Dancing with hypermobility: an exploration of the health risk and experience of generalized joint hypermobility within a classical ballet narrative

Generalised Joint Hypermobility (GJH) is a heritable disorder of the connective tissue that can manifest as extreme range of motion in the joints and is associated with tissue fragility and injury. GJH is prevalent within classical ballet and is considered both an asset and health risk to the dancer. More recently within the general population links have also been made between GJH, anxiety disorders and poor body awareness. This research brings together three discreet yet interweaved studies that explore GJH within both vocational and professional dance environments. A mixed-methods design and a pragmatist approach was applied to this research which is situated within a biopsychosocial framework. Study one established reliable and stable measures between the researcher and an experienced clinician for the standardised Beighton categorisation of GJH. A sample of young dancers (n=10), randomly recruited from a larger group of young dancers (n=70) during their annual dance screen, were tested for GJH. The intra-rater stability of measures was found to be moderate (k=.43) for the physiotherapist and high (k=.88) for the researcher, with a high (90-100%) inter-rater percentage of agreement (pa) for the Beighton categorisation. This provided quality assurance within the research for the researcher to confidently apply the standardised testing methods. Subsequently a larger cross sectional sample (n=90) of classical ballet dancers in Scotland were tested for GJH. They also retrospectively reported injury occurrence over the previous year of training. Within the study a high percentage of dancers were observed with GJH (56% for ≥4, 43% for ≥5 and 39% for ≥6 cut off) which was in line with the literature and suggests that people with GJH are often signposted or recruited into dance training. Interestingly, and in contrast with the literature, the injury per workload estimation provided a relatively low overall frequency of 1.85 injuries per 1000 hours of training and performance, and there was no significant relationship (p<.001) found between injury and GJH in study one. Building on study one, the second study was designed to further explore the relationship between body awareness, anxiety and GJH in classically trained dancers. As the literature highlights the relationship between dance training and body awareness, the second study focused on one national level, full time vocational dance training programme. This provided assurance that the participants all received the same quality and quantity of dance training. In this study statistical analysis found no significant differences in proprioception between the dancers with and without GJH. Dancers that did not present with GJH had significantly higher scores for spatial visual memory (p=0.001) and not worrying (p=.003). Dancers with GJH scored significantly higher for body listening (p=.012), emotional awareness (p=.026) and noticing (p=.026). Significantly lower anxiety measures were recorded for the dancers without GJH (p = <001). Overall, study two demonstrated that the dancers that presented with GJH had different measures for some components of body awareness and greater anxiety than the dancers that did not present with GJH. It is argued that while GJH is reported in the literature as a signpost for entry into dance training because of the associated biological marker (distensible connective tissue) and extreme range of motion this facilitates, additional psychosocial factors, such as increased emotional awareness and body listening, may also signpost GJH to dance training. Having established GJH prevalence and associated injury rates, body awareness and anxiety levels within classical ballet dancers, this research then investigated the lived experience of GJH from both the professional dancers’ and classical dance teachers’ perspective (study three) from the professional environment for classical ballet. Study three explored the experiences of nine professional international dance artists (5 male, 4 female; mean age = 32.3yrs; SD=4.99yrs; range=25-40yrs). All were referred to the study on the basis of GJH by clinical practitioners, had a classically based training and at least ten years performance experience. GJH status was further confirmed using a validated historical self-screen questionnaire. Data was collected through retrospective recall in semi-structured interviews (35 - 45 min). Thematic analysis exposed the main themes as: openness and extent of acceptance of GJH; coping strategies towards the management of GJH including mental stillness; and the dancers agreed that GJH gave them an advantage in their careers with regards to choreographic demands. They discussed needing more time than other dancers to consolidate choreographic movement, however they did not explicitly associate this with GJH. The dancers were readily able to identify and discuss the physical aspects of GJH. Psychosocial implications and experiences of GJH were discussed, but the dancers did not make direct associations between GJH, anxiety and their struggle to find mental stillness. Semi-structured interviews (45 to 50 minutes) were conducted with four dance masters (three female & one male). The dance masters had a mean of 30.8 years (SD=6.8yrs; range 25-35) experience in their role. Thematic analysis provided emerging themes that included the hypermobile aesthetic, professional values and preconceptions towards current choreographic trends, company strategies, intellectual curiosity, pedagogy and leadership. All dance masters agreed that dancers with GJH met the direction and desired aesthetic for most of today’s dance companies and choreographers. They showed a good understanding of the strengths and challenges of a physique with GJH but did not directly associate any psychosocial traits with GJH. They did however suggest that the dancers with GJH who had successfully sustained a career in dance were those who had developed intellectual and physical strategies to cope with their condition. In conclusion, this thesis provides evidence of the multi-faceted nature of GJH within the classical ballet context. In the first instance it is evident that GJH is prevalent in young classical dancer but interestingly at this stage in their career GJH is not associated with injury, possibly due to the protective feature of their dance training. In realization of the complex nature of GJH, study two highlighted further aspects that intersect the psychosocial domain of body awareness and anxiety in dancers with GJH. Study two provides evidence to suggest that GJH signposts dancers towards dance for both physical and emotional capacities. This study also provides evidence towards altered body awareness including enhanced body – mind connections and increased anxiety within GJH. Finally, whilst the dancers and dance masters clearly recognised the physical experiences of GJH they demonstrated disconnect between the psychosocial aspects they discussed and the implications of these with GJH. This brings new insight to the experience of GJH that potentially has wider implications for dance teaching learning and performance whilst also potentially influencing the creative process for dance. This may further inform practice to provide insight in to the psychosocial ramifications of this condition and a healthier environment for dancers with GJH. This is particularly noteworthy within the education for dancers and dancer teachers and potentially other aesthetic sports where GJH is prevalent