Traditions of performance and training in the arts have been established over hundreds of years, creating an idealized set of aesthetics that has been generations in the making. Take the institution of ballet, for example. The earliest recorded performances date back to renaissance Italy circa 1480, but it was France’s “Sun King” Louis XIV who popularized the form; indeed, the moniker “Sun King” was derived from his role in a ballet. Louis opened the first school for professional study in 1661, but it wasn’t until nearly 200 years later that modern pointe technique was first seen in the ballet La Sylphide in 1832. Today, much of the original choreography of La Sylphide continues to be emulated in modern interpretation.

This history illustrates how the training demands of disciplines such as ballet have established and respected ideals. A performer’s devotion to those criteria is not likely to change just because he or she is told by a PT that a certain technique threatens his or her physical well-being. However, PTs can help teach performers how to maximize their potential and manage their musculoskeletal health.

First Position: Breaking New Ground
Marika Molnar, PT, MA, and founder of Westside Dance Physical Therapy, can certainly attest to the unique challenges of treating dancers. A leader in the field of Dance Medicine, Molnar has been working for the New York City Ballet for 21 years and is the first physical therapist to be elected president of the International Association for Dance Medicine and Science, an organization created to support and research the health of dancers.

As the first PT ever to work full-time with an American ballet company, Molnar has helped blaze the trail for dance physical therapists. Many of her former patients—including San Francisco Ballet’s Artistic Director Helgi Tomasson and Miami City Ballet’s Edward Villella—have brought physical therapy into their own companies as a result of their positive experience with Molnar. “Helgi and Edward were both dancers with the NYCB and worked with me when I began here in 1980. Their history with physical therapy has prompted them to introduce it full-time to their own companies.” As a result, more PTs are getting the opportunity to work with extraordinary dancers—and the dancers are benefiting as well.

Molnar grew up with a passion for the arts and studied dance and gymnastics. She earned her Masters in Dance Education and taught for several years before deciding to return to school to study physical therapy.

It was the mid 1970s, and Molnar was entering into uncharted territory. “The rise of dance medicine is analogous to sports medicine. Now we are beginning to come into our own, but in 1979, when I graduated from Columbia, no dance company had really considered having a full-time PT on staff.”

Within a year, Molnar had been hired by the NYCB to be just that, and she has been with them ever since.

Molnar has had the extraordinary opportunity to travel abroad and observe how other dance companies organize their PT programs, including spending a week with Britain’s famed Royal Ballet. “The Royal Ballet has had a healthy PT program established for years,” she says. “In fact many companies abroad have been benefiting from on-site therapy for a long time. It’s just here in America that we are a little bit behind.”

To help educate the public and to make arts-tailored physical therapy more accessible, Molnar established Westside Dance Physical Therapy in 1986. “The therapists here are well trained in the evaluative and manual skills necessary to work specifically with dancers. They are dedicated professionals who help dancers of all ages heal from injuries to return to performing.” Westside Dance Physical Therapy is located in the Lincoln Center area and mainly caters to artists, though Molnar says about 10 percent of her client base consists of “regular” patients, usually family and friends referred by her dance clients.

Second Position: Playing A Different Tune
John T Myers, PT, MBA, first became interested in performing arts as a child, when he studied a variety of instruments including piano and guitar. In addition to his work as program director of the Physical Therapist Assistant program at Lorain Community College, Myers offers Internet-based continuing education approved by the Ohio Chapter of APTA that addresses the specific needs of this population.

Myers graduated with his PT degree from Cleveland State University in 1984. “I ended up working at the Cleveland Clinic Foundation, a very large tertiary-care medical center. We had a center for performing artists there, and when the PT seeing the musicians and actors left, she recommended me as her replacement because of my own background in music.” Myers started the position in 1985 and continued as the primary therapist for the program until he left the clinic in 1997 to enter academia. He continues to treat musicians in his private practice. “Once I started working with them, I was hooked! They are such an interesting group to work with—intelligent, motivated, hard working, often intensely focused, creative, and once aware of the benefits, they are very open to what physical therapy can offer them.”

