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Dance is an art form that requires the whole self. You've likely witnessed a talented, hardworking student inexplicably hit a block or fail to perform their best when the stakes are high. No matter how hard they work physically, getting to the next level will be an inefficient struggle until the mind becomes a more active and effective partner.

The practice of mindfulness can help. "There is a concept called 'participating' or 'flow,' in which a person is able to throw themselves completely into an activity with awareness and control but without actively focusing their attention on themselves or analyzing the details of what they are doing," says Catherine Drury, a psychotherapist and licensed clinical social worker who specializes in working with dancers. "That ability to enter wholly into movement without judgment or self-consciousness is what allows dancers to perform at their peak."


Athletes have been shown to improve their concentration through the regular practice of mindfulness techniques, and Drury says it's reasonable to assume dancers can too. " 'Mindfulness' can be described as paying attention to the present moment, with acceptance (not fighting or resisting whatever it is you are feeling) and without judgment (not being critical of whatever you are feeling)," she says. "Mindfulness trains our brains like exercise trains our bodies, allowing for better physical and emotional control, particularly in stressful situations like auditions or performances."

The Link Between Emotional Well-Being and Performance

"Dancers who are experiencing emotional difficulties are going to be more activated by stressful situations, like a demanding rehearsal or performance, and that heightened arousal causes muscle tension, fatigue, reduced flexibility and increased distractibility—all conditions that can lead to injury," says Drury. Anxiety can also increase unhelpful worrying, irritability and restlessness, and cause changes in sleep and appetite. All of these factors can make every aspect of life and training more demanding and draining.

A first step dance teachers can take is to point out to dancers the link between their emotional well-being and their performance. We can reinforce that there are mental skills that can complement their physical training.

"Mindfulness and other stress-management skills not only reduce stress over time, but also help dancers observe and identify internal cues and emotions that tell them that they're stressed, so they can intervene before their physical health and safety is compromised."

The Benefits of Mindfulness

To be successful in high-pressure situations, like performances, auditions and competitions, dancers need the same kind of control over their emotions that their technique requires they have over their bodies.

"Since awareness is the first step to gaining control of any pressure situation, an athlete's mindfulness practice has a tremendous impact on their ability to perform at full potential," says Drury. "For dancers, I would argue that such emotional awareness and mental skill-building is even more necessary as dance requires not only a high level of physical, athletic performance, but also things like artistic expression, grace and a sense of effortlessness."

Developing a regular mindfulness practice can help students deal with and prevent anxiety, be less reactive and critical, and discourage the racing thoughts that limit their abilities in the studio.

Getting Started

Drury begins to teach mindfulness by first helping dancers to be more "in the moment" in their everyday lives—while doing tasks like brushing teeth, walking the dog and washing dishes—before transferring those skills to the pressure-filled studio. While this is akin to assigning homework, there are ways to continue to reinforce this new awareness during class and rehearsals.

"For those students whose anxiety seems to be getting in the way of their dancing, engage them in conversations that bring them back to the present, and encourage them to notice their surrounding environment," she says. "Teachers can even help students identify when they are feeling anxious by narrating and labeling emotional cues in the moment." For example, you can reinforce better emotional awareness by changing a classic "Drop your shoulders" note into "You look frustrated and it seems to be causing your shoulders to lift."

If this feels beyond your wheelhouse, you might invite a certified practitioner or licensed therapist to give a workshop on mindfulness. This is a great opportunity for dancers to talk about the emotional stressors of their training. "Teaching dancers early on to prioritize their mental health will serve them more and more as they progress to higher levels of competition and professional life," Drury says.

Two Exercises for Beginners

1. An Object in the Room

When you're feeling anxious or overwhelmed, focus on one object in the room or one thing that you see. Describe it to yourself in three sentences.

"You can practice this skill when you're commuting or hanging out with friends so that it's accessible to you in situations in which it's more difficult to be mindful", says Drury. "Teachers can use this exercise to start class or transition between exercises."

