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Year : 2022  |  Volume : 4  |  Issue : 2  |  Page : 122-126

Effect of Somatosensory Intervention on Joint Hypermobility and Proprioception in Young Dancers and Nondancers: A Clinical Trial

Department of Paediatric Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission08-Apr-2022
Date of Decision22-Nov-2022
Date of Acceptance06-Dec-2022
Date of Web Publication19-Jan-2023

Correspondence Address:
Dr. Priya Patel
Department of Paediatric Physiotherapy, KAHER Institute of Physiotherapy, Nehru Nagar, Belagavi . 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_52_22

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Context: Generalized joint hypermobility is frequent in youngsters, particularly among young dancers. It can cause proprioception problems, discomfort, muscular weakness, musculoskeletal injuries, and joint dislocations. It can be a major source of lower limb injuries in dancers with hypermobility. As a result, it is critical to keep hypermobility under control to avoid damage.
Aim: The objective of this study was to determine the effect of somatosensory training on joint hypermobility and proprioception in young dancers and nondancers using the Beighton scale and comprehensive scale of proprioception.
Settings and Design: Comparative study in dancers and non dances from dancing academy.
Methods and Materials: A study was conducted on children with joint hypermobility, in which a total of 18 young dancers and 18 nondancers between the ages of 8 and 15 were selected from Belgaum's dance academy and other coaching classes. On the basis of inclusion and exclusion criteria, the youngsters were screened. Both groups received 15-min somatosensory training 4 times a week for 6 weeks. Beighton score and comprehensive observation of proprioception were used to assess hypermobility and proprioception. The assessment was done at the start of the intervention and again after 6 weeks.
Statistical analysis used: The paired t-test and independent sample t-test were used to compare outcome measures.
Results: Both groups showed considerable improvements in proprioception and hypermobility with P < 0.001 showing statistical significance. However, when a between-group analysis was performed, the postmean score for hypermobility in Group B was not significant with P = 0.32.
Conclusion: According to the findings, a 6-week somatosensory intervention improves hypermobility and proprioception in young children.

Keywords: Beighton, Dancers, Hypermobility, Proprioception, Somatosensory

How to cite this article:
Patel P, Chivate S. Effect of Somatosensory Intervention on Joint Hypermobility and Proprioception in Young Dancers and Nondancers: A Clinical Trial. Indian J Phys Ther Res 2022;4:122-6

How to cite this URL:
Patel P, Chivate S. Effect of Somatosensory Intervention on Joint Hypermobility and Proprioception in Young Dancers and Nondancers: A Clinical Trial. Indian J Phys Ther Res [serial online] 2022 [cited 2023 Sep 27];4:122-6. Available from: https://www.ijptr.org/text.asp?2022/4/2/122/368057

  Introduction Top

Dance is defined as one or more bodies moving in a rhythmical pattern.[1] Dance helps to improve self-awareness and self-esteem and enlightens the mood.[2] Group-based dance in a recreational setup may help to boost social and psychological wellness.[3] To acquire advanced techniques and style dancers, frequently strain their bodies beyond the physical limit which results in injury. The main cause of potential tissue damage is psychological stress and overuse which negatively affect their career in the future.[4]

Excessive movement within the usual plane of movement is referred to as hypermobility. Hypermobility can be selective or generalized, when there is hypermobility in numerous joints (typically 5 or more) affecting more than one limb, it is referred to as generalized hypermobility. Trauma, joint disease, surgery, or training can cause selective hypermobility, which can be inherited or acquired.[5] There is something called joint hypermobility syndrome also termed symptomatic generalized joint hypermobility (GJH) which is associated with joint pain. Asymptomatic GJH is not associated with joint pain and clearly gives a picture of hypermobility.[6]

In a study done by Deshmukh and Ramteke, prevalence of hypermobility in 2013 in Karnataka for the age group 6–12 years was found to be 34.2%. Hypermobility is more common in childhood and it depends on age and gender, it decreases as age advances and is more commonly seen in females as compared to males.[7] The prevalence of GJH is more in young dancers among young healthy children for the reason their bodies require hyperflexibility for certain postures in the dance form, hence their bodies adapt to it.

A study had shown that dancers with hypermobility commonly show anterior pelvic tilt and sickle foot which can lead to lower limb injuries mainly in the foot and ankle. This hypermobility of the feet can raise stress, which can travel up the kinetic chain and disturb the whole functioning of the lower extremities.[8] In another study, it was stated that GJH in dancers can lead to decreased physical capacity, reduced muscle strength, and reduced proprioception.[8]

Beighton score is proved to be the most valid, standardized, and reliable tool for measuring joint hypermobility as it has been used in many studies which are done on young children and have given accurate results.[9] Till now, it is commonly used in young athletes, young dancers, school-going children, ankle instability, fibromyalgia, and benign joint hypermobility syndrome (BJHS).

