A reflection on dancing, dancers and dance therapy.

Jenni WrenIn this article Earle Abrahamson asked Jenni Wren to reflect upon and discuss dancing, dancers and dance therapy. Jenni takes us through the promenade of the dancer as she explores pirouettes, pain and petrissage.

Recently I’ve been writing a blog on dance and injury, mostly from the injured dancers point of view, my own horror of dancing on injury for 9 years and literally having to diagnose the problem myself, find a specialist surgeon and getting the correct treatment.  It has been a journey that has changed me as a dancer, changed me as a practitioner and made me feel quite strongly about dancers having access to the right treatment and practitioners having the right knowledge to treat a dancer. 

My dance, choreography and massage practice have developed alongside each other over a period of 17 years.  It’s easy to forget the wealth of knowledge that is in there, or the things that go so quickly through my head when assessing, diagnosing and treating a dancer, until I have to explain it.  Even then I can overwhelm myself!

There is an increasing amount of interest out there on treating dancers but what I have discovered is there is a lack of good treatment available for them and a lack of practitioners who really know what a dancer does or needs. So as masseurs, physical therapists and hands-on practitioners, how can we start to understand the complexities of treating dancers and their bodies?

Dancers frequently need massage and will go to great lengths to seek out a practitioner who understands their type of body and what they ask of it. This generally works well through word of mouth but since dancers have little money (dance, specifically contemporary dance, remains the poor cousin in the arts), they are often without sufficient funds to take up a consistent course of treatment. 

To them, a treatment is in actual fact what someone would class as a real “treat”, but it’s necessary for them to be able to continue safely and avoid further injury.  Therefore it’s often not practical from a financial standpoint to try out a few different practitioners to find the one who understands their body best and so they normally go on recommendation.

Very rarely are dancers looking for a gentle, aromatherapy and candles, softly, softly approach.  They are looking for someone who can find and diagnose the anatomical problem, and then find a way to work it so that they can get back to where they were before; to dancing.  That’s their priority, that’s their goal. 

Firstly, a dancer with an injury is like a non-dancer who has been told they will never walk again or even worse, never be able to talk again.  Being an injured dancer is like having a speech disorder or impediment.  Imagine, if suddenly, you can’t say simple words such as “the”, “if”, “is”, “but”, “it”, or “of”.  How would you go about creating a flowing comprehensive sentence?  Similarly, how can a dancer express if he/she can no longer undertake the physical language in which they have been trained? How do you begin repair and recovery if you can’t find the reason for the sudden disability? How do you take in new body language phrases and how do you work around fear of pain, in order to be able to communicate again?  

We are spirits with minds and bodies who are often compelled to dance.  These three elements of being human are so finely connected that if one bit is broken, it affects the others.

Treating a dancer’s body is often not just treating a symptom or fixing one area of a physical injury.  It’s not always about immediately going to the point of pain either.  It has to be a holistic approach to the body, with total awareness of a well-tuned instrument that is relevant to the individual and their art form.  It’s about finding the problem, understanding and doing what is possible with the skills you have to get that person either doing the right things or getting the optimum treatment.  

Dance injuries are frequently not the same as sports injuries, and although there are similarities, it is not the same and neither are the rehabilitation instructions.  It is specialised.

For a dancer, an “expression athlete”, time is crucial when dealing with injury.  We further know that the majority of dancers will continue to work whilst injured, diagnosed or not, creating further damage and requiring more complicated treatments and rehab. 

As for the practitioner it’s about skilful listening, diagnosing, having the right tools and understanding dance and dancers.  Practitioners need to be aware that what dancers do is akin to what top sporting athletes do – however, there are considerable differences in training routines between the two groups with much more variation in movement capabilities, ranges, diets etc used in dance. We as practitioners cannot simply test the ranges of movement of dancers in the same way as for a sports person or general member of the public.  The dancer’s expected ranges of movements are beyond those. We need practitioners who understand that a key component for dancers in their work is communication through the body and that essentially they are communicators.  It is different. 

Sports science is heavily funded and information is widely available. Dance science is not (although it is improving).  Sport often involves an element of competition; the competitor is looking to beat either the other person or, at least, their personal best.  They train to do what their body is required within the sport and sometimes take on complementary training, to support that further.  They know what their body needs to do within their chosen sport, they know what their goal is, and they know, or discover, what/where the body’s strengths need to be and where weaknesses can arise. It’s not quite the same for dancers. 

imagesDancers train for a minimum of 3-5 years full time, priming their bodies into “unnatural” postural alignments and joint functions to finely tune their bodies, ready to go out into auditions with a technique and a personality.  As a dancer you enter the studio, the choreographer arrives (with their abundance of ideas to try and test out), and who sets creative tasks or describes movements to learn.  You have no idea what’s coming and have to be absolutely ready for the possibility that during that process the choreographer will ask for spirals, jumps, rebounds, suspensions, sharp sudden stops, lengthened pauses, positions without moving; and at the same time don’t stop, can you get that arabesque higher, drop lower in the tilt, dive roll – keep turning and get up on only one leg etc etc. 