2. The Five Senses

"Since we observe the world outside of ourselves using our five senses, one simple way of practicing mindfulness is to tap into these senses at any given moment throughout the day as a means of bringing yourself back to the present." Drury suggests asking yourself these questions to calm worries and interrupt negative self-talk:

What do I hear? What do I see? What do I taste? What do I smell? What do I feel?

"Remember, anxiety wants you to focus on your racing thoughts, your pounding heart, your past mistakes, your fears for the future—but focusing on your five senses brings you back to your tangible, factual reality, allowing you to concentrate on the tasks in front of you and control how you respond to them," she says.

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Just when young dancers need oxygen the most—during a challenging balance or speedy petit allégro—it often seems they instinctively hold their breaths. Sometimes this happens as a reaction to stress; other times it might simply result from a constant sucking in of the waistline. No matter, it is an important habit for dance teachers to break.

"Dancers do not want their bellies sticking out, so most of them never breathe deeply enough and only take very shallow breaths into their upper rib cage," explains Marika Molnar, founder of Westside Dance Physical Therapy. "This reduces the amount of oxygen that gets into the blood to nourish the working muscles." Limiting the breath can also bring aesthetic and functional issues, from appearing stiff or uncoordinated to experiencing fatigue and exhaustion from not getting enough oxygen to your working muscles. In order to start coaching a deeper breath or diaphragmatic breath, it is necessary to help students understand the muscles at work with every inhale and exhale. While much time is spent having dancers work on their core, most often the abdominals are the focus and the topmost muscle is ignored: the diaphragm. The diaphragm is best described as a thin, dome-like muscle that acts as a partition separating the thoracic cavity, or chest, from the abdomen.



"I think visualization helps a lot," says Molnar. "If you have a round, blown-up balloon, and you put your flat hand on top and press down, you will see that the balloon increases in circumference as the pressure on it increases. This is what happens when you inhale: The diaphragm descends and flattens out, the rib cage expands while the abdominal contents get pushed down and outward, and air rushes into the lungs." When you actively release the diaphragm through an exhale, it returns to its starting position and allows the abdominal muscles to contract.

"Using a correct breathing technique can help to stabilize the lumbar spine and distribute the forces of gravity more equally around the lumbopelvic spinal muscles through their fascial connection to the psoas muscles," says Molnar. Other benefits of diaphragmatic breath include slowing down the heartbeat, stabilizing blood pressure and encouraging a sense of calm by stimulating the parasympathetic nervous system. Along with visualization, Molnar recommends palpating students' back ribs and explaining that they should direct the breath into that area, allowing the abdomen to rise and fall as needed. "Dancers tend to pick this up very easily, because they are very kinesthetic," she says.

Breath as a Practice

Though we conceive of breathing as a natural skill, many experiences as we grow tend to stifle our innate ability to breathe deeply. Molnar prefers to teach dancers to think of breathing as a practice: "Do it every day, just like your barre," she says. While there are many ways to improve your lung capacity through specific breathing exercises, here are a two of her favorites that can be practiced anywhere at any time, in 5 to 10 minutes.

Counting the Breath

1. Start by exhaling through your mouth. "Purse your lips to really call in the deep abdominals," says Molnar. You can place your hands on your abdomen to feel your abdominals contract.

2. Inhale through your nose, with your mouth closed and your tongue resting on the roof of your mouth, its tip behind the front teeth. Move the back of one of your hands to your back ribs and feel them expand (don't be concerned with keeping the belly tight; allow it to expand naturally).

3. Begin to count to four in each direction of the breath.

4. See if you can increase the length of each inhale and exhale by one or two counts. Eventually, you might increase the exhale to a count of eight.

5. Then add a one-count pause at the end of each inhale and at the end of every exhale. Slowly increase that pause to four counts as you get more proficient.

