Concussion is defined as a traumatic brain injury resulting in a disturbance of normal brain function that may elicit a variety of symptoms.1 While the vast majority of concussion attention presently is focused on sports, this injury can happen at any moment, in any activity where an individual is at risk for a direct blow to the head or face, or is subjected to a whiplash-style impact that indirectly accelerates and decelerates the head.1 This includes the performing arts, and theater is a primary occupational field where such an injury can occur.
An undiagnosed or untreated concussion may create prolonged symptoms for patients and prevent them from returning normally to activities of daily living and lifestyle. Previous research suggests that athletes who have received two or more concussions demonstrate a significant deficit in recovering verbal memory and reaction time compared with athletes who have not sustained a concussion.2 Repeated subconcussive impacts appear to lead to detrimental sequelae, as well.3,4 Second impact syndrome is one of the most severe, albeit controversial, consequences that can arise from repeated concussions.5,6
Athletes often are reticent to report concussions7; this has been demonstrated in high school athletes, where between 72% and 88% of concussion symptoms remain unreported.8 A similar assumption is made of performing artists; however, dancers are the only known type of artist for which concussion data are published.9,10 Reasons for not reporting a potential concussion may be the fear of being disqualified from participation in an activity,7 believing the injury is not serious enough to warrant reporting,7,9 or a lack of knowledge of concussion symptoms, with a resulting inability to recognize a potential concussion.7
Concussions today receive unparalleled attention; yet, this appears to be nearly exclusive to the context of sports. Nonetheless, artistic work places artists at risk for concussion, as well. Theater performers must act, sing and dance while avoiding many complex on- and off-stage obstacles.11 Other members of any given theater production also are at risk for head injury, including stage managers, electricians, lighting technicians, set constructors, and other stagehands, as several head strike hazards are present in a typical theater environment. These include stage props, lighting equipment, and stage combat.12 In addition, special-effects equipment such as fog and smoke generators and low ambient lighting levels reduce visibility, thus impeding the reaction of actors and technical staff to imminent dangers.12
Actors themselves have identified several perils, including some that could present a concussion risk, notably poor lighting, trip hazards, and trap doors in staging.13 It is interesting, however, that a 251 page compendium of theater health and safety14 contains just two-thirds of a page on head protection and, while recommending hard hat use, gives virtually no specific acknowledgment of the dangers associated with head injuries nor offers any potential injury mechanisms.
In spite of the hazards, concussion has received scant attention in theater. To our knowledge, there are no prior peer-reviewed articles expressly describing concussion in the theater setting, although popular or trade publications contain reports of concussions that prevented actors from continuing in a show.15–18 With regard to injuries in theater performance, circus artists are the primary type of theatrical participant studied to date.19–24 Since concussion in theater is a topic that is minimally addressed in the literature, it is evident that the injury should be examined to provide a better understanding of how concussion affects those who work in the theater field. Therefore, the purpose of this study was to determine the history of head impacts, concussions, concussion symptoms, and concussion management in a sample of theater personnel.
Two hundred fifty-eight participants volunteered for the study; there were no prespecified exclusion criteria other than a requirement that the participants be age 18 or older. They were recruited from a university theater department, as well as selected professional organizations representing workers in the production and technical aspects of theater. We placed no limit on the sample size so that as broad a sample of the population as possible would be available for analysis. Participants were eligible if they were actively engaged in any position in the theater industry at the high school, university, or professional level. Approval for the study was provided by the appropriate university Institutional Review Board, and all participants gave their informed consent prior to beginning their involvement.
A Qualtrics online survey instrument (Qualtrics, Inc., Provo, UT) titled “Concussion in the theater setting” was created and its webpage link was distributed to theater personnel from a university theater department and specialized professional theater associations, including via social media. Three of the organizations were American and one was international. We recruited participants from all theater disciplines, including acting and the various components of technical theater and production. However, the nature of the organizations that agreed to promote the survey to their members was primarily related to the production side of theater rather than the acting side. Overall, because of the fluid nature of the organizations’ e-mail and social media recruitment processes, we were unable to identify an exact number of potential participants. We simply tried to attain as many respondents as possible from the sources accessible to us. Table 1 lists the primary questions asked by the survey; the entire questionnaire is available as Supplemental Digital Content 1, http://links.lww.com/JOM/A398.
The survey link was available for 3 months. We sought to assess the prevalence of theater concussion, common mechanisms of concussion injury in the theater, and rates of reporting concussion symptoms to a healthcare provider. No additional respondents participated as the 3-month mark neared, so the survey was closed and data analysis performed.
The data were analyzed by counts and percentages, as well as with descriptive statistics where applicable. The participants who reported having received at least one head impact in theater activity were categorized by age ranges, as well as by years of experience in theater. We then used Spearman rank-order correlation analysis to assess possible relationships between age and number of head impacts sustained in theater and between years of experience and number of head impacts sustained in theater.
