Things I have to say

Acute Injury Management

I am often asked by parents what to do in the early stages when their child sustains an injury. My response will differ based on a multitude of factors, such as the mechanism of injury, the physical structures that are likely to be damaged and the chronicity of the injury (is it a fresh injury of is it an old irritation that continues to niggle).

The safest bet is to book in to see your dance physiotherapist to have the injury examined earlier rather than later, to accurately diagnose the injury and establish a clear and structured plan for management from the outset. The physiotherapist will be able to assess the injury and determine the most appropriate and individualised course of treatment, which gives the dancer the best chance at making a successful and timely recovery.

However, it is not always possible to get to the physio straight away. The acronym RICE – rest, ice, compress, elevate – is well known amongst active people these days, and more importantly, amongst dance teachers who are often the first person on the scene when a young dancer injures themselves in class. The practise of ceasing the activity and resting immediately whilst icing, compressing and elevating is a good first step in managing an acute injury.

A slight update to the RICE acronym is POLICE – protect, optimal load, ice, compress, elevate. But what exactly does this mean, and how do we go about it? Here are some practical, tried and tested tips (although general in nature) based on my experience as a dancer and physiotherapist working predominantly with young dancers.

Protect

First and foremost – protect the dancer and injured body part from further damage. This might be through splinting or immobilisation, using tape or a brace. Try to limit the risk to other parts of the body; for example, with an ankle injury which is causing the dancer to limp, there is likely to be compensatory loading through adjacent joints, so using crutches until further examination can be carried out might be necessary.

Optimal Loading

Take enough weight and load off the injured area so as to not aggravate the injury or cause discomfort, but continue to move and exercise the unaffected areas as able. For example, if you have a sore toe and only one tiny portion of your body is injured, it is crucial to continue working the rest of your body or modifying certain activities with the aim of preserving strength and condition. Keep working the ankle, the knee, the hip, the body. Whatever is uninjured!

Ice

The idea is to cool down the tissues, to constrict blood vessels with the aim of stemming bleeding into the injured area, as well as limit the accumulation of inflammatory fluid. Icing is also a non-invasive and non-chemical alternative to oral analgesics, so safe for people with medication allergies or those wishing to avoid synthetic drugs. We only need to cool the skin and tissues slightly; there is no need to induce hypothermia and risk an ice burn – ouch!

  • Apply an ice pack to the painful area – the most effective ice pack is a bag of frozen peas or plastic bag full of semi-crushed ice blocks (it stays colder for longer and can mould around body parts)
  • Keep ice on for 20 minutes, then remove for 40 minutes
  • Repeat this every 1 to 2 hours for the first 2 to 3 days

Cold water bathing is extremely helpful for toe, foot and ankle injuries, as the cold water gets into all the nooks and crannies around the foot and between the toes. The gentle pressure around the limb is also helpful, and whilst uncomfortable for a short period of time, has a profound impact on recovery – ever wondered why the footballers wade in freezing cold Port Phillip Bay in the depths of winter…?! The dosage is slightly different compared to icing:

  • You may only need 3 to 5 minutes at a time, then 3 to 5 mins out, and repeat this a few times to accrue a total of 20 minutes in the water, then 40 minutes out

Compress

Applying a firm (but not tight!) compression bandage to the injured area provides a physical barrier for swelling accumulating. If the limb is to be completely immobilised, applying the bandage all the way to the extremity for uniform compressing down the length of the limb. Remember to check the skin regularly – if the skin has changed colour or appears blotchy or shiny, it can be a sign that the compression is too tight and circulation is being compromised.

Elevate

When resting, have the entire limb supported above the level it attaches to the body. For example, for a knee injury, have the entire leg elevated so the foot and knee are resting above hip height, supported on a pile of cushions or pillows, including at night time when sleeping. This becomes challenging for a back injury – sometimes we need to get creative with positioning!