"In a group class the teacher could give a combination like this: Four counts to inhale through the nose, four counts to hold, eight counts to exhale through pursed lips," says Molnar.


Breathing and Walking

"One of my favorite exercises is to combine breathing and walking," says Molnar. "Let's say you can walk three steps on your inhale and three on your exhale to start; after a while you may be able to walk five or six steps on each inhale and exhale."

This exercise is a great way to bring mindfulness to the breath and encourage coordination of breath and movement. Use the same tactile cues as above if they are helpful.

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Tip: If you get lightheaded doing this exercise in a standing position, try it sitting or lying on your back.

The Parasetter

After treating professional dancers and students for many years, Molnar developed the Parasetter, a patented roller that includes an elastic wrap for the waist, to assist in three-dimensional breathing exercises. "I love using the Parasetter," she says, "because it gives you great feedback from the posterior rib cage as you take deep inhales, and if you wear the rib wrap, you can get the sensation of the whole rib cage in motion."

PhysicalMindInstitute.com

Marika Molnar founded Westside Dance Physical Therapy in NYC. Photo by Rachel Papo

Health & Body
Photo courtesy of Schaeffer

Picture the knee joint as a crowded intersection in a busy city, with people and cars moving through it: up and down, from side to side. When this junction is flowing smoothly, traffic is a breeze and it is easy to get to where you need to be. But when there is an accident or stalled vehicle anywhere linked to the crossing, your route is derailed.

"The knee doesn't work in isolation," says Marissa Schaeffer, a physical therapist at Alvin Ailey American Dance Theater in New York City. "It is constantly affected by forces above and below."


As one of the largest joints in the body, the knee is a complicated interchange of tendons, ligaments and cartilage joining the thigh bone to the shin bone. A dancer's knee is constantly managing forces up and down the kinetic chain. The tendons connect the leg muscles to bone and help move the joint and propel dancers into the air for jumps, while the ligaments work to join the bones and provide stability. The muscles commonly known as the quadriceps and hamstrings, as well as the adductors and abductors of the hip, act on the knee from above, while the calf muscles and anterior lower-leg muscles act from below. To keep this joint healthy, adequate strength and control of these muscle groups, relative to one another, are key.

Of the many acute and chronic knee injuries that can occur, Schaeffer most frequently sees overuse injuries in the pre-professional dancers she treats—patellofemoral knee pain, for instance, and patellar tendinopathy, commonly known as jumper's knee. The bad news—that the cause of these injuries is usually the result of poor technique and inadequate conditioning—in this case is also the good news: With a focus on a proper neutral pelvis, true turnout, balancing strength between muscle groups and some specific cross-training, dance teachers can empower dancers to keep this joint healthy.

The Biggest Culprit: Turnout

"If you turn out from your hips, most dancers won't have 180-degree turnout," says Schaeffer. But in an effort to meet this near-universal demand, dancers borrow from other places. Some may use the floor to force turnout, trying to get more rotation from the tibia to make a nice line. But this misalignment in the lower leg changes the angle of stress and the way the patella is tracking. It also can cause increased torque across the knee, which stresses the tendons and ligaments that cross the joint. "And if you are in anterior pelvic tilt, which helps you force turnout, a chain reaction follows, pushing you back into hypermobility of knees," Schaeffer adds.

As a first step, Schaeffer recommends finding and using a neutral pelvis in order to ease dysfunction along the chain. This more efficient and honest turnout may in fact be "less." But the added benefits of controlling knee extension and hypermobility are value-adds in the long term. "My genuine hope is for dance teachers to recognize that 180 is not a realistic goal," she says.

Promoting Self-Care

Over time, floor work and specific choreography can cause degenerative changes to the knee joint. Schaeffer insists that dancers should always have knee pads in their dance bags. And staying ahead of your students' schedules and anticipating the rep that may be on the horizon can help you develop a specific cross-training routine to prepare. Schaeffer advises dancers to do their own research before an audition or class with a visiting professor. "You can look up a choreographer's work on YouTube," she says, "and get a sense of the demands. To protect your knees, you need adequate strength and control of the muscle groups."

