Rev. Bras. Ciênc. Esporte vol.39 número2

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www.rbceonline.org.br

Revista

Brasileira

de

CIÊNCIAS

DO

ESPORTE

ORIGINAL

ARTICLE

Dynamic

evaluation

method

of

lower

limbs

joint

alignment

(MADAAMI)

for

dancers

during

the

plié

Kaanda

Nabilla

Souza

Gontijo

a,∗

,

Cláudia

Tarragô

Candotti

b

,

Grace

dos

Santos

Feijó

c

,

Laís

Paixão

Ribeiro

c

_,

_Jefferson

_Fagundes

_Loss

b

a_Universidade_Federal_do_Rio_Grande_do_Sul_(UFRGS),_Escola_de_Educacc¸ão_Física,_Programa_de_{Pós-graduac¸ão}_em_Ciências_do

MovimentoHumano,PortoAlegre,RS,Brazil

b_Universidade_Federal_do_Rio_Grande_do_Sul_(UFRGS),_Escola_de_Educac¸ão_Física,_Departamento_de_Educac¸ão_Física,_Porto_Alegre,

RS,Brazil

c_Universidade_Federal_do_Rio_Grande_do_Sul_(UFRGS),_Escola_de_Educac¸ão_Física,_Curso_de_Educac¸ão_Física,_Porto_Alegre,_RS,_Brazil

Received13May2013;accepted13January2014

Availableonline5March2016

KEYWORDS Validation; Evaluation; Dance; Physiotherapy

Abstract In classical ballet, thejoint misalignments during the pliécan generate various injuries. To evaluate potential misalignments during the plié the aimof thisstudy was to presentamethodfordynamicevaluationoflowerlimbalignmentarticulation(calledMADAAMI). MADAAMIwasvalidatedby12experts,andfortheevaluationofitsreproducibilityandfor agree-mentwith3Dkinematics,20dancerswereassessedusingavideorecordingoftheirplié.For statisticalanalysisweusedtheKappacoefficient(k)(p<0.05)andpercentageagreement(C). WeconcludethatMADAAMIhadsatisfactoryreproducibilityandintra-rateragreementwith3D kinematics(k>0.40andC>80%), anditisasuitable andvalid methodfor useby thesame examiner.

PALAVRAS-CHAVE Validac¸ão;

Avaliac¸ão; Danc¸a; Fisioterapia

Método de avaliac¸ão dinâmica do alinhamento articular dos membros inferiores (MADAAMI)debailarinosduranteoplié

Resumo Noballetclássico,osdesalinhamentosarticularesduranteopassopliépodemgerar váriaslesões.Paraavaliaressespossíveisdesalinhamentosduranteasuaexecuc¸ão,oobjetivo desteestudofoiapresentarum MétododeAvaliac¸ãoDinâmicadoAlinhamentoArticulardos MembrosInferiores(chamadoMADAAMI).OMADAAMIfoivalidadopor12especialistase,para

∗_{Corresponding}_author.

E-mail:[email protected](K.N.S.Gontijo). http://dx.doi.org/10.1016/j.rbce.2016.02.016

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a avaliação da suareprodutibilidade e da sua concordância com a análise cinemática3D, 20dançarinosforamavaliadosatravésdeumagravaçãodevídeoemqueexecutavamoplié. ParaaanáliseestatísticafoiusadoocoeficienteKappa(k)(p<0,05)eopercentualde concordân-cia(C).ConcluímosqueoMADAAMItevereprodutibilidadeintra-avaliadoreconcordânciacom a análisecinemática 3D satisfatórias (k>0,40 e C>80%)e se caracterizou como um método adequadoeválidoparausoporumúnicoexaminador.