Myers says making musicians aware of the benefits of physical therapy can at first be a challenge. “Many performers are reluctant to seek help or delay seeking traditional medical and rehabilitative treatment. For some, there is a belief that pain is a normal part of making music and that the solution is to ‘play through it’ or just endure. Others are concerned that seeking help may endanger their employment or career. Both scenarios make the PT’s job tougher, since they cause delays.”

However, Myers says his own musical background goes a long way toward breaking the ice. “I’d had experience with practice schedules, recitals, stage fright, different instruments, different types of music, and even the vocabulary of music. That vocabulary, especially, is incredibly helpful in building credibility and rapport with patients. To be able to speak the language of medicine, plus the language of music, makes the PT a very valuable resource for the musician patient.

“A lot of time with musicians is spent translating information about their medical conditions into terms and concepts that they can use,” continues Myers. “Often a patient’s complaints may be not be phrased in medical terms such as pain, numbness, or fatigue, but in musically related terms instead, such as: ‘loss of speed;’ ‘loss of forte;’ ‘loss of coordination or facility’ for specific instrument requirements; inability to control tone production; or problems with ‘technique.’ Not all therapists are used to dealing with complaints phrased in this manner, so it helps to have some knowledge of music to understand what exactly those terms imply. Ergonomic changes that can be very helpful for some musicians may be difficult for the average practitioner to recognize because of his or her lack of familiarity with the instrument, type of technique, classical playing styles (which sometimes cannot be changed), and the physical demands of the instrument. For example, most violinists are perfectly willing to consider increasing the height of the shoulder rest that sits under the instrument, but to suggest an increase in the chin rest would immediately make your opinions ‘suspect’ in the eyes of many violinists.

“Performers can become fearful and confused about their condition, about the possible effect of an injury on their careers,” says Myers. “For the PT to be able to ‘meet them half-way’ between the world of music and medicine means a lot. It allows us to more effectively build rapport, and to educate and advocate for them where needed.”

Third Position: Bringing Therapy Home
Jennifer Gamboa, PT, MPT, is President of the Performing Arts Special Interest Group (PASIG) of the Orthopaedic Section of APTA. She has a lengthy history with the arts, having begun her career as a modern dancer in Washington, DC. She performed and taught for several years before deciding to study physical therapy at Shenandoah University. Despite the demands of her PT class schedule, Gamboa continued to dance and teach. “I didn’t actually stop performing until 1997. It was a hard decision, but physical therapy can be so creative, and I knew there was so much I could offer the community as a therapist.”

Gamboa naturally made many connections in the dance world through her work as an instructor and performer. She and the therapists in her practice, Body Dynamics, often work off-site in a variety of capacities. Her staff teaches a weekly Pilates class at the Fairfax Ice Arena, where both recreational and professional skaters train. Gamboa also works with Leigh Roberts, PT, MPT, at the Kirov Academy of Ballet, an elite ballet boarding school in the DC metro area.

Gamboa herself teaches a weekly class at the Arlington Center for Dance. Established in 1981 by Kathryn and Kenneth R Fredgren, the ACD is a center for serious dance instruction; indeed, many of its graduates have gone on to careers in major companies such as the Dance Theatre of Harlem, Stuttgart, Joffrey, Ballet West, San Francisco Ballet, and the Royal Ballet.

Kathryn, the Center’s Artistic Director, says that her ultimate goal is “to develop a generation of dancers who train intelligently. We are trying to prepare them for every aspect of professional life in our curricula, from genre study through body mechanics.” ACD’s advanced dancers work in The Center Dance Company; a performance group that produces professional level shows for the public. The Company apprentices train nearly 20 hours per week in technique, class work, and rehearsal.

