If you are an artist, coach, producer, or clinician you know that keeping circus artists training and performing uninterrupted by injury is crucial to our field. Do you currently seek out information on injury prevention in circus arts? Where do you find it? There is research out there that’s difficult for the public to access due to the publisher’s copyright, and the latest information about injuries in circus bodies is usually published in scientific journals. It can take over a decade for that knowledge to make its way into a clinical setting and even longer to reach the training realm. As a circus medicine physical therapist, I have been involved with circus for over 30 years and actively straddling the divide between the two worlds. I love nerding out, reading the research that is out there, and even more, I am thrilled to discuss it with others, communicating it to the rest of the circus world. I’m interested in figuring out how we can shorten the distance and bridge that gap from research and researcher to the clinic, into the studio, and onto the stage.

Pre-pandemic collaborations

Put yourself back before the pandemic when we went to conferences, sat around big tables, networked, and made new friends. You’re in a room listening to a talk by a researcher whose paper you just read, or that colleague you always meant to connect with. That’s where I was in October 2019, when the International Association of Dance Medicine and Science (IADMS) hosted their annual conference in Montreal. 

Why was I, a circus medicine physical therapist, at a dance medicine conference? Two reasons: first, the conference organizers had purposefully included circus arts in the programming. They reached out to circus presenters and collaborated with Cirque du Soleil to facilitate tours and presentations in their home city. Second, the researchers from the Performing Artist and Athlete Research Lab (PEARL) were going to be there. They had just published a paper on the injuries and health problems in the student population at Codarts.1 I was so excited to meet them! I emailed before the conference to set up a meeting to ensure I would get to chat with them about the future of circus research. My nerdy circademic heart was excited to be there! 

I wasn’t the only one who was thinking it was time for all of us who were interested in circus research to meet. The team at CRITAC (Center for Circus Arts Research, Innovation and Knowledge Transfer), the research group at École National de Cirque, invited many of the speakers who were presenting circus-based information to join them at their facilities to sit down and exchange ideas. It was exhilarating to hear what everyone was working on and where their hypotheses were heading. As a clinician, educator, interpreter, and evangelist of research, I had ideas to contribute regarding what I’d love to see studied, but my main mission was collaboration and conversation.

Something we all agreed on was that circus-based research is challenging. The definition of a circus artist is diverse. How can we look at acrobats, jugglers, aerialists, and actors and say what the injury rate is? With the limited research on injuries in circus, research authors have struggled with these classifications and defined the groups in various ways. One study distinguished between “acrobat” and “non-acrobat.”2Another classified “acrobatics with equipment” different from “floor acrobatics.”3 A separate challenge comes with comparing data. For example, research authors used different definitions of injury4: was an injury something that prevented an artist from training for one day? Something that caused them to simply modify their training? Or is it only an injury if the event required a visit to a medical provider? What about the artist’s self-definition of an injury? If it is reported by the artist, how might their own definition of injury affect the data?5    

We finished our discussions, the conference wrapped up, and we all said our goodbyes as we headed to homes around the world. Just months later, the world shut down with the pandemic, and everyone went back to reading, writing, and appreciating research in journals as they came across our inboxes. 

The biggest news in circus injury research   

Fast forward (slow forward, glacial pace forward) through the heart of the pandemic. Here we are in 2022. Lots of great research – circus and otherwise – has been published, especially in the last two years. Just since 2020 there have been over 20 articles published that are related to circus artists, their bodies, and injury. These range from looking at students’ warm-up and its relationship to injury7, to physiological changes in circus students bodies8, to a longitudinal look at seven and a half years’ worth of data from a collegiate circus school.9

In 2020, when the International Olympic Committee (IOC) released a consensus statement on the methods of recording and reporting sports injuries and illnesses, researcher Dr. Stephanie Greenspan had the idea to create a circus equivalent.6 Some of the global circus researchers that had made connections at the IADMS conference the year before were joined by colleagues to form a working group. They intended to tackle the question, how do we talk about and track injuries in circus? The goal is to provide researchers with a common language about circus injuries and illness so that future research can uniformly compare data sets.  

This has been a huge boon for our circus science community. However, since we aren’t always able to easily compare the data, the most recent publication of the circus-specific extension of the IOC’s consensus statement in August may be the one that changes the paradigm.6 Hopefully this paper will give us the tools to eventually contextualize and compare the research that is to come.

It’s long, and detailed, and definitely worth a read in its entirety, but let’s dive into the important bits here!

1)     Defining Injury:

This consensus helps us have a definition of injury forresearch in circus: “Injury is tissue damage or another derangement of normal physical function due to direct or indirect participation in circus activities, resulting from the rapid or repetitive transfer of kinetic energy.”

2)     Defining the mechanism of injury:

This is where we figure outhow the injury happened. Was there an identifiable event? Was there contact with an object,the ground, another artist? Was the contact direct or indirect?

Is it an acute onset with a sudden injury– like a fall – or a repetitive movement that either gradually or suddenly causes pain?

3)     A standard way of defining the extent of the injury:

This includes where the injury occurred and what tissues were involved and how much time the artist wasn’t able to train or perform.

4)     A standard way of tracking exposure to circus activity by session of trainingor performance:  

This helps researchers establish injury rates that are specific to circus training and disciplines which will allow us all to have an understanding of how likely it is for an artist to get injured.