Some further differences to sport – dancers are asked to think of creative dynamics, movement qualities, light and breath, ground and earth.  OK, so we’ve fixed the movement, it’s rehearsed; the body knows what it’s doing.  Wait, the choreographer wants you to put a character on top of that and some spoken word.  OK, we keep building on the work, the body and brain is keeping up, I’m now dancing, thinking about my character and talking, ensuring my breath is in the right place at the right time.  You can be asked for anything at any time and so we have to be ready for change – it’s the only constant thing a dancer’s body has.  It’s multi-tasking at its best and the ranges of movement and skills unique to anything else we can find to compare.

So what are we talking about?  It is biomechanics plus a large degree of creative talent, plus physiological skills, plus determination and other things to make all that happen.  But, what about when a choreographer layers emotion?  Suddenly you are asked to do exactly all of that, but in an angry manner, in a happy manner, in the emotion of repulsion or anything else. Muscles feel and respond to emotions too and this in turn can affect how they function, especially in the fascial matrix (another huge and incredibly useful area to understand as a practitioner).

Furthermore, contact in dance is not considered in the way it is in a contact sport, but it is very much a contact activity.  One of my works “Blind Passion” was all about being able to do contact work in dance, in a slow and controlled manner, to witness the muscles in movement and in addition be true to the technique by doing it all blindfolded, allowing the body’s kinetics to read and lead the movement through contact. We are not always dancing alone and there are weight bearing factors which often have to be considered when assessing, diagnosing, treating and rehabilitating. 

My best advice to any practitioner treating, wanting to treat or work with dancers is…  Go and watch some dance!  Go into a rehearsal studio, find out about the techniques, choreographic demands and pressure that dancers face to perform, get to know about dance and dancers.  Start to understand the biomechanics of dance and gain an understanding of different dance styles, techniques and terminologies. 

Yes, a dancer is a dancer is a dancer, but a ballet dancer will not be using the same forces as a break dancer.  A body is a body is a body.  Yes, this is true, but a dancer’s body has extreme mobility in comparison to the majority of other body disciplines that can involve gruelling boot camp style classes. They have to develop long, lean and strong muscles trained in very specific ways through practicing variable techniques that are both contradictory and complementary to each other.  The dancer has to have control of their body in such a way that the body is readily able to switch between techniques while controlling every single movement, to have the best and diverse instrument at any given time, so the dancer can be that versatile and employable dancer. 

And remember, dancers may not know how to express in words what exactly is going wrong with their bodies, but they do know and will probably try to demonstrate it. You, as the practitioner, need to think out of the box and work with them, not SIMPLY on them.

Jenni Wren is a dancer, artist, therapist and tutor at Hands-on Training, who has spent a significant part of her life understanding dance injuries, having suffered many herself. “So effortless is the dancer when things go right.  Their bodies are instruments of beauty and expression, convey stories and orchestrate emotion. When things go wrong there is often untold misery, suffering, pain, neglect, loss of self image and identity”. How do dancers cope in this highly competitive and often abnormal environment? How and what do we, as massage therapists, need to understand – including the specific and unique factors that impact dancers? 

A Boiled Egg is Hard to Beat! by Earle Abrahamson

Towards changing teaching methods and influencing learner minds

A lexophile, (a word used to describe those that have a love for words) has been carefully considered and used in the title of this article to invite humour but more importantly explain the concepts of change and resistance to change.

Recently I spoke with a group of massage therapy tutors to understand their pedagogies and methods of teaching. It was apparent that many had developed methods over time and were not open to different ways of thinking and doing.

Within the literature there is a body of evidence that deals with resistance to change and discusses obstacles to change in terms of troublesome knowledge and threshold concepts. The proponents of the theory explain that once a thought or concept is transformed into another state of knowing or knowledge it is difficult to return to the original state. For example, once a potato is mashed it cannot return to being a potato in its original shape or form. This theory of troublesome knowledge and learning thresholds is useful in understanding how one chooses to navigate knowledge barriers and manage the dissemination of new knowledge.

Teaching, or more importantly teaching adult learners, often creates a montage of challenge. Learners bring beliefs, ideas, values, and aspirations which may or may not align with those of the tutor.  Massage therapy teaching involves the complex organisation of theory in practice and engages the learner with the learning content in an applied way. Content is dissected into learning units which is then built into knowledge clusters. Learners need to understand the value of the learning before they are able to apply knowledge in multiple ways and situations. Reasoning and knowledge development are skills that often challenge conventional learning methods and move the tutor and learner into new and often alien territories of knowledge and knowledge discovery. If one stays fixed in a set method of teaching or learning, then the learning lens may become clouded and the discovery of new knowledge lost.  It is this challenge of challenging complexity that invites new methods of teaching, learning, dissemination and application of knowledge. Professional practice incorporates a philosophy of practice, i.e. an understanding of how to defend ones beliefs in practice and challenge current methods of application of technique and knowledge.