For the last 10 years, Gamboa has taught alignment and conditioning classes to the ACD’s Company apprentices. And just as Gamboa herself is passing on the knowledge, so are the students themselves, who have in turn begun to tutor their own peers. “I am here once a week to ensure that they are doing the work properly,” says Gamboa. “In addition, one of our major goals is getting the dancers active in doing these exercises on their own. We’re trying to instill habits for them to maintain throughout their professional lives, whether there is a PT on hand to guide them or not.” To that end, Gamboa and Fredgren have encouraged some of the older girls with more experience in the conditioning techniques to pass it on to the younger dancers, allowing a senior student who has worked extensively with Gamboa to “peer instruct” under faculty supervision for a 1/2 hour cool-down session following one of the pointe classes. “The girls love it,” says Fredgren, “and it is particularly effective since the younger ones tend to look at the seniors as mentors.”

In addition to her work with ACD, Gamboa works with the Kirov Academy of Ballet. “When we started there 5 years ago, we met with great resistance from the faculty and staff, which is very old-school. We began by educating one student at a time, and, as our work continued over the years, the school became more amiable toward listening to what we have to say about cross-training, injury prevention, and technique re-education. In fact, just last year we were able to introduce a comprehensive health and wellness program into the curriculum that incorporates cardiovascular and weight training, Pilates, yoga, and stretch, as well as physical therapy. It is an evolving relationship, and we are still educating the faculty, whose demands on these kids can be at odds with what their bodies are able to handle.”

But as Gamboa concedes, the reality is that the traditions of classical ballet are established. Traditional ballet schools like the Kirov are not just extremely competitive but also represent the hallmark of dance ideals. Consequently, a student of this level is more apt to push his or her limits, and sometimes even defy his or her own anatomy to achieve the artistic ideal. “The PT has to be able to compromise. He or she also has to build a relationship with the students and teach them self-management skills that maximize their potential and minimize the threats to their musculoskeletal system.”

Indeed, a big component dictating the success of performing arts physical therapy is knowing when to leave the patient alone. According to John Myers, “PTs treating musicians have to find a way to integrate a progressive practice/playing schedule into rehabilitation. Treatment may require adding major ergonomic and biomechanical changes, which can have a huge impact on the musician’s technique. You really have to strike a balance with all these factors. For example, the issue of how much time a musician should spend practicing has many facets—is this part of endurance training for his or her rehab? Or is it going to cause further damage and symptoms? Are we doing it to keep the musician’s technique from degrading and to motivate him or her? Essentially it’s about striking a balance between patients’ need for healing, our professional opinion about what’s right for them, and their own professional needs. What do you say to the patient who can’t play more than 20 minutes without severe pain, but who has the most important audition of his career in a week, and is willing to perform through the pain? We like to think that our treatment is the most important thing for them, but sometimes we have to see the situation from their perspective, and graciously help them back off from one or another obligation, including their physical therapy.”

Additionally, Myers points out that musicians don’t follow the same type of schedule as other patients. “While at the Cleveland Clinic, I didn’t always have the opportunity to see people for regular follow-up, since many commuted to the facility for periodic consultations. But even those living nearby were encouraged to take responsibility for the problem themselves, and I did not schedule a lot of visits with them. Instead, I would follow them at periodic intervals to reassess, problem-solve, and advance their programs. I did not feel that having them come into the clinic a couple of times a week was helpful, cost effective, or appropriate.”

Fourth Position: Flexibility is Not Just for Dancers
Gamboa says her goal is to make physical therapy accessible and flexible to the needs of the artists. Her willingness to go to the dancers rather than waiting for them to come to the clinic is what led to her association with touring shows like Fosse, which just completed a month-long engagement at Washington DC’s National Theatre. “Two hours before curtain, the dancers were provided the opportunity to sign up for 15-minute slots. We did some stretching and work with them to warm up for performance. They would also come into the clinic for individual consultations.”