Need some personalised advice on injury management? Get in touch!

info@charissafermelis.com

 

The methods outlined above are intended as a guide only and are provided on the basis the reader will be responsible for assessing the relevance and accuracy of the content in reference to their specific situation.

 

Taking Dance Physio to Regional Victoria

Few things give me more professional joy and inspiration than teaching the next generation of young dancers about their bodies.

Last weekend I ventured out to Bairnsdale in regional Victoria to the Jan Pianta School of Dance – the longest running dance school in East Gippsland, headed up by Jan Pianta. East Gippsland holds a place close to my heart, as my childhood family holidays for many years were spent camping and caravanning around the beaches and bush of the region.

Over the past decade, the scope of dance medicine has widened dramatically. Dance students from recreational dance schools, as well as pre-professional and full time programs are able to access top tier expert dance physiotherapy services and quality care, once reserved for professional dancers. It is now customary for dance teachers in the capital cities to refer their students to dance physiotherapists for injury management, pre-pointe assessments and technique evaluations. However, it is not always possible for rural parents to make multiple trips to the city for specialised dance physiotherapy services. My desire is to bring these services to regional centres, to enable all dancers access to the same dance health advantages and opportunities within their own communities, as are available in urban areas.

The morning was spent with Jan’s senior students, assessing some niggling foot injuries, providing a second opinion on ongoing management, and examining students’ readiness to commence pointe work. The dancers were energised and engaged, taking on new corrections and techniques maturely with the utmost respect for their bodies.

The afternoon involved taking groups of students through practical and educational workshops:

  • Safe Stretching for the 5-9 year olds
  • Active Anatomy for the 10-12 year olds
  • Taming Turnout for the 13+ girls.

The dancers left the sessions with a bunch of homework to do, new concepts to wrap their brains around and a sense of empowerment that they are able to improve their technique and reduce their injury risks them selves with the crafty little tricks.

It was an absolute pleasure to be involved in the physiotherapy care Jan Pianta’s dancers – I can’t wait to see their progress when I head back to Bairnsdale next time.

 

The Rise

Never underestimate the power of a beautifully controlled, expertly executed rise.

Dance physiotherapists place great importance on the technique, control and endurance of a single leg rise to demi pointe when assessing a dancer’s readiness to commence pointe work. It gives us valuable insight into where a dancer may be lacking in their development and areas that must be addressed in preparation for pointe class. I recently contributed a blog outlining the considerations for commencing pointe work.

The rise is also pivotal in the overall function of a dancer’s leg, as it ‘gives rise’ to fundamental technical skills such as the push off and landing in petit and grand allegro, the posture of the standing leg during pirouette, and the step up position of a posé just to name a few.

Regardless of whichever injury a dancer may present with, I will often examine the rise as a starting point and progress the assessment from there.

Qualities I look for when assessing a rise:

  • Comprehensive body alignment in standing – on two legs and on one leg
  • Lower back posture
  • Hip and pelvic stability
  • Knee extension”pull up”
  • Ankle alignment
  • Height of the rise on to demi pointe
  • Foot alignment
  • Toe control
  • Early upper calf muscle activation
  • Precision and consistency throughout the movement
  • How many excellent quality rises can they complete?

When building the ideal rise, establishing optimal technique first is the priority. Only then can we work to gradually build strength and endurance.

Dance physios tend to be quite clever people who can analyse the elements of a rise and predict where the necessary changes are to be made, and how to make them. Either through manual hands-on physiotherapy or through a structured, tailor-made home exercise program. However, we won’t know what to prescribe specifically until we see the rise performed in front of us!

Contact me at info@charissafermelis.com for further information of to have an assessment at home or at your dance studio.