If I return to the title of this short article, and illustrate my thinking in terms of a boiled egg, then once the egg has boiled, i.e. once we are set in our ways, it becomes increasingly difficult to see and apply new ways of teaching and learning. If, however, we beat the egg first, we may be able to look at each scrambled part, consider its value, and realise the potential for scholarship, new learning, and knowledge transfer. This approach should encourage a more dynamic focus on the importance of learning, where the tutor/teacher facilitates the process of knowledge transfer and encourages challenge and cognitive dissonance. Through doubt and exploration of knowledge one can begin to build a philosophy of practice that is underpinned by evidence based reasoning.

Teaching and learning are dynamic interactive processes. The challenge for tutors is to create a learning environment that allows the learner to settle into an unsettled world. This is important as it creates a trigger for sustained knowledge development. Such an environment will challenge and provoke knowledge, and drive the learner towards self-discovery and reflection. Teaching and learning needs to reside in such an environment, and learners need to be challenged to develop new and different ways of learning and using knowledge. Resistance to change could damage the learning dynamics and environment. One possible strategy to mitigate against this potential damage would be to establish teaching and learning communities of practice. Within these communities of practice tutors and practitioners could come together to share ideas, explore new ways of working, and promote a culture of active engagement.

Don’t just do it, do it justly – by Earle Abrahamson

Moral, Ethical, and Legal Concerns  Are we truly ready? 

There is one area of massage therapy training that almost escapes the comprehension of the learner, an area of training that is inextricably woven into the fabric of practice and practice decisions. This area involves legal, moral and ethical concerns.  How best do we teach students the importance of these concerns, how much tuition is sufficient and at what level?

This short blog will attempt to outline key questions in order to provide a backdrop to the importance of understanding and implementing legal, moral and ethical components into massage therapy practice and training.

Massage therapy is under voluntary regulation through the Complementary and Natural Health Council (CNHC). What this means is that massage therapy is governed by a code of practice. This code of practice provides the public with an overview of expected standards and reassurance about the process of receiving massage from qualified practitioners. When we consider the nature of the voluntary regulation, we need to carefully understand the processes that govern massage practice.  Take for example, the client consultation form. Is it simply a means to record client data or a legal binding contract between practitioner and client? If we consider the latter we need to know how the law operates with respect to data protection and disclosure. It is beyond the scope of this blog to delve into the legalities of the issues raised. What is important is to ask questions and seek relevant advice on items for inclusion.  Once we receive information from a client, how do we record it? Who has access to it? Are we allowed to use the information when referring a client to another healthcare professional? What form of consent is required? Which questions are important, which are redundant? Is knowing too much troublesome?

The information we receive needs to be considered from an applied perspective. In other words, why do we need this information? What decisions are being made as a result of the information we have? What regulations are in place to restrict access to the information we have or hold on file? How is the information audited? How is the information stored? These questions trigger a cascade of concern and extend beyond the foundation training of a massage practitioner. Only through practice do we fully realise and appreciate the unique position we hold in terms of client management and confidentiality.  During massage training, students are often asked to record treatments in a reflective journal. Are tutors justified in asking for client information or do we need to learn how best to disclose the information we have?  Our statutory obligation is to gain informed consent from a client receiving a treatment. Informed consent, as the name suggests, implies that the client has fully understood the nature of the treatment and knows what to expect from the therapy and practitioner. What happens when one deviates from this? How best do we as practitioners, tutors and students protect ourselves and clients?  Retrospective action is not an ideal option. We need to be ready to ensure that our practices are sound, ethical, morally aligned and within our legal limits. In practice this further extends to the way we market ourselves and services. Is the information we use to promote what we do accurate and valid? Here, the practitioner needs to assume responsibility for managing the marketing of services, products and self. The simple take home message is check first, ask the right questions, seek advice and ensure that the practice domain is legal.

When establishing a practice, learn what is required, review and revise consultation documents, and think carefully about how best to market and promote yourself. It is only at this point that true learning begins. Massage training programmes provide the skeleton for professional practice, professional practice on the other hand, provides the opportunity to populate, develop, and map the skeleton to relevant policies, regulations, and structures.

So in contrast to Nike – don’t just do it – make sure you do it justly.

Beyond Recognition by Earle Abrahamson

Earle AbrahamsonI was recently awarded a fellowship by the Institute of Complementary and Natural Medicine (ICNM). The fellowship was in recognition of my sustained contribution to complementary medicine, teaching, scholarship and practice.  After receiving the fellowship I thought hard about the word recognition and its importance within the compendium of complementary medicine and therapeutic practice. 

