Performing arts medicine has evolved significantly over the past decade because more health care providers have recognized the unique medical needs of performing artists and the need to establish comprehensive health programs emphasizing an interdisciplinary approach to these patients. Educational training and professional expertise make athletic trainers uniquely qualified to provide care to performing artists. As the field of performing arts medicine continues to grow and evolve, athletic trainers and other health care practitioners are finding new and exciting opportunities to engage with this diverse group of patients to prevent, treat, and rehabilitate injuries suffered as a result of participation in a vast array of performing arts activities.
Scifers: What patient populations are included in performing arts medicine?
Wilkenfeld: This really depends on who you talk to, and the list of patient populations can be rather lengthy. I like to think of performing arts medicine as being very broad and incorporating not only the performers but individuals who support the performers. Ballet, modern/contemporary, jazz, tap, and ethnic genres of dancers, television, movie, and theater performers, and instrumentalist and vocal musicians certainly come to mind. Additionally, I include technical and production crew, competition and entertainment dancers, circus artists, visual artists, and individuals involved in sports with a strong aesthetic base (eg, gymnastics or synchronized swimming).
Russell: This is not as easy a distinction to make as one might think. I take a very broad view of performing arts patients because of how I designed my program at Ohio University, but, more importantly, because I know that anyone who works in performing arts is severely underserved (and often poorly served) by the health care profession. At my university, dancers, musicians, theater performers, theater technicians, marching musicians, entertainment performers, and entertainment technicians are individuals who are either patients in my clinic or research participants. Beyond that, dance patients can include competition, entertainment, and ethnic dancers, in addition to the traditional genres of ballet, modern/contemporary, and jazz/tap that usually come to mind. Musicians include both instrumental and vocal. I consider marching band separate from music because the majority of our university's marching band members are not music majors. Synchronized swimming, figure skating, entertainment wrestling, and other sports that have a strong aesthetic foundation also could be reasonably included.
Santos: Performing arts medicine includes stage performers (musicians, dancers, actors, acrobats, and other circus artists), stage crew, and other “behind-the-scenes” professionals. In our conservatory setting, we also treat visual artists, film-makers, and individuals engaged in shop-based activities such as prop makers and wig makers. The common thread running through most of the field is repetitive motion with extreme occupational demands.
Scifers: How have you seen performing arts medicine grow and evolve over the past decade?
Russell: In my work with post-professional athletic training students, I have witnessed a marked increase in the number of inquiries from potential graduate students and young professionals about the performing arts medicine program I lead, as well as about how to enter the field. In conversations with my performing arts medicine colleagues, we discuss that there appear to be more students wanting to gain exposure in the field than there are places where they can participate in such experiences. Furthermore, it's always exciting when we hear about a university or clinical facility that adds a new position devoted to caring for performing artists. I also have seen a rise in the number of performing arts medicine articles published in a wide variety of journals. All of these are indicators that the field is growing, and they are gratifying trends.
Santos: The interest from students and current professionals has exploded over the past 10 years. People grasp that athletic trainers' skills and knowledge are directly transferable to the performing arts, that performing arts is an area that is currently underserved, and that it's a fun and exciting setting in which to work.Groups like Athletes in the Arts and the National Athletic Trainers' Association Council on Practice Advancement Performing Arts Work-group have increased the profile of performing arts medicine and built on the work of organizations like the Performing Arts Medicine Association and the International Association for Dance Medicine and Science. Research like that coming out of the SHARE (Supporting Healthy Arts Research) Consortium led by Dr. Jatin Ambegaonkar is increasing the body of arts-specific knowledge and inspiring future research.Perhaps most importantly, there is a desire for performing arts medicine support from arts administrators and the artists themselves who are aware that there are professionals who can help them to remain active and excel in their chosen areas.
Wilkenfeld: Much like Dr. Russell mentioned, through my work with professional athletic training students, I have seen an incredible surge in the number of requests for performing arts clinical education sites and inquiries about how to enter the field of performing arts medicine. There has been an increase in new clinical positions devoted to the performing arts. Professional organizations such as those mentioned previously are working with arts educators and administrators to make positive policy changes, and social media has been a major driver for change by allowing clinicians and professional organizations to easily and quickly reach thousands of artists around the globe and share health and wellness information. Finally, I have noticed that the body of performing arts medicine knowledge produced through professional presentations and peer-reviewed journals has grown significantly. All of these changes are encouraging and seem to point in the direction of growth for the field of performing arts medicine for the foreseeable future.