PALABRASCLAVE Validación;

Evaluación; Danza; Fisioterapia

Métododeevaluacióndinámicadelalineamientoarticulardelasextremidades inferiores(MADAAMI)debailarinesduranteelplié

Resumen Enballetclásico,losdesajustesarticularesduranteelpliépuedengenerardiversas lesiones.Paraevaluaresosposiblesdesajustesduranteelplié,elobjetivodeestetrabajofue presentarunmétodoparalaevaluacióndinámicadelaalineacióndelasextremidades infer-iores(conocidocomoMADAAMI).MADAAMIfuevalidadopor12expertosyparalaevaluaciónde sureproducibilidadydesuconcordanciaconlacinemáticaen3Dseevaluóa20bailarines medi-antegrabacionesdevídeoduranteelplié.Paraelanálisisestadísticoseutilizóelcoeficiente dekappa(k)(p<0,05)yelacuerdodeporcentaje(C).SeconcluyóqueMADAAMIcuentacon reproducibilidadintraevaluador,quelaconcordanciaconlacinemáticaen3Dfuesatisfactoria (k>0,40yC>80%),yqueesunmétodoadecuadoyválidoparasuusoporelmismoexaminador. ©2016Col´egioBrasileirodeCiˆenciasdoEsporte.PublicadoporElsevierEditoraLtda.Estees unart´ıculoOpenAccessbajolalicenciaCCBY-NC-ND(http://creativecommons.org/licenses/ by-nc-nd/4.0/).

Introduction

This study was conducted to evaluate changes in move-mentpatterns,whichisarecurrentconcernofprofessionals andresearchersinthefieldofPhysicalEducationandSport (Gomes et al., 2009). In recent years,checking lists (CL) has been introduced as an alternative, practical and sci-entific method,tomeasure change in motor performance overtime(Gomesetal.,2009;Meira,2003).Withtheuseof theselistssportscoachesandphysicaleducationteachers, canforexample,deduceifapatternofmovementina par-ticularsportisevolvingornot,becausetheyallowfor the comparisonofmotorperformanceatdifferenttimes(Gomes etal.,2009).Suchlistsalsoassistinmaintainingorchanging themethodof‘‘teaching---learning---training’’(Colletetal., 2011).

Intheliteraturetherearereferencestotheuseof tra-ditionalCLinsports,suchasjudo(Gomesetal.,2009)and volleyball(Meira,2003;Colletetal.,2011).Nevertheless, indance,morespecifically,inclassicalballet,thereareno studiesthatlinkCLasamethodtoevaluatethetechnical performanceof dancers. Inaddition,therearenostudies thatshowanyvalidatedtoolthatenablesthequantification ofqualityofexecutionofbasicballetmovesduringlessons. Thus,itisspeculatedthatthemethodofCLcanalsobeused intheenvironmentofclassicaldance,helpingdance teach-ersandotherhealthprofessionalssuchasphysiotherapists, cliniciansandfitnesstrainersandotherswhodealdirectly withthisaudience, identifypossible incorrectmovements performed during basic technical movesworked in ballet classes.Furthermore,thismethodologyappliedtothe train-ingofclassicaldance,wouldenablethedetectionoflevels

ofproficiency,theinferenceintheevolutionofaproficiency leveltoanotherandtheprescriptionofthemostappropriate actionforeachlevelofproficiencyofclassicalballet.

Whereas the plié1 _--- _one_of _the _most _important_moves

of the methodology of classical dance, inherent in all dance movements --- from the simplest to the most com-plex (Vaganova, 1945) --- when executed correctly and repeatednumerous times during a class or choreography, canleadtoproblemswiththespine,knees,feetandankles (Gantz,1989),andalsoconsideringthelackofresearchto assisttechnicallytheprocessofteaching---learning---training in classical ballet, this study aimed to: (1) present the dynamic evaluation method of lower limbs joint align-ment (MADAAMI, from Portuguese: Método de Avaliac¸ão DinâmicadoAlinhamentoArticulardosMembrosInferiores) fordancersduringtheplié,(2)performcontentvalidation oftheproposedinstrument,(3)verifyreproducibilityinter andintra-raterand(4)identifythecorrelationbetweenthe resultsofMADAAMI(qualitativemethod)withthoseobtained bykinematic evaluation (quantitative method)during the plié.Hence,theMADAAMIconstitutesasamultidisciplinary instrumentbecause,apartfromusebyteachersand profes-sionalswhofollowtheevolutionofthedancers,itmayalso