Recognition serves multiple purposes, as it allows one to acknowledge important relationships and work towards enhancement of goals and objectives.  For me personally, recognition affords me the opportunity to appreciate the client-therapist relationship. This is a unique interpersonal relationship centred around legal, moral, and professional considerations.  In recognising the client’s role, the therapist learns to respect the dynamics of therapy and moves towards an educational model of explanation, therapy choice, expectations and after care.

These components are crucial for professional practice and further allow the client to understand that the treatment is provided within a professional framework. In dissecting the conceptual undertones of recognition as a construct, I realised that the questions I ask the client reflect upon my ability to use my knowledge and select the skills necessary for treatment. I further learned that recognition is more than a word, construct, or concept it is a lived practice wherein therapist and client constantly work together to understand, plan, and deliver treatment. Knowing how to apply a skill is distinctly different to recognising the need for application.

 Hands-On Training provides unique workshops wherein these very ideas are discussed, explored and explained through interaction and network forums. In conclusion, it is not being recognised that is important, it is how we recognise what is important that becomes the key to successful practice. I have learned that professional conduct, scholarship, respect and professional development are areas of my practice that often lie beyond recognition, but rest within a bed of recognising interpersonal space and learning how to value it.

Massage at The Royal Free Hospital

Back in March of 2013 I met an extraordinary man. A very straightforward and modest man – but one with great vision and determination. His name is Keith Hunt.

I’d heard about him, initially, as he’d just received an MBE in the 2013 New Year Honours List – for services to Complementary Therapy. And then everyone was talking about him. I found he’d trained through the same organisation as me – the Massage Training Institute – the gold standard in quality deep tissue massage. If you have ever received a massage from someone MTI trained you will instantly know the difference…

I asked Keith to give a talk to fellow MTI practitioners about massage for the elderly and those living with dementia, to complement a session about giving massage to people with physical disabilities. He instantly said yes, and added that he also wanted to cover “massage in a hospital environment’.

This was fascinating stuff, and something I knew nothing about. Over a 20 year period Keith had gently developed a working relationship with The Royal Free Hospital in Hampstead, North London – raising awareness of the value of massage as a complementary therapy, working effectively alongside surgical and medical procedures.

As a consequence, the hospital now boasts its own Complementary Therapy department – the only one in the UK, I believe. Keith, supported by a handful of part-time massage therapists, are all actually paid – funded by The Royal Free Charity; the rest of the team is made up of volunteers – now including myself.

As an aside, I realised some years ago whilst doing support work at another health agency that the NHS would collapse without the thousands of volunteers working within its environs. Organisations such as Child line, Age UK, Scope, Diabetes UK, Action aid, The Samaritans and many, many more are almost entirely staffed by volunteers.

The Royal Free is a 12 floor, 900 bed hospital, specialising in liver transplants and the treatment of scleroderma – an auto-immune wasting disease.  When Keith – well known for his cheery disposition and bright pink T-shirts – first started giving massage, treatments were offered only on the haematology wards. Now the service is extended to the whole hospital – for both in-patients and out-patients – though not necessarily all departments take it up. It is down to the awareness and involvement of the nursing & physiotherapy staff, on each ward, to refer a patient…

My time since I joined the team has been spent mainly on the wards specific to Oncology (Cancer), Liver transplants, Scleroderma , Care of the Elderly (COE) and PITU (Planned Investigative Treatment Unit) – where infusions, such as chemotherapy, are administered. But we give massage to anyone, from little children to those holding their Queens telegram.  And it is available for staff too, though the patients come first…

In the last 12 months, Keith and his team have given over 21,000 free massage treatments!!!

The massage itself is not standard as you would offer a more active, physically healthier person. It is essentially very gentle, very slow and rhythmical – providing relief and comfort rather than ironing out knots. The words “deep tissue” simply don’t come into it. Favoured massages are lower legs and feet – a wonderful antidote for those lying in bed for days on end and taking variable cocktails of medication, often resulting in significantly reduced mobility and excessive water retention; which can lead to oedema.  Anything deeper could be counter-productive to each patient’s healing process.

As a therapist working predominantly with fitter and more mobile clients, I have found my time at The Royal Free humbling. It is a pleasure to give massage to such an array of people, and to be the occasional bright moment in the day for so many of those confined to their beds. 

In conclusion, ideally every hospital – and hospice – should have a Complementary Therapy Department. It makes such a difference – just ask those who receive the massages. But it needs the commitment of someone like Keith Hunt to set up and run – and it needs money. This should not be something that exists on the goodwill of volunteers…

To find out how to learn massage for hospitals and hospices, go to: Massage in Hospitals and Hospices