Scifers: What health care disciplines are included under the umbrella of performing arts medicine and how do you collaborate with each one?
Russell: There are many different health care disciplines that have much to offer performing artists. There are the obvious and common ones: athletic trainers, physical therapists, and physicians. However, there are many physician specialties that benefit artists, along with other types of providers, including chiropractors, podiatrists, and mental health professionals. Our clinic's medical director is an osteopathic physician, and an osteopathic approach is especially useful for performers, particularly osteopathic manipulative medicine. Performers regularly consult other key specialists, including massage therapists, acupuncturists, audiologists, speech-language pathologists, dietitians, and alternative and complementary care practitioners. Of prime importance is that only properly qualified and licensed individuals should provide health care. For example, well-meaning teachers are consulted regularly about injuries, even though they are not health care providers.Another important consideration is establishing alliances with artistic directors, stage managers, arts instructors, and others with whom health care professionals often are unaccustomed to collaborating. Solid relationships with these individuals can help ensure performers' compliance with their health care protocols.
Santos: As in any athletic training setting, we rely on strong relationships with physicians and advanced practice providers who direct care and order diagnostic testing, pharmaceutical interventions, and other medical services. At the University of North Carolina School of the Arts, our on-site medical team provides general medical care, and collaborating sports medicine physicians provide weekly clinics. The medical staffs also provide on-site performance coverage. Another essential member of the performing arts medicine team is a registered dietitian. We screen all of our dancers for relative energy deficiency and other injury risks, making referrals for dietary consultation when there is concern for suboptimal fueling. Dietitians support injury prevention and performance optimization through evaluation and management of dietary needs. Mental health professionals and sport/performance psychologists can also be incredibly effective in injury prevention by addressing mental barriers to performance and teaming up with rehabilitation professionals during a recovery period. If a student at our institution is going to miss classes for more than 1 week, the athletic training staff is likely to recommend speaking with one our counselors to work through the frustration, potential loss of identity, fear upon return to activity, and pain management.Because performing artists are often moving from one location to another, they are likely to be established with a physical therapist from a previous injury. In my experience, an allied, collaborative approach (eg, sharing documentation and communicating directly when needed) is best to ensure the patient, athletic trainer, and physical therapist are working toward the same goals. Chiropractors, massage therapists, acupuncturists, and naturopaths may also contribute to the care of performing artists. In general, performing artists seem drawn to hands-on treatments and may be more interested in or trusting of alternative or non-Western approaches. I have seen various types of care be successful in getting artists “over the hump” of an injury or musculoskeletal complaint and help maintain a performer's health. Again, forming a plan with the performer for comprehensive care ensures that everyone is working together.
Wilkenfeld: There are many health care disciplines that should be included under the umbrella of performing arts medicine. These commonly include athletic trainers, physical therapists, speech-language pathologists, occupational therapists, podiatrists, chiropractors, mental health providers, and various physician specialties. Performing artists also greatly benefit from other specialists, including massage therapists, acupuncturists, dietitians, and other complementary and alternative practices. Collaboration not only with these individuals, but also with the artistic staff is vitally important to ensure the health and well-being of the performing artist. Just like the traditional athletics setting, there can be pressure from artistic staff to return a performer to activity before he or she is medically cleared. Developing a medical model where qualified and licensed health care providers, in collaboration with the artist, make health care decisions independent of the artistic and administrative staff is the best approach in my mind.
Scifers: What are some of the unique challenges associated with practicing in performing arts medicine?
Russell: Perhaps the most significant among many challenges is getting artists to trust health care practitioners. A specific challenge for athletic trainers is helping artists understand how athletic trainers work in a performing arts setting. Athletes generally are exposed to athletic trainers, team physicians, and other professionals during their junior and senior high school and college sports programs. This is not true for artists, so artists must be educated about the types of care available and the importance of accessing that care before injuries become more difficult to manage. Another significant challenge is changing one's approach to taping and bracing. Wardrobe requirements and aesthetic concerns typically do not allow the same type of taping and bracing that we apply to traditional athletes. However, a fun part of performing arts medicine is using our creativity to solve challenges like these.