Proprioception is also an important factor especially when it comes to dance, as this is the form where the maximum complexity of movements is involved.[10] Proprioception is assessed by comprehensive observation of proprioception which is previously used in the assessment of autism spectrum disorder, developmental disabilities, and sensory processing disorder. It takes 15 min to complete the coefficient of performance (COP) and is easy to evaluate. It is an observational tool that measures different aspects of proprioception.[11]

Somatosensory training will help to increase proprioception by improving body awareness and ankle and knee joint stability. Such exercises necessitate the control of instability and will also modify abnormal motor patterns, abnormal activation patterns, and insufficient muscular mass stiffness, as well as reduced joint strain during training.[12] This will be the first study to use this protocol for GJH in dancers.

As GJH is not yet confirmed to be good for young dancers and its adverse effects are mainly causing reduced proprioception. To our best knowledge, there is a dearth of literature which suggest somatosensory training to improve proprioception and prevent joint hypermobility in young dancers and nondancers. Thus, the present study will evaluate the effect of somatosensory training on hypermobility and proprioception in young dancers and nondancers.

  Subjects and Methods Top

All the dancers were recruited from all dance schools and academies in Belagavi, Karnataka, and coaching classes other than dance classes for nondancers. Eighteen young dancers and 18 nondancers with GJH were included on the basis of inclusion criteria, i.e. age group 8–15 years both male and female, fully active in dance classes from past 3 months taking classes for 5 h/week, and having Beighton score of ≥5/9 for hypermobility. Participants were excluded if history of lower limb surgery or dislocation in the past 1 year or any recent injury, young dancers who remain absent from class for more than a week during the intervention, who are not willing to participate, and any diagnosed physical and mental issues hampering the active participation in physical activity.

Outcome measures

Beighton score

It is a scale that assesses children's hypermobility. It consists of 9 points, and if a child's Beighton score is 5/9, he or she is diagnosed with GJH. The items on the scale are as follows: Passive dorsiflexion of the fifth metacarpophalangeal joint (little finger) is >90°, (2) The thumb is passively opposed to the flexor aspect of the ipsilateral forearm, (3) Extend the elbow by at least 10°, (4) Extend the knee by more than 10°, and (5) Without bending the knees, place the hands flat on the floor. The score is either 0 or 1, with 0 indicating no hypermobility and 1 indicating hypermobility at that joint. The reliabilty of the Beighton Score is 0.96.[9]

Comprehensive observation of proprioception

The COP is a 15-min criterion-referenced short observational technique that the clinician uses to observe the kid while he or she is free to play. It has 18 questions that focus on motor and behavior-regulatory components of proprioceptive processing in children. Each item is scored on a Likert scale ranging from 1 to 5, with 1 indicating typical performance and 5 indicating the most severe kind of proprioceptive processing impairments seen in children.

The reliabilty of the COP is 0.91.[11]


  • The intervention group was given somatosensory training 4 times a week for 6 weeks. The program includes weight-bearing exercises that emphasize both muscle strengthening and proprioceptive stimulation. The exercises were performed on both hard and unstable surfaces. After practicing the exercise with open eyes, the exercises were performed with closed eyes. Nondancers group was given the same training protocol with the same frequency and for the same time duration at their home in the presence of the therapist
  • Somatosensory training: [12]
  • Standing on one leg, performed with the raised leg moving from the arabesque (ballet posture) to standing upright, with the knee of that raised leg forward. Then back to the arabesque. Fifteen repetitions
  • Bend the knees and usually with the feet turned right out along with raising the leg, 15 repetitions
  • Reach more high with a raised leg, slowly performing external rotation, and return. 15 repetitions
  • The raised leg performs circular movement by stretching it out. Fifteen repetitions
  • Standing in toes attempt to detach one foot from the ground and with the raised leg perform external rotations and returns
  • Progression: At week 2, both groups started to exercise using the same protocol, with closed eyes; at week 5, on a balance disc or board, with open eyes; and, at week 6, with closed eyes on a balance disc or board
  • Postintervention assessment was taken, and the result was tabulated and analyzed.

Statistical analysis

Data were analyzed using statistical software SPSS version 26.0 (SPSS Inc.Chicago, IL,USA). Excel spreadsheet was used for the calculation and tabulation of data. Continuous variables were represented by mean ± standard deviation. Categorical variables were represented by frequency tables. Comparison of variables within the group was done using paired t-tests. Between-group comparison of variables was done using an independent t-test. P = <0.05 was considered statistically significant.