Gamboa says her backstage work is usually engaged through her personal networking with other PTs in the field. ”When you have a successful relationship with a touring group, you are often asked by that company for references to PTs in the places they are going next. So a lot of my work—such as what I did with Fosse, and with Cats before that—has been a result of my knowing a PT who has worked with the company somewhere along the way. That is one reason why working within the PASIG is fabulous: It really gives me the opportunity to get to know people around the country, and we are always helping each other out.”

Gamboa’s professional contacts as a dancer made her initial work as a physical therapist possible, but, overall, the majority of her clientele has been built around her willingness to come to them, educating them about physical therapy on their own turf and in their own language. “Performers are not generally going to solicit you for a preemptive strike against injury. What we as therapists need to do is get out into the performance community and sell ourselves: Educate dancers and musicians about how we can help them before they have to ask.

“In my experience, the best therapists for this genre are those with a broad base of physical therapy experience, not necessarily those who know dance or music inside and out,” continues Gamboa. “While that knowledge no doubt facilitates communication with the patients, and it opens professional doors, the most important qualification of dealing with this group is creativity. As a PT, you have to be ready for any and all possibilities with these patients, since they are so physically active, and the individual cases that you see are as unique as the dancers themselves.

“And I think in order to be a good performing arts PT, you have to be a good therapist,” she continues. “It’s not really necessary to specialize specifically to dance or music in that respect. Having the personal experience in the genre is something separate—it influences the communication with the patients, and the understanding of their demands, but it has limited bearing on your effectiveness as a clinician. More important is one’s understanding and skills in orthopaedic and manual therapy, and the ability to look at the big picture: To analyze the musculoskeletal system as a whole, rather than focus on an isolated area at a time.”

Fifth Position: Changes in Classroom Choreography
Both Gamboa and Marika Molnar maintain that some of the most significant work to be done is among performers in training. “They are the future,” says Gamboa. “For that reason, a lot of important performing arts physical therapy is happening in the classroom. It is about teaching students the correct habits right now, before they get injured.” Dancers are athletes, and, just like sports’ up-and-coming high school-and-college level stars, they, too, need to be conditioned in their youth to look at overall fitness.

Says Molnar, “The best way to change their habits is to educate them. Many dancers have grown up under the misconception that cross-training is bad for them, that they should focus only on dance. But they need to realize that their bodies have to be allowed down time and alternative exercise that accentuates different muscle groups. The hardest thing for us to do is to get them to understand and value the importance of rest. Sometimes they have to take a few days and let their bodies heal and rejuvenate—particularly if they are rehabilitating from a specific injury. Nothing prevents them from exercising other areas in the interim; the idea to dance through it is not necessarily the most productive approach.”

The consensus of most performing arts physical therapists is to emphasize the overall fitness of the dancer. Injury prevention, cross training, and extracurricular activity are just some of the ways Molnar endorses. “Our goal is to get healthy dancers, since healthy bodies are in better condition to withstand the stresses of dance and are more likely to rebound from injury quickly. In fact, we recently shared a study with our dancers regarding the fitness and recovery times of people who study outside disciplines, such as yoga, hip-hop dance classes, or swimming, as compared with those who did not cross-train or participate in any mental relaxation exercise. The differences were stunning, and I think sharing those results with the dancers has really helped open their eyes.”

Helen Myers, MFA, Dance Program Coordinator at New Mexico State University, says that physical therapy is an integral part of her students’ training. A dancer and choreographer, Myers tore her anterior cruciate ligament about 10 years ago. She was able to successfully rehabilitate the injury with the assistance of surgery coupled with 9 months of physical therapy. “I am obviously a first-hand believer in the benefits of physical therapy for dancers!” Myers says her students discuss injuries as part of their curricula, including how to identify their severity. “I believe that dance training is definitely augmented by both a healthy lifestyle and a thorough knowledge of anatomy.”