Of the original 258 respondents, data from eight were dropped because the participants declined to provide complete answers early in the survey. Another four reported they were younger than 18 years old; these were automatically exited from the survey, leaving a total of 246 participants (121 males, 120 females, five unreported sex). Their ages were collected categorically: 18 to 22 years, 40 participants; 23 to 27 years, 49 participants; 28 to 32 years, 33 participants; 33 to 37 years, 26 participants; 38 to 42 years, 20 participants; 43 to 47 years, 15 participants; 48 to 52 years, 12 participants; over 52 years, 51 participants. The theater roles of these respondents are shown in Table 2.
The participants’ reported the following years of experience in the theater industry: less than 2 years, 1 participant; 2 to 5 years, 32; 6 to 10 years, 44; 11 to 15 years, 41; 16 to 20 years, 26; more than 20 years, 102. Thus, the respondents were largely mature in their understanding of the theater environment.
Figure 1 outlines the progression of the participants through the survey. After further reviewing the survey data, complete datasets that included answers to all questions about head impact reporting were available for 209 participants. One hundred ninety-nine (95%) of these stated that they recalled an incident in their lifetime when they received an impact to their head. Of the respondents who had experienced such an impact, 140 (67%) reported having sustained the impact while participating in theater. Therefore, the prevalence of ever experiencing a head impact during theater for this sample is 67%, or 140 of 209.
Table 3 categorizes the respondents according to their answers to key questions regarding previous experience with concussion. Notably, almost half (44 of 98, 45%) of those who received a head impact accompanied by concussion-like symptoms did not report their injury to anyone. Of the 54 who did report their injuries, less than two-thirds of them (n = 35, 65%) consulted a healthcare professional. Of the 25 participants who confirmed they were diagnosed with a concussion by a healthcare professional, seven (28%) revealed that they were released to return to theater activities without any precautions, instructions, or graded return-to-activity protocol such as the recommendations made by the international concussion consortium that convened in Berlin in 2016.1
Table 4 details the number of lifetime head impacts in theater activities that were reported by our survey respondents. Of the 140 survey respondents who indicated they struck their head during theater activity, 55 (39%) reported having done so more than 5 times. More than three-quarters of them (108 of 140, 77%) said they had received a blow to the head 3 or more times.
Spearman rank-order correlation yielded no significant relationship between age and number of head impacts reported as having occurred during theater activity (rho = 0.118, P = 0.163). The numbers of head impacts reported by the theater personnel in each age bracket are presented in Table 5. Spearman rho for the number of head impacts versus years of experience in theater showed no correlation (rho = –0.066, P = 0.438).
The purpose of this study was to determine the history of head impacts, concussions, concussion symptoms, and concussion management in a sample of theater personnel. This was a descriptive study of data collected from a convenience sample of members of theater organizations. Based on a 67% prevalence of at least one head impact during theater activity in our respondents, our findings suggest that concussion should be a major concern for those working in the theater industry, especially in the production and technical fields. While it is impossible to know how many of the reported impacts resulted in a true concussion, certainly the substantial number of head impacts with concussion-like symptoms that were not reported to someone in authority generates cause for concern. As has been previously reported, athletes and dancers7–9 are prone to not reporting head impacts that result in concussion-like symptoms. Our data suggest that theater workers have the same tendency.
We found virtually no relationship between age and number of head impacts reported, nor between years of experience in theater and number of head impacts. Thus, while it may seem intuitive that theater personnel who are older or in the industry longer should sustain more impacts because they have more exposures, this was not supported by our data. This is an interesting finding, and may underscore the dangers of head trauma inherent in theater, since younger theater workers appear to be as likely to sustain several head impacts as older workers are.
Remarkably different from our results for theater personnel are those for dancers presented by McIntyre and Liederbach,9 one of very few published articles specifically addressing head injuries in performing arts. In their group of 153 dancers, 23.5% reported having sustained a concussion (however, the data were self-reported and it is not known if these were truly diagnosed concussions). When asked simply if they had hit their head and felt concussion symptoms, 31% of the participants reported having done so. In contrast, more than twice as many, or 67%, of our theater respondents self-reported having experienced a head impact in theater. While 86% of McIntyre and Liederbach's participants reported their concussion to someone and 62% of them reported a head impact that elicited concussion-like symptoms, 65% of our theater participants did so. The similarity in the latter numbers compared with the rate of reporting of concussions in the dancers may relate to how performing artists perceive the severity of a head impact and the severity of their symptoms.
Moreover, a further explanation for the differences may be that half of McIntyre and Liederbach's dancers had access to onsite healthcare; this would make it easier for injury reporting and appropriate care. While we did not inquire about the healthcare environment of participants in our study, our experiences with the theater industry suggest that rapid onsite evaluation and care arrangements—akin to the availability of athletic trainers and other healthcare professionals to athletes—are unlikely in many, if not most, venues. In addition, a common theme in both dance9 and sports25 is that a lack of reporting is due to a dancer or athlete not believing an injury is severe enough to report. We observed a lack of reporting tendency in our study, too. This, coupled with relatively poorer access to healthcare for theater compared with sports, underscores an opportunity for improvement.