  Results Top

A total of 34 children were recruited , among them males recruited in both groups ( Group A and Group B) total were 17 males where in group A had 11 males and group B had 6 males. For female distribution, Group A had 6 females and group B had 11 females. [Table 1]
Table 1: Gender wise distribution in both the groups

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The mean No. of hours spent dancing was 6.06 ± 0.90. Most of the dancers had 1-2 years of practicing years, the mean no. of years practicing dance was 1.53 ± 0.80.[Table 2]
Table 2: Hours and Years spent by dancers

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The mean age, height, weight for 34 participants was 10.35 ± 1.61 in years, 127.84 ±10.96 in cms , 27.71 ± 5.11 in Kg respectively. The mean BMI value for 34 participants was 16.91 ±1.98 in Kg/m2. Considering age, height, weight and BMI there was clinically significant difference but no statistically significant difference noted between both the groups. [Table 3]
Table 3: Comparison of age, height, weight, BMI in both the group

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There was significant difference in pre and post scores of Beighton scores in both the groups with mean pre score of 5.47 ± 0.51 and mean post score of 3.94 ± 0.34 and p value 0.001. Also COP scores were found to be statistically significant with t value of 13.013 and p value less than 0.001 in both the groups with pre mean score 23.06 ±1.77 and post mean score of 19.79 ± 1.27. [Table 4]
Table 4: Total score of Beighton and COP for both group (pre and post)

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Group A pre and post mean of Beighton score for hypermobility was statistically significant mean value of 5.65 ± 0.49 and 4.00 ± 0.35 respectively. COP pre mean of 24.18 ± 1.59 and post mean of 20.41 ± 1.18 was also significant with p value of < 0.001. [Table 5]
Table 5: Within group comparisons of Beighton score and the COP score

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There was significant difference in between pre and post mean of COP in both the groups with p value of 0.001 and less than 0.003 respectively. There was clinical significant difference but not statistical significant change in post mean scores of Beighton in both the group with p value of 0.32. But pre mean of Beighton for both the groups was statistically significant with p value 0.04. [Table 6]
Table 6: Between group comparisons of Beighton Score and COP score

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The results of the study show that somatosensory training was effective in improving both hypermobility and proprioception in both the group..

  Discussion Top

The current study evaluated the effect of somatosensory training on joint hypermobility and proprioception in young dancers and nondancers. The findings indicate that GJH and proprioception in young dancers and nondancers aged 8–15 years were improved following a 6-week somatosensory intervention.

In the current study, the age group included was 8–15 years with GJH supporting with the fact the tendency of soft-tissue flexibility to be maintained is delayed as age advances. A study done by Steinberg et al. revealed that young dancers aged 8–10 years with joint hypermobility showed a similar joint range of motion compared to dancers without Joint Hypermobility(JHM) in the same age group. However, when the adolescent group aged 10–16 years was studied, they showed increased joint ROM compared to same age group dancers without joint hypermobility, it was clear that in dancers with JHM, the tendency of soft-tissue flexibility to be maintained is delayed as age advances.[13] Another study done by Deshmukh and Ramteke had shown that GJH in India is more prevalent in the age group around 6–12 years.[7]

The current study is showing significant improvement in the hypermobility in both the groups of dancers as well as nondancers with P < 0.001 postintervention where joint control might be attained and reduced instability. A study by Sirajudeen on children with GJH focused on improving balance, muscular strength, kinetic control, and functional stability with exercises such as unilateral stance, mini squats, and single-leg knee bend, and later progressing to wobble board which showed improvement in joint control and joint stability. The study concluded that PT plays an important role in the management of joint hypermobility by reducing instability and improve joint control which is in line with the present study.[14]

In the present study, there was an improvement in the proprioception abilities of both groups. The literature suggests that hypermobility is the main cause for altered proprioception in the young population. Steinberg et al. in their study mentioned that any proprioception training should focus on improving the knee and ankle joint control in weight-bearing positions which mainly will focus on three components of motor control, i.e. spinal reflexes, cognitive ability, and brainstem activation. The protocol used in their study was helpful in improving postural balance and disturbances in proprioception.[12] A study done by Sahin et al. in children with BJHS used proprioceptive exercise to improve their balance and joint position sense, the exercise progressed from exercising with eyes open to eyes closed and from a stable to an unstable surface, this will give additional proprioceptive input allowing for better stability and control.[15] The protocol used in our study shows a similar pattern of progression.

A randomized controlled trial (RCT) was conducted on hypermobility in children considered 6 weeks of generalized and targeted physiotherapy exercises which had been proved to bring effective change in the children.[16] Another study was conducted on children aged between 10 and 18 years who were skaters who were given proprioceptive exercises for 6 weeks and had shown improvement in their ankle stability and balance.[17] The present study the intervention was given for 6 weeks for 4 sessions in a total of 24 sessions and the duration of the intervention was 15 min.

In our study, we also considered Group B nondancers with GJH because as to our best knowledge, there is a dearth of literature which have compared both groups by giving the same somatosensory intervention to evaluate improvement in which group is more faster and better. It was found that both dancers and nondancers had the same effect of the intervention which means it can be used in children with GJH.