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Figure1 ImagefromthevideocamerausedinMADAAMI

illus-tratingadancerperformingthepliéduringdataacquisition.

beusedbyphysiotherapistsandcliniciansasanevaluation tooltomonitortherehabilitationprocessof musculoskele-talinjuries causedbymisalignmentjoint(Hincapié etal., 2008;Barnesetal.,2000;Kadel,2006;Nilssonetal.,2001).

Materials

and

methods

DescriptionofMADAAMI

Thedynamicevaluationmethodoflowerlimbsjoint align-ment(MADAAMI)consistsof afilming(Fig.1)ofthelower limbsduringthepliéand ascoresheet(Appendix1).The filmingwasdone withavideo cameraplaced1.75m from thelineagainsttheheelofeachdancer,andonatripodto 47cmfromthefloor.Thispositionalignedwiththesecond toeoftherightfootatthestartingpositionofthesequence ofmovements(firstpositionofthefeetfromclassicalballet technique).Ametaltape-measurewasplacedonthefloor atthisfinger,aligningitwiththecenterofthetripod,which helpedwiththecentralizationofthecamera(Fig.1).The aimofthescoresheetistoevaluatefourtechnicalcriteria thatguidetheexecution oftheplié(HowseandHancock, 1992;Clippinger, 2007; Fitt, 1996):(1) maintainingpelvic stability,(2)neutralpositionofthepelvisalongthemove, (3)maintenanceof externalrotationof thehipjoints (en dehors),assessedbyalignmentofthekneejointwith ipsi-lateralsecondtoe,and(4)maintainingthesupportofthe longitudinalarchofthefootduringthemove.

Thus,toevaluatethesefourtechnicalcriteria,thescore sheetshowsthescoringpliédidacticallydividedintothree phases(withkneesextended;duringdemiplié2_;_and_during

thegrand plié3_),_which _were _further_subdivided _into_four

stages of motion: static, during the descent; end of the

2_Demi_plié_(‘‘semi _{flexion’’)}_is _a _flexion_of _the_knees _without liftingtheheelsoffthegroundto,approximately,halfofthetotal rangeofkneeflexion(Vaganova,1945;HowseandHancock,1992; Fitt,1996).

3_Grand_plié_(‘‘large_{flexions’’)} _is _a_maximum _flexion_of _knees accompaniedbyheelrisingoffthegroundtoitsmaximumrange offlexioninallpositionsofthefeet,exceptinthesecondposition (Vaganova,1945;HowseandHancock,1992;Fitt,1996).

movement, and duringthe ascent (Fig.2). The execution of the plié used in the assessment protocol consists of MADAAMIdancer performingwas: twodemipliésandtwo grandpliéswiththefeetinfirstandsecondposition.4_For

thisimplementation,only theleftlegis movedtochange a standingclassicalpositionof thefoot, thus keepingthe rightfootfixedtotheground.

TheratingsandtheirscoresinitiallyprovidedbyMAADAMI are ‘‘excellent’’, equivalentto 4 points; ‘‘good’’, equiv-alent to 3 points; ‘‘regular’’, equivalent to 2 points; ‘‘insufficient’’, equivalent to 1 point; pelvis positioning ‘‘retroverted’’or‘‘anteverted’’,equivalentto1pointeach, andlastly,inpositioningthepelvis‘‘neutral’’, correspond-ingto4points.