An area of particular disappointment highlighted by our results is the group of respondents with a diagnosed concussion who reported their healthcare practitioners released them back to full theater activity with no restrictions or graded return-to-participation protocol such as that widely recommended for sports.1 This may be attributed to reported gaps in healthcare providers’ knowledge about how to diagnose and manage concussions26; but, it is a situation that must be corrected.
We located nine primary research articles about theater injuries. They all were related to the circus arts type of theater, and all reported the results of general injury surveys. Four did not mention the words “head” or “concussion.”19–21,27 In actors from London's West End, three head injuries were self-reported by 211 actors without specification of diagnosis or etiology28 and in 152 actors on Broadway, three unspecified head injuries were disclosed, as well.13 One study reported no head injuries.29 One study identified the head being affected in 15.2% of accidents in acrobatic types of theater activities across 17 years,23 but did not identify the nature of these injuries.
A 5-year investigation of Cirque du Soleil performers revealed seven concussions that each resulted in a time-loss of 15 days or more.22 However, this article is of limited utility because, while the authors specified that concussions had occurred, the injuries were reported generally under the category “Head and Neck.” This makes a true understanding of concussion incidence in the study impossible. Although the reported overall injury rate in theatrical circus artists may be relatively low,23,24 studies typically have focused on the performers rather than the production crew members and, thus, neglect a major category of theater worker at risk of head injury.
What little concussion data that can be derived from this body of theater injury literature is greatly at odds with our results. Two-thirds of our respondents reported receiving a head impact while working in theater; more than three-fourths of these were struck in the head 3 or more times. While our retrospective, self-reported data do not allow us to estimate the number of these head impacts that would have been diagnosed as concussions, seven of every 10 respondents to our survey indicated they experienced concussion-like symptoms stemming from their head impact, but they continued participating in their theater activities. Considering the negative consequences of both multiple subconcussive impacts3 and additional impacts prior to metabolic healing of the brain from a concussion,4 these data are cause for alarm.
Several injury mechanisms reported among dancers10 may also be seen in theater personnel; examples are stunting, diving, flipping, unintentional drops, trips and slips, and repetitive head-whipping motions. As recommended by Rossol and Hinkamp,14 some theater environments are regulated for hard hat use, although lack of compliance in wearing them and hardhat styles that do not have chinstraps—making them unsuitable for certain job positions in theater—may contribute to the high prevalence of head impacts we noted.
A limitation of our study was the weighting of the results toward theater personnel on the technical side and a concomitant under-representation of personnel on the performer side. This would have occurred because two of the larger associations from whom participants were invited represented the production portion of the industry. Thus, if more nonperforming participants from these organizations responded compared with participants representing the performing aspect of theater, the results would be skewed toward that sub-population. It is clear, however, that the opportunities for head injuries are plentiful in the production/technical component. Our results are likely more generalizable to these individuals than to actors and others in the performance component. This highlights a valuable vein for future research: the extent to which actor and non-actor theater personnel differ in their rates of head impacts.
We also were limited in some of our analyses because we were unable to identify a pure denominator group from which to calculate a response rate to our survey. This is an acknowledged issue when internet-based recruiting—such as e-mail and social media used by the organizations that agreed to promote the project to their members—are used to solicit participants, as the number of individuals who truly receive the opportunity to engage in the study cannot be determined. E-mails may not be delivered or may end up in one's spam folder, and social media invitations may sprawl across the internet.
In our view, a selection bias of individuals who had sustained a head impact—particularly multiple impacts—was possible, but unlikely, because the survey was promoted to the target organizations in a straightforward way with no leading statements in the recruiting materials that would have inadvertently targeted those with a history of head impact. Whether a selection bias related to age could account for the one-fifth of the participants being over age 52 and two-fifths having more than 20 years of experience in theater is unknown. In addition, we acknowledge the possibility that individuals who had sustained more severe or a greater number of head impacts in their careers were more likely to recall their incidents. Nonetheless, the fact that we have shown that these incidents occur with apparent regularity and that there is a potential for inadequate healthcare attention supply important points for discussion among theater personnel.
In conclusion, this descriptive study suggests that occupational head impacts in the theater industry occur frequently and often are accompanied by concussion-related symptoms. These incidents require much better diagnostic and management procedures than is currently practiced. Theater venues are replete with opportunities for head impacts, particularly for those engaged in production and technical roles. We recommend further research on this topic. A move is needed toward adopting methods that increase awareness of the prevalence and seriousness of this occupational injury in theater. In addition, implementing practices to improve concussion care for theater personnel is warranted.
The authors gratefully acknowledge Dr. Janet Simon, Assistant Professor of Athletic Training at Ohio University, for her assistance in preparing the survey for this research and providing expert review of the manuscript's content.
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