The present study results have showed statistical significant improvements in proprioception but when hypermobility was considered between groups changes were not significant. This may be because we had not considered type, reasons behind the hypermobility during the inclusion criteria, and genetic causes can also lead to hypermobility in children which takes a longer time to recover thus in between-group analysis, there was not much significant difference in postintervention hypermobility.

  Conclusion Top

The present study concludes that a 6-week somatosensory intervention is effective in improving hypermobility and proprioception in young dancers and nondancers with GJH.

The future scope can be (1) A RCT can be conducted to give more solid evidence of intervention effectiveness, (2) The intervention's long-term impact on hypermobility and proprioception can be investigated, (3) Joint specific proprioception can be measured using the same protocol, and (4) Impact on performance can be considered.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bläsing B, Calvo-Merino B, Cross ES, Jola C, Honisch J, Stevens CJ. Neurocognitive control in dance perception and performance. Acta Psychol (Amst) 2012;139:300-8.  Back to cited text no. 1
Georgios L, Ioannis G, Olga T, Dimitris C, Maria K. The effect of a traditional dance program on health-related quality of life as perceived by primary school students. J Educ Train Stud 2018;6:96-103.  Back to cited text no. 2
May T, Chan ES, Lindor E, McGinley J, Skouteris H, Austin D, et al. Physical, cognitive, psychological and social effects of dance in children with disabilities: Systematic review and meta-analysis. Disabil Rehabil 2021;43:13-26.  Back to cited text no. 3
Motta-Valencia K. Dance-related injury. Phys Med Rehabil Clin N Am 2006;17:697-723.  Back to cited text no. 4
Coles W, Copeman A, Davies K. Hypermobility in children. Paediatr Child Health 2018;28:50-6.  Back to cited text no. 5
Scheper MC, Engelbert RH, Rameckers EA, Verbunt J, Remvig L, Juul-Kristensen B. Children with generalised joint hypermobility and musculoskeletal complaints: state of the art on diagnostics, clinical characteristics, and treatment. Biomed Res Int 2013;2013:121054.  Back to cited text no. 6
Deshmukh AA, Ramteke P. Prevalence of generalized and selective joint hyper-mobility in school going children of age 6-12 years of central India. Int J Sci & Healthcare Res. 2020; 5(4): 96-104.  Back to cited text no. 7
Ambegaonkar JP, Cortes N, Caswell SV, Ambegaonkar GP, Wyon M. Lower extremity hypermobility, but not core muscle endurance influences balance in female collegiate dancers. Int J Sports Phys Ther 2016;11:220-9.  Back to cited text no. 8
Smits-Engelsman B, Klerks M, Kirby A. Beighton score: A valid measure for generalized hypermobility in children. J pediatr 2011;158:119-23.  Back to cited text no. 9
Blanche EI, Reinoso G, Chang MC, Bodison S. Proprioceptive processing difficulties among children with autism spectrum disorders and developmental disabilities. Am J Occup Ther 2012;66:621-4.  Back to cited text no. 10
Blanche EI, Bodison S, Chang MC, Reinoso G. Development of the comprehensive observations of proprioception (COP): Validity, reliability, and factor analysis. Am J Occup Ther 2012;66:691-8.  Back to cited text no. 11
Steinberg N, Tenenbaum S, Waddington G, Adams R, Zakin G, Zeev A, et al. Isometric exercises and somatosensory training as intervention programmes for patellofemoral pain in young dancers. Eur J Sport Sci 2020;20:845-57.  Back to cited text no. 12
Steinberg N, Hershkovitz I, Zeev A, Rothschild B, Siev-Ner I. Joint hypermobility and joint range of motion in young dancers. J Clin Rheumatol 2016;22:171-8.  Back to cited text no. 13
Sirajudeen MS. Physical therapy management for child with generalized joint hypermobility. Majmaah J Health Sci 2020;8:113-9.  Back to cited text no. 14
Sahin N, Baskent A, Cakmak A, Salli A, Ugurlu H, Berker E. Evaluation of knee proprioception and effects of proprioception exercise in patients with benign joint hypermobility syndrome. Rheumatol Int 2008;28:995-1000.  Back to cited text no. 15
Kemp S, Roberts I, Gamble C, Wilkinson S, Davidson JE, Baildam EM, et al. A randomized comparative trial of generalized versus targeted physiotherapy in the management of childhood hypermobility. Rheumatology (Oxford) 2010;49:315-25.  Back to cited text no. 16
Mudaliar P, Dharmayat S. Influence of strength and proprioception training on functional ankle stability among young skaters. Indian J Health Sci Biomed Res (KLEU) 2017;10:317.  Back to cited text no. 17


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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