Muscle flexibility and core strength are important components of any cross-training routine for healthy knees. "Be sure to foam-roll and stretch, but also keep in mind that a muscle can appear tight or less extensible because it's been overworked or it doesn't have enough strength to withstand the demands you've placed on it," she says. Also, there are a variety of reasons muscles can lack extensibility, including having poor core control. Sometimes it is as simple as adding in more squats or transverse abdominis work to an existing routine.

Ultimately, because stress to the knees can be referred from misalignments or weaknesses elsewhere in the body, the best tip Schaeffer can give is for dancers to be their own detectives: "Ask 'What was different today? Could this pain be because of a different rep, or is it due to repeating the same thing over and over?'" While she prefers compression to icing to ease a little swelling, she advises seeing a physical therapist or medical professional if knee pain lasts more than a few days or is recurrent.


Photo courtesy of Schaeffer

A more honest and efficient turnout may be less than 180 degrees.


Preventive Exercises

"You don't need more exercises," says Schaeffer. "Just make the simple exercises more heady." She favors tactile cues, allowing dancers to use their own hands on themselves to explore neutral spine in basic strength, conditioning and technique exercises. Here are two favorite ways to coach proper turnout with a neutral pelvis and an easing of stress in the knee joint.

Clamshells

1. Lie on one side with your knees bent, heels in line with your sitz bones.

2. With the feet touching, open your top knee to the ceiling, maintaining equal length on the side of your torso and keeping the pelvis stable.

3. Repeat to fatigue before moving to the other side.

Tip: If you have trouble keeping the hips quiet or maintaining the length of the top side of the torso, pad the underside of the torso near the low rib cage with a rolled-up tea towel or washcloth, or perform this exercise with your back against the wall.

Turnout on Rotating Discs

1. Place a piece of tape at the center of your knee (at the patella) and another one centered over the bump on the top end of your shin bone (tibial tuberosity). Check the alignment of the tape with your legs in parallel position in a mirror.

2. With a disc under each foot, practice moving into turnout, or external rotation, on the discs while maintaining the alignment of the tape. (You can set up the discs perpendicular to the mirror to do a self-check on the alignment of the tape, or ask a friend to help.)

3. Use this guide as you move through pliés and relevés in first position and variations on one leg. The tape can also be a helpful self-check while doing sautés in first position

The Whole Core

"Your pelvis is also included in the core, so if hips are shifting or rotating in the frontal and transverse planes due to weakness of the core—what I call 'sassy hip'—it can also shift stress down to the knees," says Schaeffer. If you are looking to strengthen the core to better support your knee health, don't forget to include a thin skeletal muscle on top of it all—the diaphragm—since proper use of the breath is part of a strong center."

Teaching Tips
Physical therapist Meredith Butulis in action. Photo courtesy of Twin Cities Orthopedics

After a long tennis match or a basketball game, elite athletes often head straight to the locker room and hit the exercise bike. On first thought, this might seem to be overtraining, but in fact, they are pedaling as a way to cool down properly.

"All of our blood vessels get dilated and blood goes out to muscles when we are doing cardiovascular work," says Meredith Butulis, a physical therapist specializing in dance medicine. "The blood goes mostly to the leg muscles, and blood pooling there is a real phenomenon. If your blood doesn't get back to the heart and brain, you can pass out."

She goes on to explain there are two ways to recover from an intense workout: actively, using a low-intensity movement to gradually bring the heart rate down, or passively, with no activity at all. The latter requires little explanation—how many times have you seen a dancer do a run-through and follow it up by sitting down on the side of the studio in a static stretch? But for many reasons, including the real possibility of blood pooling that Butulis describes, a passive recovery is not the best choice for dancers.