Contentvalidation

Twelve professionalexperts indanceandkinesiology,who hasexperienceinteachingandlearningclassicalballetfor at least 10 years, were asked toevaluate the content of MADAAMI.Theseevaluatorsreceivedfortheirconsideration, avideo demonstration ofadancer performinga sequence oftheplié,thescoresheetandaglossarysupplement con-tainingtheinstructionsforuseofMADAAMI.Wasaskedthe evaluators to: (1) fill out the MADAAMI score sheet from theirobservationof thevideo,and(2)answera question-naire that consisted of seven questions, each having as objectiveresponseoptions:‘‘verysuitable’’,‘‘suitable’’or ‘‘unsuitable’’. The questions were relatedto the ease of visualization of the stability and alignment of the dancer inthevideo, aswellasontheunderstanding ofthescore sheetandglossarysupplement.Beyondthesequestions,the evaluatorswereabletoaddsuggestionsandpropose modi-ficationstotheinstrumentinadescriptiveway.

Basedontheanswers,suggestionsandmodifications of the12evaluators,changesweremadeinboththeMADAAMI scoresheet,aswellasintheglossarysupplement.To com-pletetheprocessofcontentvalidation,theevaluatorswere askedtoratethenewscoresheetandthenewglossary,from theobservationofthesamevideo.Therefore,the evalua-torshadtocompleteasecondquestionnaire,withresponse options: ‘‘very suitable’’, ‘‘suitable’’ and ‘‘unsuitable’’, aboutthechangesmade.

Interandintra-raterreproducibility

TwentydancersfromthreeballetschoolsinPorto Alegre-RS-Brazil wereselectedintentionally.Inclusioncriteriawere: female,practiceballetregularlywithafrequencyofatleast twice a week during the data acquisition period,have at least 5 years of uninterruptedpractice of classical ballet

4_Both_the_first_and_the_second_positions_of_the_feet_is characte-rizedbythesearchofalignmentofthemedialedgesofbothfeet formingamaximumangleof180◦_between_them_and_with_the_only

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EK

DD1

DD2 AD2 DG2 AG2

AD1 DG1 AG1

D1 G1 EK D2 G2

Figure2 Sequenceofthesteppliédidacticallydividedintothreephases:withkneesextended(EK);duringdemiplié(D1and

D2);andduringthegrandplié(G1andG2);andthefourstagesofmotion:static(bothEK);duringthedescent(DD1,DD2,DG1

andDG2);endofthemovement(D1,G1,D2andG2);andduringtheascent(AD1,AD2,AG1andAG2).

andnot showingany kind of injury duringcollection. The EthicsCommitteeof theFederal University of RioGrande doSul(UFRGS)approvedthisstudy(number46019).

At thisstage, threeresearchers(called Res1,Res2 and Res3), which were physiotherapists and practitioners of classical ballet for over 10 years without interruption, wereinvitedtoanalyzethecollected20videos.Thethree researchersindividually evaluatedthe videos onone day, without any contact between them and their responses were comparedto each other to verifyinter-rater repro-ducibilityofMADAAMI.Sevendayslater,theyreassessedall videosforverification,then theintra-raterreproducibility oftheinstrument,allowedforcomparisonoftheirresponses beforeandafterthisperiod(ThomasandNelson,2002).

ConcordancebetweenMADAAMIand3Dkinematic evaluation

Forthereliabilityanalysis,thesame20dancerswerealso subjectedtoa3Dkinematicevaluation,consistingofa sys-temwithfourdigitalvideocameras(JVCGR-DVL9800)with asamplingfrequencyof50Hz(50framespersecond).Each camerawasconnectedtoamicrocomputer,andconnected toeach other througha wirelessnetwork (Araújo, 2002). Furthermore, these four cameras simultaneously record-ingandsynchronizedwiththecamera,whichwasusedby

MAADAMI(SonyDSCH50),allowingthesubsequent compar-isonoftheresultsofbothevaluationmethods.