Charissa

Recovery during dance competition season

The winter dance competition season is fast approaching, and for many young dancers it is an exciting opportunity to perform on stage. However, the school holidays, rather than being a time for rest and recuperation between busy school terms, can transform into a hive of additional activity with dancers participating in winter schools and eisteddfods. In Melbourne for example, a dancer may have a performance of her classical solo one morning in Frankston, followed by a jazz troupe that afternoon in Werribee, followed by a lyrical duo in Heidelberg the next morning. Punctuate this schedule with extra rehearsals and workshops; a hectic timetable, with high intrinsic expectation and perceived pressure from teachers and parents can lead to a physically exhausted and emotionally drained young person. And in a few days…term 3 starts!

I remember this all too well. In amongst all this dancing, I somehow needed to find time to stay abreast of school study, engage with my non-dancing peers and also just chill out!

I’ve outlined some methods below to assist with recovery during those heavy dance periods, to maximise performance potential and help minimise the risk of injury.

PHYSICAL RECOVERY

Purpose: reduce muscle soreness, begin the tissue repair process and restore function.

  • Stretch following activity – long indulgent stretches, working through all the major muscle groups, holding the stretch for 30 seconds but repeating each 3 to 5 times
  • Ice pack – utilise an ice pack at home (or a bag of trusty frozen peas!) on any acute injuries to help reduce pain, swelling, bruising and inflammation
  • Soak feet in cold water – to soothe tired feet, especially helpful after dancing en pointe
  • Massage – either by making an appointment with a myotherapist or massage therapist, or by working on a foam roller or spikey massage ball at home
  • Compression garments – wearing compression leggings or compression socks (on flights or on long car trips home after dancing) will help prevent swelling pooling in the feet and assist with blood circulation
  • Postural drainage – resting with the feet elevated up the wall helps with venous return
  • Adequate sleep – the National Sleep Foundation recommends a teenager aim for between 8 and 11 hours of sleep per night
  • Optimal nutrition – replenish glycogen and protein, water rehydration

EMOTIONAL RECOVERY

Purpose: settle the emotions.

Competition season can be an emotionally challenging time, with heightened stress and expectation. It is crucial in the down time between performances to participate in pleasurable activities in a calm environment.

  • Share fun times with family and friends
  • Watch a funny movie with an enjoyable, positive message
  • Read a book
  • Listen to music
  • Spend time outdoors for fresh air and vitamin D
  • Take the dog for a walk
  • Avoid using electronic devices

 MOTIVATIONAL RECOVERY

Purpose: control the thoughts.

Many aspects of dance competition are out of your control – you cannot control what other performers do on the day, you cannot control the decisions of adjudicators, you cannot control the results. So it is important to focus on the things you can control.

  • Make a list of the positive things achieved on each day
  • Keep a training diary to ensure you stay on track
  • Assess short-term goals for the next few weeks
  • Reaffirm long-term goals for the months ahead
  • Make plans to address any problems or obstacles such as costume repairs or choreography modifications
  • See your dance physiotherapist to assess any acute injuries and to develop an ongoing management plan

Research is underway to investigate the optimal recovery regimens for various sports. So my recommendation is to explore the methods outlined above to establish a strategy that works best for you!

Email info@charissafermelis.com for further information.

Best of luck for the upcoming dance competition season!

Charissa

Commencing Pointe Work: What To Consider…

Commencing pointe work is a rite of passage for many young dancers. It is an exciting milestone, eagerly anticipated by dance students, teachers and parents alike.

However, dancing en pointe is not a natural thing for a human body to be doing; few dancers are fortunate to have been born with the exact physical attributes required for safe dancing en pointe.

As a dance physiotherapist, dancers are referred to me by their ballet teachers for a pre-pointe examination. We conduct a thorough physical assessment to determine the student’s strengths and weaknesses, to establish whether the dancer will physically be able to achieve pointe work, and to implement a pre-pointe preparation plan.