Nicholas Quarrier, PT, MHS, OCS, Vice President of the PASIG, is a faculty member of the physical therapy department at Ithaca College in Ithaca, New York, which is also a respected music educator school. Quarrier says he is very conscious of the fact that the music education students at Ithaca will go on to influence the next generation of performers. “We offer an elective course to the music department that highlights the care and prevention of injuries,” he says. “We have had a fantastic response from the students, who seem to just come out of the woodwork to enroll.”

Final Curtsy
In the professional world of the NYCB, Marika Molnar concedes that having the time to devote to cross discipline is often easier said than done, particularly when the company is in season. “The season generally lasts 16 weeks in winter—we started in December and will continue through February. During that time, we are under a grueling schedule, and generally dancers will not know until the night before whether they are slated for rehearsal the next day.”

The typical dancer’s weekend schedule in season consists of a mid-morning class, performances in both matinee and evening shows (with a short lunch break in between), then home from the theatre around 11pm. During the season the company gets one full day a week off, which is Monday.

General rehearsal time is much less strenuous, and it is those times when Molnar says many of her dancers take advantage of the opportunity to cross-train. “The hip-hop classes in particular are very popular, since they give an outstanding aerobic workout and involve dancing to popular music—which is very different from ballet, where it’s stop-and-go and flexibility oriented.”

As Molnar points out, it is very difficult to replicate the experience of dancing on stage, since during a 2-3 minute variation (a choreographed dance combination), speed and technique create particularly demanding working conditions. “They are moving so fast out there that they often don’t have even the time to breathe. They’ll often come off stage from this beautiful variation just hacking because their bodies haven’t gotten enough air.”

“Modern choreography is a prime example of the conflict between training ideals and performance demands,” says Gamboa. “Dancers are now being required to achieve athletic and aerobic feats on stage that traditional barre and floor work does not prepare them for. As a result, some of the ballet training is a little bit anachronistic.”

That is why cross training is essential. “Classes like hip-hop give the dancers the cardiovascular workout they require, making them stronger and better prepared for the deprivation they are subject to on stage,” says Molnar. “And hip-hop is performed in parallel position rather than in turn out, which gives dancers’ hips and knees a break.”

Just as important to a dancer’s general health is mental relaxation, which Molnar says is most popularly sought in yoga or Pilates. “They are related disciplines to ballet, yet much more organically based. The emphasis is on breathing techniques and gentle stretching, rather than quick bursts of activity. Plus the forced removal from mental stress is extremely beneficial.”

“The same thing is true of musicians,” says Gamboa, “yet the challenge is that, unlike dancers, musicians don’t tend to think of themselves as athletes. But it is just as important that they be taught to warm up their bodies before practicing their music and relax when needed.”

Again, Gamboa maintains that the most effective way to reach this population is through the schools. “Musicians go through more structured education than the average dancer, and there is a much larger window for teaching them the proper habits. And many musicians use advanced study as a means not only of performing, but also of gaining qualification as an instructor. That is why it is even more important to ingrain them with the proper outlook of physical therapy, because they will eventually pass the traditions of their own study on to their students.”

“Musicians are wary of participating in anything that threatens their livelihood,” reminds John Myers, “and more often than not they are under the impression that therapy will be their enemy, because it will impose itself on their rehearsal and playing demands. What we need to do is get into the community and show them how untrue that is, and how effectively the two disciplines can work together.”

According to Myers, the evaluative process in a musician can often be more complicated than in other types of patients. Their vocation, hobbies, and free-time activities generally revolve around their talents. “In addition, they may tend to self-treat initially, seek help from instructors who may not be knowledgeable about medical matters, or even from alternative therapies (which may or may not help a particular condition). There also seems to be a higher incidence of neuromuscular problems that are difficult to diagnose in this population than what I normally experience in a ‘traditional’ outpatient population, such as multiple problems layered on top of one another. And there are some unusual syndromes that are fairly common in performing artists that may not be routinely seen or recognized otherwise, like focal dystonia, a neurological disorder where muscle cramping supercedes a motion in progress. Some people also refer to this as occupational palsy or writers’ cramp.”