Specificanatomicpointsonthebodyofthedancerswere identifiedby22reflectiveballshapedmarkers(15---20mmin diameter),attachedwithdouble-sided tape.The protocol fortheplacementofreflectivemarkers,adapted fromWu etal.(2005),wasconductedbyateamoffourexperienced andtrained evaluators.The anatomical pointsof interest werechoseninordertoevaluateonlytherightlowerlimb (Fig.1),andamongthemtherightfemoraltrochanter,the rightposteriorsuperioriliacspinesandrightanterior supe-rior(PSISand ASIS), the leftanteriorsuperior iliac spine, thepubicsymphysis,therightanteriortibialtuberosity,the rightsfemoralcondyles(medialandlateral),thesecondtoe oftherightfoot,therightnavicularbone,themedialregion ofthe1stmetatarsophalangealjointandcalcaneusboneat right,thehumanrightsmalleolus(medialandlateral)and the lateral region of the 5th metatarsophalangeal joint and calcaneusbone at right. Two technical markers (one for the thigh and one for the tibia) were used in order toensurethekinematictrackingpointsduringmovement, movedbeneaththeskin,suchasthefemoralcondyles.

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developedusingMATLAB®_,_which_provide_stability_values_of

themiddle footstability andpelvic positioningand align-ment of the ipsilateralknee andfoot in accordance with thefollowing technicalcriteriaguide the implementation oftheplié:

Criterion 1 --- ‘‘Midfoot stability’’:we analyzed the vari-ationoftheheightofthemarkerpositionedontheright navicularbone totheground. Tosortthestabilizationof themidfootusedthefollowingparameters:(1)‘‘optimal stabilization’’---decreaseinheightofthenavicularbone, apartofmovingtoanother,lessthan0.7cm,(2)‘‘stable’’ --- down0.7---1.3cm,and(3)‘‘unstable’’---fallmorethan 1.3cm(Sabinoetal.,2012).

Criteria2and3--- ‘‘Positioningandpelvicstability’’:from theline drawnbyjoiningPSISandASIS,weanalyzedthe angle andangularvariationofthislinetothehorizontal. To sortthepositioningofthepelvis(criterion2)weused the following parameters:(1) ‘‘neutral’’ --- pelvicangles between 12◦

and 15◦

, (2) ‘‘retroversion’’ --- pelvic ang-lesbelow12◦_,₍₃₎_{‘‘anteversion’’}_---_pelvic_angles_greater

than 15◦

.To ensurepelvicstability (criterion3)we used thefollowingparameters:(1)‘‘pelvicinstable’’---angular variationexceeding3◦_from_one_part_of_the_movement_to

the nextpart, and(2) ‘‘pelvisstable’’ --- variationangle ofat most3◦ _from_one_part_of _the_movement_to_another

(Achcar,1998;Vaganova,1945;HowseandHancock,1992; Clippinger, 2007; Fitt, 1996; Kapandji, 2000; Tribastone, 2001).

Criterion 4 --- ‘‘Alignment between knee and ipsilateral foot’’:(i)wedrewa straightlineconnectingthemarker placedonthesecondtoeoftherightfootwiththecenter point equidistantfromthemarkersplacedonthemedial andlateralregionsoftherightcalcaneus(representingthe straightlineofreferenceinthisfoot);(ii)wascalculated bythecenterpointofthekneebyobtainingthelocation ofthemarkersplacedequidistantfromthemedialand lat-eralfemoralcondyles(representingthekneecenter);and (iii)wasperformedtheprojectionofthekneecenteronthe groundsothat,fromthisprojection,throughoutthe execu-tionofthemovewecalculatedthedistancebetweenthis point andtheprojectedreferencestraight leg(assuming thatwhenthedistanceisequaltozero,wehaveaperfect alignmentbetweenboth).Tosortthealignmentbetween knee and foot ipsilateral we considered the following parameters:(1) knee‘‘aligned’’--- metricvariationfrom

−1to1cmdistancebetweentheprojectionofthecenter ofthekneeonthegroundandthereferencelineofthe ipsi-lateralfoot;(2)‘‘medialmisalignment’’---metricvariation lessthan−1cm;and(3)‘‘lateralmisalignment’’---metric variationexceeding 1cm (Achcar, 1998; Vaganova,1945; HowseandHancock,1992;Clippinger,2007;Fitt,1996). The results derived from quantitative analysis (3D kine-matic) were compared with the results obtained in the qualitative analysis (MADAAMI) from a single researcher drawn between the three participating ones in the previousstep.