The International Association for Dance Medicine and Science has developed the following recommendations for young dancers commencing pointe work:

  • Not before age 12.
  • If the student is not anatomically sound, do not allow pointe work.
  • If she is not truly pre-professional, discourage pointe training.
  • If she has weak trunk and pelvic muscles or weak legs, delay pointe work
  • If the student is hypermobile in the feet and ankles, delay pointe work
  • Consider implementing a strengthening program where appropriate.
  • If ballet classes are only once a week, discourage pointe training.
  • If ballet classes are twice a week, and none of the above applies, begin in the fourth year of training.

Stage of physiological development and mental maturity are key factors. Girls mature at different rates; ‘normal’ encompasses a broad range of physical shapes and variations in emotional intelligence.

Without appropriate foot and ankle bony morphology (shape) and adequate range of movement into plantarflexion (a pointed position), a girl will struggle to actually rise on to pointe. Conversely, a foot that is hypermobile and über flexible, may not have the essential strength within the arch to support the foot shape en pointe. Both ends of the mobility spectrum cause problems; poor habits quickly set in and the likelihood of injury is exacerbated. Hence why developing adequate intrinsic foot muscle coordination, activation and strength is vital.

Repeated single leg rises from flat to demi pointe reveals several technical capabilities. If concerns are identified in any of these, they must be addressed prior to commencing pointe work:

  • Trunk control
  • Pelvic and hip stability
  • Knee control
  • Calf muscle activation
  • Ankle alignment and stability
  • Toe control
  • Balance

Students must be able to accomplish 25 perfect single leg rises (in a row!) before fatigue, to be considered ready to commence pointe class. It will take around 5 weeks to increase repetitions from 15 to 25, so get practising!

Often, pointe classes are scheduled at the end of a normal ballet class, when the students are most fatigued and at the greatest risk of injury, so teachers need to keep this in mind when planning class timetables.

The vast majority of students are not ready to commence pointe work after their initial physiotherapy assessment – there is much homework to do! From my experience, a diligent, patient but motivated student can achieve remarkable things.

CHARISSA FERMELIS

Physiotherapist B.Phty APAM

 

How long have you been sitting at your desk for this morning??

Like me, have you been at your desk all morning in front of a computer, in and out of emails, on and off the phone, but otherwise pretty sedentary? Well…

GET UP – GET MOVING – GET STRETCHING

Simply getting up and about and moving around regularly is enough to reduce nasty things like back pain, neck pain and stress creeping in to ruin your day. I’ve worked on this STRETCHING GUIDE FOR OFFICE WORKERS recently which you may find helpful. Some stretches might seem a bit extreme for your capabilities or a bit NSFW (mum: that means ‘not suitable for work’), so do what you can. Something is better than nothing!

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Photos curtesy of Medibank.

There’s something in the water…

There’s something in the water in Camberwell at the moment…I have three pregnant colleagues and four pregnant friends who are each trying to navigate their way through the various stages of their pregnancies. I seem to be having similar conversations recently with these wonderful women about some things to be aware of, from a physiotherapy and Pilates perspective, while they are exercising. So I thought I’d jot down a few things to keep in mind for other women out there…

Pregnancy & Pilates

Pilates is a unique method of exercise, which requires concentration, control and precision. Pilates exercises are versatile and easily modified, so are ideal for pregnant women while your bodies change. However, like any mode of exercise, it must be practised correctly to ensure safety and effectiveness.

Hormonal Changes

The hormone ‘relaxin’ is released with one of its roles to relax connective tissue. This increases soft tissue laxity, affects joint stability, and potentially leads to conditions such as pelvic instability and pelvic girdle pain. Movements that challenge pelvic stability or involve asymmetrical forces around the pelvis should be practiced with caution, as they can provoke dysfunction in the pubic symphysis or sacro-iliac joints. Modify Pilates exercises to become bilateral and symmetrical, reduce twisting and rotational forces through the pelvis, and always promote correct activation of the pelvic floor muscles and lower abdominals. Repertoire involving gluteus maximus contraction is also beneficial in providing stability across the back of the pelvis.