5)     Circus discipline classification:

This breaks down the different circus disciplines into 8 subgroups of similar stresses on the body so that the data is more relevant. For example, with this classification implementation, injury rates for aerial artists – who perform on apparatus suspended from rigging – would be separate from acrobats – who work with human propulsion and even from other ground acrobats – who focus on balance and control.

6)     An appendix with data collection tools!!!

There is a weekly questionnaire for collecting research data and a form for healthcare practitioners to standardize a report of circus injury.

Ok, that’s a lot of stuff! But why should we care?

As circus artists, we want to keep our bodies safe to move and perform the way we want and need them to. Having better data collection gives us better research. That research can then be read by movers and clinicians like me to have a better understanding of the problems that circus artists run into, when and how they get hurt, and we can start to figure out how to apply these concepts with the goal of preventing some of the injuries from occurring in the first place. In short, helping artists get back to doing the things they love.

It can be a challenge to access many of the articles that have the most up to date information because much of the scientific research published around the world is in journals that are behind paywalls. If you look for many of the articles I have cited here, unless you have institutional access, you most likely will be unable to read them. So, one of the important things about this consensus statement is that it is open access which means thateveryonecan read it and use the information in their clinic and research.

To make this journey full circle, at the end of the month I will be returning to the IADMS conference for the first time since that 2019 meeting. This time, the conference will be in Limerick, Ireland, and we’ll see what comes next for circus science!

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Where to find the full article on the circus injury consensus statementhttps://bmjopensem.bmj.com/content/8/3/e001394Some of the great organizations mentioned in the articlePEARL https://pearlresearchlab.com/CRITAChttps://ecolenationaledecirque.ca/en/school/critacWhere to learn more about circus scienceInternational Association of Dance Medicine and Science (IADMS) https://iadms.org/–         Next conference October 29th – 31st 2022 in Limerick, Ireland (virtual and in person)Australian Society for Performing Arts Healthcarehttps://www.aspah.org.au/–         Next conference November 26-27 2022 (online conference)Performing Arts Medical Associationhttps://artsmed.org/–         Next conference July 6-9 2023 in New York City, USA

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References

1. Stubbe JH, Richardson A, van Rijn RM. Prospective cohort study on injuries and health problems among circus arts students. BMJ Open Sport Exerc Med. 2018;4(1):e000327. doi:10.1136/bmjsem-2017-000327
2. Shrier I, Meeuwisse WH, Matheson GO, et al. Injury patterns and injury rates in the circus arts: an analysis of 5 years of data from Cirque du Soleil.Am J Sports Med. Jun 2009;37(6):1143-9. doi:10.1177/0363546508331138
3. Wanke EM, McCormack M, Koch F, Wanke A, Groneberg DA. Acute injuries in student circus artists with regard to gender specific differences.Asian J Sports Med. Sep 2012;3(3):153-60.
4. Wolfenden HE, Angioi M. Musculoskeletal Injury Profile of Circus Artists: A Systematic Review of the Literature.Med Probl Perform Art. Mar 2017;32(1):51-59. doi:10.21091/mppa.2017.1008
5. Bolling C, Mellette J, Pasman HR, van Mechelen W, Verhagen E. From the safety net to the injury prevention web: applying systems thinking to unravel injury prevention challenges and opportunities in Cirque du Soleil. BMJ Open Sport Exerc Med. 2019;5(1):e000492. doi:10.1136/bmjsem-2018-000492
6. Greenspan S, Munro D, Nicholas J, Stubbe J, Stuckey MI, Van Rijn RM. Circus-specific extension of the International Olympic Committee 2020 consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport.BMJ Open Sport Exerc Med. 2022;8(3):e001394. doi:10.1136/bmjsem-2022-001394
7. Hakim H, Puel F, Bertucci W. Injury assessment in circus student-artists population; preliminary study.Science & Sports. 2020/06/01/ 2020;35(3):154-160. doi:https://doi.org/10.1016/j.scispo.2019.07.006
8. Decker A.Longitudinal assessment of physical, physiological and psychological characteristics of elite circus student-artists. University of Manitoba; 2020.
9. Stuckey M, Richard V, Decker A, Aubertin P, Kriellaars D. Supporting Holistic Wellbeing for Performing Artists During the COVID-19 Pandemic and Recovery: Study Protocol.Front Psychol. 02/04/2021 2021;12:577882. doi:10.3389/fpsyg.2021.577882

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Main Image:  At Cirque du Soleil headquarters (left to right) Drs. Adam Decker, Emily Scherb, Joanna Nicholas, Stephanie Greenspan. Photo courtesy of Emily Scherb.

Dr. Emily Scherb, PT

Physical Therapist, Educator -United States

Dr Emily Scherb earned her Doctorate In Physical Therapy from Washington University in St. Louis. She has been a practicing circus artist for over thirty years and has worked as an aerial and flying trapeze instructor across the US.
As founder and owner of The Circus Doc, Dr. Scherb has presented continuing education programming for circus educators and healthcare professionals on the unique physical demands and challenges of working with circus artists.
Her bestselling book Applied Anatomy of Aerial Arts was the first to address the biomechanics and physical demands involved in circus training.
Dr. Scherb lives in Seattle, WA where she owns Pure Motion Physical Therapy. Her clinic is dedicated to working with professional and recreational circus artists. As a board member of Seattle Dance and Performing Arts Medicine, she participates in free healthcare clinics for performing arts in the Pacific Northwest and educational programming to expand knowledge around performing arts medicine. Dr. Scherb is also an active board member of the American Youth Circus Organization/American Circus Educators.

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