

NG: Where can people read more about your theories and programs?

NA: I am currently talking to a number of partners to try arranging some sessions looking at functional rehabilitation and specific stability training but I still remain primarily a clinician.

NG: I'm asking all of our contributors for their top three books, the ones every S&C coach should have in their library? We've had some great answers and I'm building a virtual library on the links page of the web-site....what are your top 3?

NA: One of my principal reference books is Clinical Sports Medicine by Peter Brukner and Karim Khan. It provides a good quick reference guide to the normal and not so normal pathologies I see in clinic. Then I tend to spend a bit of time with the bigger anatomy and physiology texts like Gray's. Sorry, it tends to be building my cases around comparisons to "normal" anatomy and biomechanics.

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