Statisticaltreatment

Data were analyzed using software SPSS 18.0, adopt-ing the statistical significance level of p<0.05. For the

content analysis, objective responses (‘‘very suitable’’, ‘‘suitable’’and ‘‘unsuitable’’) fromthe 12 invited evalu-ators were coded and subjected todescriptive statistics, through the frequency table. To evaluate the MADAAMI inter and intra-rater reproducibility and to evaluate the concordanceofMADAAMIwithkinematicevaluationratings MADAAMI score sheet (‘‘excellent’’, ‘‘good’’, ‘‘regular’’ or ‘‘insufficient’’) were grouped into only two distinct groups: (1) ‘‘correct’’, correspondingtothe classification ‘‘excellent’’, and (2) ‘‘incorrect’’, corresponding to the threeotherclassifications.Similarly,thefourcriteriausedin quantitativeanalysisweregroupedintotwodistinctgroups: (1)‘‘correct’’,correspondingonlytothebestclassification, and (2) ‘‘incorrect’’, corresponding to the other classifi-cations. Thus, toevaluate the reliability of the MADAAMI with3D kinematic evaluation, weused thepercentage of agreement(C)andtheextentofCohen’sKappa(k).Kappa valueswereclassified as‘‘weak’’(k≤0.2), ‘‘reasonable’’ (k 0.21---0.4),‘‘moderate’’ (k0.41---0.6), ‘‘substantial’’ (k 0.61---0.8)and‘‘almostperfect’’(k≥0.81)(SimandWright, 2005).InthepresentstudyallKappavaluesgreaterthan0.4 wereclassifiedas‘‘satisfactory’’.

The final MADAAMI followed the classification criteria adaptedfromGrantandDavis(1997),Rubioetal.(2003)and

Noll(2012):(1)‘‘Accepted’’Criteria,ifallvaluesofKappa for inter and intra-rater reproducibility and the correla-tionbetweenMADAAMIratingsand3Dkinematicevaluation aregreaterthan0.4,andallpercentagesofagreementare greaterthan80%,(2)‘‘AcceptedwithExceptions’’Criteria (underthesameconditionsdescribed,itcanonlybeused bythesameexaminer),and(3)‘‘Rejected’’Criteriaforthe other valuesthatdonotfit inthetwoprevious classifica-tions.

Results

Thecontentvalidation,performedby12evaluators,initially presentedresultsthatindicatedtheneedofimprovements intheinstrument(Fig.3---1stquestionnaire),which,after implementation, presented all the responses classified as ‘‘very suitable’’ (Fig. 3 --- 2nd questionnaire). Given the favorable outcome of the applicability and relevance of theevaluativecomponents,theMADAAMIsubmittedcontent validity.

Twenty dancers with age of 26.6±8.3 years, 18.2±

7.7 yearswhopracticeballet withaweekly frequency of 3.7±1.7 classes were evaluated to reproducibility tests. In general, the intra-rater reproducibility results showed that thehigherinter-rater for both thevaluesof C andk (Tables 1---3).Ofall theMADAAMIcriteria, onlythe‘‘knee aligned’’ in the first and second position of feet in all stagesofmotionandthe‘‘midfootstable’’onlyinthefirst positionoffeetinmove‘‘staticphasewithkneesextended’’ beforethe demiplié, wererated as‘‘Accepted’’,can be usedindependentlyoftheassessor.AllotherMADAAMI cri-teria, including the previous two were ‘‘Accepted with Exceptions’’ after checkingof the greats and satisfactory resultsofintra-raterreproducibility,demonstratingthatthe instrumentisvalidtobeusedbythesameevaluator.

