Royal commission: keeping ballet dancers en pointe

Greg Retter tells Gill Hitchcock how physios with NHS backgrounds and an evidence-based approach will help keep the Royal Ballet’s dancers on their toes this Christmas.

The Royal Ballet’s 2016 crowd-pulling Christmas programme – The Nutcracker and Sleeping Beauty – is a sell-out. Yes, ballet is an art, but the dancers are also like athletes or sports people, working through a pressure-packed season. It starts in September, and ends a physically punishing 10-months later.
Go back stage at the company’s base in London’s Covent Garden, along corridors edged with racks of elaborate costumes, take a lift filled with ballerinas to the fourth floor and you’ll find the Monica Mason health suite. It’s where dancers – for whom a typical day starts with classes at 10am, followed by rehearsals and may, if there’s a performance, end at 10.30pm  – are treated for injuries.
Since 2013 this open-plan space, with its gym, physiotherapy clinic and Pilates studio, has been a backdrop for the care of dancers, under the leadership of clinical director Greg Retter. 
‘With the dancer it’s about the artistry, so probably my biggest challenge is trying to come up with innovative and interesting ways to bring an athletic mentality into this very grand, old artistic form,’ Greg says.
The dancers need the strength and flexibility to cope with the repetitive nature of the performance. In addition, they must have a lot of flexibility and their cardiovascular fitness has to be ‘up to speed’, he explains. ‘They need really good psychological preparation, and to understand the recovery process and how to make themselves ready to go again the next day.’
Because the work rate for dancers is actually higher than for athletes, he says it is vital that this athletic preparation is ‘firmly cemented’ into their regime.
Greg qualified as a physiotherapist in New Zealand in 1990. ‘Like a lot of Kiwis, I came for two years of travel over in the UK and ended up staying. I picked up some excellent jobs in the NHS, and worked there for seven years.’
His NHS roles took him to South Wales, Essex and Oxford where he worked at the Radcliffe Infirmary and with the university rowing team – an experience that eventually led to four years with the British Olympic Association delivering an intensive rehab programme. 

Physiotherapy’s role

Olympic sport was where he thought of remaining for a good while, until 2013 when he was alerted to the Royal Ballet’s search for a clinical director. He saw the potential to apply the knowledge he had learned through Olympic sport at this renowned institution, which was founded in 1931.
The catalyst for this newly-created post had been the Royal Ballet’s growing realisation that it must prioritise the health and wellbeing of its dancers and ensure they could fulfil their potential throughout long and healthy careers. ‘I was very clear in the interview that I had no dance experience as such, but they were looking for someone with a rehab background,’ he says. ‘And I was fortunate that the Royal Ballet had just undergone some significant changes, in particular a big investment in healthcare for the dancers.’
New investment backed the creation of the Monica Mason health suite. It meant that dancers were offered strength and conditioning programmes, Pilates, Gyrotonic, nutrition, psychology, massage therapy, sports medicine and physiotherapy services. And it ensured everything happened under the guidance of a clinical director.
According to Greg, this high level of support mirrors best practice in the sporting arena. And it sends a strong signal that the dancers will be cared for and supported by a highly-qualified and well-resourced team. ‘Physiotherapists are central to the clinical delivery for all those dancers who need help and guidance in terms of the performance elements, and particularly if they become injured.’ he says. ‘In a rehab model, the physiotherapist guides the clinical pathway of that dancer’s return and liaises with all the different specialists to ensure he or she remains on a very clear and structured rehabilitation programme.’

Egos must be ‘set aside’

The season starts with a ‘screening’ programme covering all the dancers, so that any health concerns are picked up by a physiotherapist who will then seek a way of addressing them. And a multidisciplinary team of health specialists – physios, doctors and nutritionists included – meet regularly to discuss how their areas of expertise can complement each other.
‘Ultimately, we are looking at the end result and so what are the areas we need to work on, does the dancer require more central strength, or more control, or a combination of both,’ says Greg. 
‘The physiotherapist is central to the process, because we will understand how that dancer is working, in the Pilates studio or in Gyrotonic, and then what requirements they have from the ballet coaching, or from the strength and conditioning, and how nutrition and the psychology feed into that. 
‘Obviously it requires a lot of communication and the physio is the person who facilitates that bridge of communication across the different areas.’
The Royal Ballet’s physios – three full-time, and seven ‘bank’ physios who work weekends – come from backgrounds in dance and sport. But first and foremost, Greg believes, they have to be excellent physiotherapists, able to work well in a demanding environment and good team players. 
‘If you are the central point of contact, then it’s really important to set your ego aside and be able to harness the whole support network around the dancer,’ he says. ‘It’s the team, it’s the collective engagement that makes the difference, not just a single individual.’

Seasonal ‘spike’ 

Another key factor for the Royal Ballet is whether its physios have had good clinical experience in the NHS. ‘We used to look for that in sport as well. I think it’s important that you have a strong grounding in a part of your career as a physiotherapist.’
Any organisation worth its salt will examine its practices and look for evidence-based change and improvement. For the Royal Ballet, SmarterBase, a database of injuries, treatments and outcome measures, introduced some three years, puts it in a better position to analyse its healthcare interventions. ‘We now know for a fact that if a dancer has poor calf capacity, if their calf muscles are not strong enough, then they are much more likely to suffer with a bone stress response in their lower limb,’ says Greg.
Meanwhile, in a first for the Royal Ballet, this summer it entered into an academic partnership that will provide sports science services to the company. The partnership with St Mary’s University, Twickenham, will explore issues around the dancers’ work rates. The aim is to shed light on the physical attributes required for a successful career and how the company can deliver the best support and care.
Greg describes the volume of work at Covent Garden as ‘much more significant’ that anything he has seen previously. A typical touring company will perform for two or three weeks, and then return to base for a rehearsal phase of up to six weeks. For the Royal Ballet, however, once the season starts, the churn of rehearsals and performances is continual. At any one point the dancers might be performing in two, or even three, different ballets, and then rehearsing two or three more. Time off during this period is limited to a mere one week.
‘We do get spikes of injury around Christmas when the repertory increases, but we are trying to put in place as much preventive work as possible,’ he says. ‘As physios, we try to reinforce the message about how the dancers can prepare themselves, and of a good recovery strategy, so they can maintain that high work rate through what is a very challenging part of the season.’ fl
Gill Hitchcock

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