Santos: Aesthetic demands, whether real or perceived, can wreak havoc on a performer's physical and mental health and require awareness, rapport-building, and multidisciplinary, creative problem-solving skills to address. Other challenges include equipment (pointe shoes, heavy costumes, etc.) and environment (bright and/or low lighting, uneven surfaces, etc.), year-round training, and performing artists' unfamiliarity with periodization and the basics of physical fitness. An initial hurdle might be getting performing artists to view what they do as a physical activity and themselves as athletes.Administrative challenges include lack of funding and access to care, and it can be difficult to build a team of qualified practitioners. However, as noted previously, interest and knowledge are growing, so this concern may resolve over time.
Scifers: What additional educational preparation is needed for athletic trainers practicing in a performing arts medicine environment?
Wilkenfeld: I recommend that athletic trainers interested in practicing in a performing arts setting further their education by researching the discipline. They should develop a continuing education plan that focuses on attending conferences for organizations such as the International Association for Dance Medicine and Science and the Performing Arts Medicine Association. Additionally, membership in one or more of these professional organizations will ensure access to their peer-reviewed publications and a diverse community of health care providers and arts educators. Finally, there are several workshops, courses, and programs that offer training and certifications in performing arts medicine.
Russell: It is imperative that performing arts health care be delivered with compassion and respect for the artistic, yet highly physical, nature of what performers do. This is especially true for athletic trainers and other health care professionals who do not have a background in performing arts. So, prior to embarking on an educational plan, this attitude must be in place. Next, I recommend continuing education conferences, such as those provided annually by the organizations that Dr. Wilkenfeld identified. Additionally, membership in those two organizations will include a subscription to their journals, the world's only scientific journals devoted exclusively to performing arts medicine, the Journal of Dance Medicine & Science and Medical Problems of Performing Artists. Here, an athletic trainer will be acquainted with current research in performing arts medicine. There also are organizations that offer short courses and certificate programs in performing arts medicine. The bottom line is that an athletic trainer in this field should further his or her education by becoming as immersed in the discipline as possible.
Santos: There are multiple performing arts medicine-related continuing education courses and educational programs available these days that have potential to expand knowledge and connect you with colleagues in the performing arts setting. Look for a clinical experience, even a brief one, with a preceptor who works in the performing arts. Most importantly, become the best athletic trainer that you can be. Your skills and knowledge will transfer to any field, and your desire to help others will propel you forward.
Scifers: What recommendations would you make to a health care provider looking to transition his or her practice to performing arts medicine?
Russell: First, become active in professional organizations that promote the field. There is no substitute for interaction with like-minded professionals who share a passion for performing arts medicine. Second, get into the performing arts medicine literature and become well read in the types of injuries and conditions that confront performing artists and how these are managed. Third, become an arts consumer—attend artistic performances and meet artists. This is an essential ingredient to providing the compassionate, specialized care that performers require. Finally, imagine the ways that your current knowledge of health care can be translated to a performing arts context. Put yourself mentally in a performing arts environment and decide how you would effectively care for performing artists. They are wonderful to work with, and they deserve appropriate care by competent and empathetic professionals.
Wilkenfeld: Become active in the social media groups and professional organizations. Attending conferences is a great way to network and create opportunities for yourself. Reach out to local performing arts studios and companies to observe classes and rehearsals and to better envision how you can translate your athletic training skills to the performing arts setting. Finally, look for opportunities in your own backyard. You can make a major difference in the health and wellness of young artists by working with a local health network or physician group to provide health care services to local studios and theater groups. Be creative and have fun. This is a great group of individuals to work with.
Santos: Just start. I generally don't advocate that licensed athletic trainers give their services away, but performing arts medicine is a growing field. So, it may be worth finding a mutually beneficial situation that will serve the performers' needs and give you some valuable experience. Once you've got your foot in the door, be prepared to demonstrate your worth and advocate for your patients. Finally, provide opportunities for others to come after you to learn and gain experience.
This clinical roundtable was conducted on May 29, 2019.
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