In addition, many artists gravitate toward alternative medical treatments, a predilection that can be a both a blessing and a challenge. “I am the largest skeptic that ever walked the earth,” says Myers “and I’m a firm believer in the scientific method—doing good research to prove the method behind our therapies. I’ve had the opportunity to participate in a fair amount of research in my career, and I think it is essential in our profession.

“On the other hand, I try very hard to keep an open mind. I’ve taken courses in many of the alternative therapies to see what they are about and try to evaluate them for myself. Furthermore, I am very careful in discussing what I would call alternative treatments with patients. They may have ‘bought into’ them already, so I try not to offend the patients or destroy their belief systems. The only time I take a stand is if I think that what they are getting into is injurious to them, or contrary to what I am asking them to do. Then I explain that I feel they need to concentrate on one or the other, and that, in some cases, physical therapy and alternative treatment may conflict. Generally they do give physical therapy the chance to prove itself.”

According to Molnar, rarely is an injured performer debilitated to the point that he or she is forced to give up performing completely. In her 21 years of working with the NYCB, Molnar recalls remarkably few experiences telling dancers they could not work again; in fact, it has only happened twice. “Both cases were young dancers—about 16 years of age—who had developmental impairments, which is not something you can rehabilitate. It was very difficult to have to sit them down and tell them that what they were dreaming of doing was not something they could physically withstand.”

Otherwise, Molnar has been successful getting her patients back onto the boards and under the lights. “We’ve had people come in here with severe injuries, including ruptured Achilles, reconstructed ACLs, even a total hip replacement! And in all of these cases we’ve been able to return them to dancing, teaching, or choreography.

“My ultimate goal is to get them back to what they love to do,” she continues, “not to keep them away. And though it is a stressful environment, with proper technique and skill they can be strong enough to withstand the pressures. And that awareness of their bodies is what we try to teach them.”

When injuries do occur, prompt attention is generally the best indicator of success. “If the problem has been caught early, the situation has the potential to resolve fairly quickly,” Myers states. “Only rarely have I seen patients with truly acute phase problems. Sometimes that impact was a result of the symptoms, and sometimes it was a result of previous treatment advice. More than once I saw people who hadn’t picked up their instruments in a year or more because their local physician or other practitioner had recommended that they rest until their symptoms went away, and the symptoms never went away. This was a major complicating factor in some cases. Certainly, the acuity and how long the symptoms have been present have a tremendous influence on the treatment planning.”

“I am also a firm believer that I cannot make anyone better,” says Myers. “I can teach patients what they need to know, help them to problem-solve, give home exercises, teach how to prevent or control symptoms, and many other things; but, ultimately it is the patient who must take responsibility. It is truly a partnership.”

Myers and Gamboa both say that their work with performing artists has focused and enhanced their own understanding of physical therapy, even some of the more administrative details such as patient history and note-taking. “A lot of subjective information has to be taken from a musician,” says Myers, “which has helped me to improve many of my evaluation skills. Most importantly, my experience has reinforced for me the need for continuous re-evaluation of patients, the need to never make an assumption, to never become locked into any particular diagnosis or treatment plan, and to be willing to always take a fresh look every single time.”

“You need to have the ability to think outside the box,” agrees Gamboa, “to be able to take whatever comes at you, be it in the clinic or in the classroom. Although many dance injuries are vocation specific, that doesn’t mean the patient won’t have the same problems as a nondancer. As PTs we need to be intuitive to all possibilities.”

Gamboa, Myers, Molnar, and Quarrier agree that physical therapists who work with musicians and dancers really need to have respect for the requirements of training and performance. Having a personal history certainly helps toward having empathy for those challenges. “Understanding the specific demands of their profession is probably the best thing we can offer patients in this population,” says Myers. “For those of us who are interested in both the arts and therapy, there is nothing more rewarding than seeing a musician or dancer return to form.”