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Photo by Scott Shaw, courtesy of Williams

Have you ever looked at a student's posture and said: "Close your ribs" or "Don't grip your glutes" or "Use your abdominals more"? While that pinpointed correction may or may not have achieved the desired results in the moment, such phrases naturally raise a bigger question: "But how?"

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Health & Body
Tension in the legs is related to core weakness. Photo courtesy of AZ Dance Medicine Specialists

In the lead-up to competition season, "Again! From the top!!" can be overheard in studios across the nation. As students rehearse their routines ad nauseam in the final push to get ready, longer hours can sometimes mean that warm-ups get lost and increased repetition can create overuse injuries. Plus the extreme tricks and greater demands for flexibility can put stress on the joints and tendons of growing and adolescent bodies.

"In the dance industry, we are very used to releasing and stretching," says Dr. Alexis Sams, physical therapist and owner of AZ Dance Medicine Specialists. "But the key to injury prevention is matching mobility with stability. You are not going to get the results you want without doing the stabilizing work." While Dr. Sams does not recommend that students self-diagnose an injury and believes in the necessity of a professional assessment when a student reports pain, she has found that many overuse injuries can be prevented by strengthening the core and glute muscles, and sticking to a proper warm-up. Here are three common places where students report pain, what may be causing it, and the best exercises to address and prevent the injury.

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Adequate dorsiflexion mobility is needed to find a supple demi-plié needed to bound into the air and land safely. Getty Images

Dancers are trained to think often about the range of motion, stability and power of their extended lines: the point of the foot, the reach of the penché, the explosion of the sauté in the air. But finding that same mix of flexibility and strength in the flexed foot is just as integral to technique and injury prevention. Without adequate dorsiflexion mobility, it is nearly impossible to find the kind of supple demi-plié needed to bound into the air and land safely.

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Health & Body
Ashley Wegman, Atlanta Ballet; courtesy of the author

Working as the physical therapist for the Atlanta Ballet, Amanda Blackmon often sees dancers who report hip pain, high hamstring strain or sacroiliac sensitivity and soreness. And while there are a host of reasons for such pains, including the often discussed gripped glute and hip flexor muscles, there is one overlooked culprit: dysfunction in the pelvic floor muscles. Though pelvic floor health has become a hot topic for women postpartum who often need to strengthen weakened and compromised muscles, there is a different set of concerns when it comes to athletes and dancers. "I often see a hypertonic pelvic floor," says Blackmon, "meaning the muscles are overactive or gripped and tight. Also, the obturator internus muscle is an external rotator that is also part of the pelvic floor. When that is gripped (particularly in turnout), it can refer pain to several places around the hip and high hamstring."


A healthy pelvic floor can both contract and relax

The pelvic floor muscles form a figure eight underneath the pelvis, supporting the bladder, bowels and uterus in addition to working as part of your core muscles alongside the diaphragm, abdominal and spinal stabilizers. A healthy pelvic floor is able to both contract and relax, moving in tandem with the diaphragm as you breathe. "The pelvic floor should naturally turn on when a dancer lands a jump, to protect from downward pressure that could otherwise result in incontinence," says Blackmon. "Instead, a lot of dancers are just turning on the glutes and overworking their abdominals and adductor muscles."

Imagine a balloon

One reason for this may be the prevalence of "squeezing" or "in and up" cues in dance and movement modalities. Another reason just might be a lack of awareness of how these muscles best function and what it really feels like when they are working. Blackmon prefers that dancers think of an image of a balloon to understand how their diaphragm, abdominal muscles, pelvic floor and spinal stabilizers create the full container that is their core. The diaphragm and pelvic floor muscles should move in the same way at the same time as dancers breathe, while the spinal stabilizers and abdominal muscles ideally provide posture and balance for the front and back of the body. And like a balloon, too much pressure from any side will cause an imbalance. In dancers, Blackmon usually sees imbalance coming from a few places: a gripped or overactive pelvic floor that is not able to properly contract when needed; a diaphragm that is stuck, due to held breath; and an overactive rectus abdominis, which can exert too much downward pressure on the pelvic floor, making it impossible to engage or lift up.

