Injury Prevention in Circus Arts: an approach we need to talk about more (part one)

[alert type=”info” close=”false” heading=”The case for Functional Movement and Corrective Exercise in recreational circus arts instruction”] What follows is the written version of the talk that Kate Surgen and I gave at the American Circus Educator’s Conference. I should have posted this ages ago, but it got delayed for all of the usual reasons. Regardless, the intention here is to start a discussion about something that is both really important and too often misunderstood. [/alert]

Start with Why

Circus is many things to many people.

It can be an escape, a means of creative expression, an exploration of possibility, potential and a medium for personal growth and discovery or a vehicle for stimulating social change…

It can be the place where you feel most at home, surrounded by a supportive, loving and quirky community…

But make no mistake: circus arts are physical! (And physically demanding).

What Kate and I both have in common is that we suffered significant injuries that prematurely ended our circus careers…or at least, changed them irrevocably. Speaking for myself, flying trapeze was my first love (followed very closely by straps)…and because of my injury, I can’t fly anymore.

As in never again.

Actually, there are a lot of things I can’t do anymore because my left shoulder can’t go fully overhead anymore, but let’s be clear: falling in love with flying trapeze and the experience of realizing you can’t ever do it again because of an injury really, really sucks.

I would love to spare people that experience…hence, this whole blog.

I am, however, currently taking some tentative steps back into the world of partner acro and am even entertaining the notion that I might be able to perform (in a small staff performance) with my wife again. I’ll let you know how that goes.

So, a funny thing about unexpected life-altering injuries is that they can end up providing opportunities that might not otherwise have been pursued. In my case, it gave me the opportunity to dive into learning about how to prepare the body for doing incredible things while reducing the potential for injury.

As such, I have been living in two different worlds for some time now: the strength and conditioning world and the circus world. There are conversations going on in the strength and conditioning world that we, the recreational circus arts world, should be having…but we’re not.

(And by ‘we’re not’, I mean that based on what I’ve experienced in my travels and the conversations I’ve been a part of and been witness to—both in real life and through the Book of InstaTwitters—our community needs to up its game).

So this post is about an approach to injury prevention that deserves more attention—and assimilation—into the world of recreational circus arts.

But first: Injuries in Recreational Circus Arts

Let’s be clear: injury rates in recreational circus arts are very difficult to quantify. Because…

What counts as an injury?

If someone ‘reports’ an injury (student tells teacher about it), does it get recorded?

And what about the injuries that no one reports or records?

All of which means that we can’t really speak to the overall numbers or rates of injuries…because we don’t really have accurate numbers.

[Yes, there have been efforts to study this, but my own experience working with one of the largest providers of circus arts education suggests that there is a lot of room for improvement in terms of overall validity of the data.]

Confounding all of this, there is also a bit of a cultural acceptance within the circus community for training while injured.

Think of how often we hear people say things like the following:

Circus hurts.

Oh, I just tweaked my (insert body part here)…

Yeah it hurts, but it feels fine after I warm up…

My (insert body part here) is acting up…(often followed by ‘it will feel fine after I warm up’)

Aside: we need to be clear about the difference between discomfort and pain. Discomfort—especially with circus activities—is to be expected, but it should be in the muscles and not the joints or tendons. Pain is different. No exercise should cause you pain.

“Pain at the onset of an exercise is neither normal nor healthy and is indicative of a problem”

–from Does it hurt? By Mike Boyle.

If something causes you pain, it means your body isn’t ready for it. Actually, it might mean you have an injury that needs the attention of a medical professional. (Go see one).

(Seriously, book an appointment today).

Circus arts are growing in popularity. More and more people are finding circus…

And that is fantastic.

There is however, a certain reality we must acknowledge. This is a reality that the strength and conditioning world is working hard to navigate. The fact is that more and more, members of the general population are coming to (insert athletic endeavor here; examples include the gym, sports teams…circus arts classes) with a relatively low level of physical or movement literacy…or, put another way, a (really) young training age.

What I mean by physical/movement literacy and training age is to convey the idea that people are coming into circus with a relative lack of experience with physical training and the variety and intensity of movement that comes along with it. Most importantly, it means that their muscles and tendons and ligaments and joints do not have the same capacity for withstanding the stresses of training purely because over the course of their lifetime, they simply haven’t done that much training.

I mean, let’s face it: modern life isn’t particularly active. We don’t spend our days pushing, pulling, squatting or bending over to lift things.

This is a reality that the world of recreational circus arts (circus educators) needs to be aware of…and it’s something we should be actively working to address.

This is a concept that should really be at the forefront of circus instructors’ minds when training all of their students—most especially the newbies—because circus arts can place demands on the body that count as relatively high for those with a young training age. That basically means their bodies could be more vulnerable to breakdown.

Could be. This isn’t to say treat people like they’re fragile…but it is to say that just because someone appears to be managing the training process without noticeable injury doesn’t mean that we aren’t slowly creating one.