Postural changes

Throughout the progression of your pregnancy, the natural spinal curvatures become exaggerated, with increased lumbar lordosis (sway back) due to the weight of the baby pulling forwards, and compensatory increased thoracic (upper back) kyphosis. Add to this, increases in spinal joint laxity and compression. The prevalence of reported lower back pain during pregnancy ranges from 35-61%. Pilates workouts need to focus on postural education and endurance, and encourage thoracic extension and lumbar flexion to elongate the spine.

Abdominal Musculature

As your baby grows, your abdominal muscles will be stretched in all dimensions. This altered length-tension relationship of the muscle fibres changes their ability to contract and dynamically support the spine. A diastasis (separation) of rectus abdominus is common, which can prevent optimal function of the core. In Pilates, ensure your deep abdominal muscle, the transversus abdominus, is activated prior to the superficial abdominals. Encourage a “drawing in” of the lower abdominals throughout, and discourage excessive outer abdominal loading by avoiding crunches and sit ups.

The Pelvic Floor

Increased weight in the pelvis places greater pressure down on pelvic floor muscles, leading to potential incontinence (loss of bladder or bowel control) during pregnancy and compromised intra-pelvic stability. Incorporating specific pelvic floor activation into the Pilates program will help condition the pelvic floor to manage incontinence symptoms and assist with pelvic stability. Strengthening has also been shown to promote a quicker 2nd stage of labour and reduce the risk and severity of pelvic floor trauma during birth. When activating your pelvic floor, you should be able to feel a definitive squeeze and lift sensation.

Weight Gain

The recommended healthy weight gain during pregnancy is between 11kg and 16kg. It is influenced by many factors such as pre-pregnancy weight, baby weight, amniotic fluid, increased blood volume and increased breast size. This places increased stress on all joints, and allows less space for abdominal and pelvic organs. Sometimes women feel dizzy when lying on their back for extended periods as the pressure of the growing baby compresses pelvic veins and reduces blood flow back up to the heart, so you may be unable to exercise on your back after the first trimester. Take care with prolonged periods of supine lying; try propping the upper body on a wedge cushion, or change positions between exercises. Cushions can also be strategically placed around the pelvis and chest for prone work.

Cardiovascular & Respiratory Systems

The demand on your cardiovascular system escalates, with an increase in resting heart rate, cardiac output and total blood volume, and a decrease in blood pressure. Reduced venous return can produce swollen ankles and conditions such as carpal tunnel syndrome in the hands. Exercising in postures where the limbs are elevated in relation to the trunk will improve venous return to the heart. With available space in the abdomen at a premium, women must be aware of reduced lung volume and aerobic capacity during exercise. Pilates exercises should feature emphases on thoracic mobility, chest expansion and breathing techniques.

I’d love to hear your comments and answers to the following questions:

  • Have you experienced any of the above changes?
  • What modifications have you made to your Pilates program and exercise regime throughout your pregnancy?

Ballet research to optimise performance

Whilst I was a physiotherapy student at La Trobe University, I was always impressed with the focus on excellence in research and staying at the forefront of sport and exercise innovation and discovery.

As a graduate and proud alumni, I am so excited to learn that La Trobe will be collaborating with one of our country’s premier dance companies, The Australian Ballet Company.

The medical team at the ABC are world leaders in dance injury research and injury prevention. They have a proven impressive track record in injury prevention and continue to be ahead of the game in applying elite sports medicine principles in a dance and performance setting. I am looking forward to seeing this professional partnership grow with the aim to optimise dancer performance and recovery, and help us gain new insights into the prevention of dance related-injuries.

Read more about this exciting development here.

Bend It Stretch It

I worked with Medibank’s BE Magazine throughout 2016 to deliver a comprehensive STRETCHING GUIDE which can be followed by just about anyone – sedentary office workers, recreational runners, gym enthusiasts and anyone wanting to improve their joint mobility, muscle length and overall wellbeing. Click here to be taken to the Guide!

 

Image credit: Medibank BE Magazine 2016

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