The solution, in any case, is to learn how to fully relax and fully contract the pelvic floor without overcompensating with bigger, stronger muscles. While Blackmon does not always discuss these highly intimate muscles with younger dancers, she does offer the following exercises as a way to help dancers find more awareness. Identifying how to contract and release these muscles, as well as orienting the ribcage and pelvis in the most advantageous alignment for proper posture, can help keep the "balloon" balanced and maintain the integrity and functionality of a dancer's pelvic floor.

Happy Baby

Ashley Wegman, Atlanta Ballet; courtesy of the author

Breathing in this abducted position allows a dancer to find their pelvic floor muscles without being confused by overactive adductor, gluteus or abdominal muscles. The diaphragm is like a plunger that resides right underneath your lungs. When you breathe in, your lungs expand, and the diaphragm and pelvic floor both drop downward (this is when the pelvic floor should relax). When you exhale, they both lift up (this is when the pelvic floor should contract).

1. Lie on your back with your legs apart in the air, knees bent at a 90-degree angle. Hold onto the outside edges of your feet.

2. Aim to reach your sitz bones away from your head so you can find a lengthened spine and the most neutral pelvis possible.

3. As you exhale, feel a gentle pulling of the navel to spine and a relaxation of your pelvic floor. Your pelvis should stay stable and neutral during the contraction of this muscle.

4. As you inhale, allow your belly to rise gently. You can try bearing down during the inhale to drop your pelvic floor muscles (just as you would when you need to relieve bladder or bowels). Take 10 complete breaths, alternating between releasing and contracting.

Deep Sumo Squat

Ashley Wegman, Atlanta Ballet; courtesy of the author

This supported squat is a nice stretch for dancers and allows any gripped pelvic floor muscles the chance to release and can help relieve constipation caused by such gripping. "In Asian cultures, this is a posture for naturally relaxing in order to go to the bathroom," says Blackmon.

1. In a wider than hip-width stance, feet and knees slightly turned out, hold on to a door frame or other stable surface at hip level.

2. Allow your knees to bend and your hips to sink into a deep squat.

3. Take a few deep breaths here and think of dropping or lowering the pelvic floor.

4. To stand up, send your weight back into your heels as you stretch your knees (creating a sort of flat back, hamstring stretch position) before bringing your torso up over your legs. This works to prevent gripping to stand up.

5. Repeat 5–10 times.

Roll Downs on the Wall

Ashley Wegman, Atlanta Ballet; courtesy of the author

A healthy pelvic floor works in tandem with the diaphragm in a pumping action. For dancers, inhaling also enables spinal extension (aka arabesque) and quite often a dysfunctional pattern can arise where the ribcage becomes stuck in extension if the pelvic floor is gripped and not working properly. Therefore, finding flexion in the thoracic spine can help get the diaphragm and pelvic floor moving functionally again between contraction and release.

1. Stand with your back against a wall, feet about 10 inches away in front of you. Allow negative space for your cervical and lumbar curves away from the wall.

2. On an exhale, begin rolling your head forward and down toward the ground, peeling your spine off the wall. Keep your hips and the lowest part of your ribcage connected to the wall.

3. On an inhale, press down through your feet and restack your spine tall against the wall. Repeat 5–10 times, taking care not to overtuck your chin or your hips so that you can focus on curling through your ribcage.

The Mind/Body Connection

"There is a personality component," says Blackmon. "A gripper is a gripper, and this kind of anxiety-prone, Type A personality can exhibit itself in holding the breath, clenching the jaw and gripping the pelvic floor." In addition to the exercises, finding ways to relax the mind and manage stress may be key to a healthy and functioning pelvic floor.

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