[bctt tweet=”Just because someone appears to be managing the training process without noticeable injury doesn’t mean that we aren’t slowly creating one” username=”@circus321″]

That’s actually the most challenging part of all of this: we understand acute, traumatic injury really well and mitigating the risk of such an injury is rather straightforward. What we do not have a good feel for are overuse injuries or injuries that are the result of gradual over-stressing of a tissue…or, more specifically, we could do better with prevention here.

It bears repeating: just because someone appears to be managing the training process without noticeable injury doesn’t mean that we aren’t slowly creating one.

[And this applies to trainees/performers/athletes of all experience-levels].

Context: things circus educators should know…

Warning: I’m about to get a little trigger-happy with the bold text.

In the General Population…

An estimated 35% of people (aged 20-40) have some form of asymptomatic (meaning pain-free) lumbar spine degeneration.

40% of Americans have an asymptomatic disc bulge by the time they are 40 years old.

• Brinjikhi, W. et al. (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, 36, 811-816.

Sher, et al. studied 96 asymptomatic shoulders and found rotator cuff tears in 34% of the cases (across all age groups).

 

In Athletic Populations…

In one study of high-level gymnasts, 36 out of 36 shoulder MRIs showed “signal abnormalities” indicating some form of asymptomatic shoulder pathology (RC tears, labral tears, etc.).

• DeCarli, A., et al. (2012). The gymnast’s shoulder MRI and clinical findings.   J Sports Med Phys Fitness, 52(1), 71-79.

Among high-level dancers, researchers have noted that poor training often results in a variety of hip pathologies: anterior hip pain, labral tears, iliacus tendinitis, trochanteric bursitis. Overall, dancers are significantly more likely to have (hip) labral lesions than the general population.

• Sammarco GJ. (1983) The dancer’s hip. Clin Sports Med. Nov. 2(3):485-98.
• Kolo, F.C., Charbonnier, C., Pfirrmann, C.W.A. et al. (2013) Extreme hip motion in professional ballet dancers: dynamic and morphological evaluation based on magnetic resonance imaging. Skeletal Radiol. 42: 689.

 

Why is this important to know?

Knowing this gives us the opportunity to consider two questions:

• What caused the damage?

And,

• What might cause these folks to cross the symptomatic threshold? (That is, what might cause these currently pain-free situations to become painful? Or, to be really simple: what might make it worse?)

In terms of possible/probable causes, there are obviously myriad possibilities. One is that there was some sort of one-time traumatic incident where the tissue was overloaded and voilà, damaged tissue.

Another possibility is that somehow the damage happened gradually, over time. This is the one that deserves our attention.

In a healthy body that’s moving well, we have good alignment throughout the range of possible movements. It’s kind of like a car: when the alignment is off, you get uneven wear. If you don’t take care of the alignment, eventually you’ll find yourself at the mechanics with a hefty bill.

For humans, the analogous concept is functional movement. Dysfunctional movement results in uneven wear over time.

Dysfunctional movement patterns are associated with increased injury risk.

• Bushman, TT., et al. (2016). The Functional Movement Screen and Injury Risk: Association and Predictive Value in Active Men.   Am J Sports Med., 44(2), pp. 297-304. doi: 10.1177/0363546515614815. Epub 2015 Dec 10.

…which means there’s a very good chance that some (or many) of the currently pain-free pathologies present in about a third of the adult population got that way because of faulty movement.

Combine this with insufficient tissue capacity for whatever demands they’re making on their bodies…

(And just to be explicitly clear: by ‘insufficient tissue capacity’, I mean insufficient strength).

…and there’s also a very good chance that faulty movement and/or loads that exceed capacity (read: doing things their bodies aren’t strong enough to ‘buffer’) will lead to those damaged tissues becoming painful.

So…a quick recap

Given that modern life tends not to involve a great deal of movement…

And, there is a connection between dysfunctional movement and injuries…

And about a third of people have some sort of tissue damage that was likely a result of dysfunctional movement or demands that exceeded the capacity of the tissue (muscle, tendon, ligament, cartilage…) and that will likely become worse if new/higher demands are placed on a body that doesn’t move well…

It’s fairly safe to say that modern life is basically anti-circus: not only does life outside of circus classes generally fail to prepare our bodies for circus, it’s very often doing the opposite of preparation (whatever that is).

Basically, everything that the body needs to be able to do for circus, modern life weakens and reverses all of that.

A great example is overhead shoulder range of motion. Circus demands not only full range of motion, but significant strength and motor control in that position. Modern life (i.e.: too much sitting without enough exercise deliberately designed to counter the sitting) can result in reduced shoulder range of motion (and consequently, strength).

And the point to all of this is to say that we need to make sure we are proactively working to prevent existing tissue damage from becoming worse…and, better still, working to prevent that kind of damage from occurring in the first place.

 

 

And this is where I’m going to stop myself—for this week. This post has turned into a full-blown essay and what with everyone’s busy lives and limited time for reading, I thought I’d break this up into parts. Now that we’ve done a ‘definition of terms’, so to speak, in part two I’ll go over the most common movement dysfunctions, a bit about what they look like (so you can start spotting them) and begin discussing ways to address them.