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0 2 4 6 8 10 12 14

Pelvic preview

Pelvic score on the spread sheet

Knee alignment

preview Knee alignment score on the spread sheet

Navicular preview

Navicular score on spread sheet

MADAAMI glossary suplement

Score of 3 joints on spread sheet

MADAAMI glossary suplement

Nu

mb

e

r of

exper

ts

Suitable Very suitable Unsuitable

1stquestionnaire 2nd questionnaire

Figure3 Frequencyoftheanswerfromthe12evaluators,referringtoboththe1stasthe2ndquestionnaireforvalidationof

contentMAADAMI.Caption: 1stquestionnaire:containsseven questionsabouttheeasyvisualizationoftechnical criteriainthe

videoandabouttheunderstandingofthescoresheetandtheMADAAMIglossary.2ndQuestionnaire:containstwofinalquestions

thatassesswhetherthemodificationssuggestedbyevaluatorsforthescoresheetandglossaryareappropriate.

ratedas‘‘AcceptedInstrumentwithExceptions’’to evalu-atethestabilization ofthemidfootduringallstepsofthe plié(Table4).

Theresultsconcerningthevalidationofagreementof cri-terion2(‘‘Pelvicpositioning’’)demonstratethatMADAAMI wasclassifiedas‘‘RejectedInstrument’’toreviewthis tech-nical criterion, called the score sheet as‘‘Description of pelvisposition’’in allpartsofthemove,both beforeand afterthe‘‘descent’’and‘‘ascent’’andintheendofdemi pliésandgrandplies(Table5).

Regardingthevalidationofagreementofthecriterion3 (‘‘Pelvicstability’’),theresultsshowthattheMADAAMIwas ratedas‘‘AcceptedInstrumentwithExceptions’’to evalu-atedynamicallypelvicstabilityatallphasesinwhichthere is movement the lowerlimbs, or in steps ‘‘descent’’and ‘‘ascent’’oftheplié(Table6).

Theresultsconcerningthevalidationofagreementofthe criterion4(‘‘Alignmentbetweenkneeandfootipsilateral’’) presentedinTable7,showthatMADAAMIwasclassifiedas ‘‘Acceptinstrument’’toassessthisalignmentinallphases

Table 1 Values ofKappa coefficient (k) andconcordance (C)for intra-rater reproducibility (average ofresults from the threeresearchers:Res1×Res1;Res2×Res2; Res3×Res3),andinter-raterreproducibility(averageoftheresultsofeachtwo researchers:Res1×Res2;Res1×Res3;Res2×Res3)oftheevaluativeMADAAMIcriteriaregardingalignmentandpelvicstability.

Variables Intra-raterreproducibility Inter-raterreproducibility

Evaluationcriteria Phasesofthemove MovementStep Average(k) Average(C) Average(k) Average(C)

1stfeetposition

Alignedpelvis Withkneesextended Static 0.75 88% 0.29 63% Stablepelvis

Duringdemiplié

Descent 0.57 82% 0.23 60%

Alignedpelvis Endofthemove 0.65 86% 0.45 73%

Stablepelvis Ascent 0.66 85% 0.11 53%

Duringgrandplié

Descent 0.61 83% 0.27 63%

Alignedpelvis Withkneesextended Static 0.79 90% 0.36 67%

2ndfeetposition

Duringdemiplié

Descent 0.63 85% 0.33 65%

Duringgrandplié

Descent 0.96 98% 0.04 57%

Alignedpelvis Withkneesextended Static 0.75 88% 0.27 63%

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Table2 Values of Kappa coefficient (k)and concordance (C) for intra-rater reproducibility (average of results from the threeresearchers:Res1×Res1;Res2×Res2;Res3×Res3),andinter-raterreproducibility(averageoftheresultsofeachtwo researchers:Res1×Res2;Res1×Res3;Res2×Res3)oftheevaluativeMADAAMIcriteriaregardingalignmentbetweenkneeand foottomidfootstability.

Kneealignedwith foot(1stfeet position)

Withkneesextended Static 1.00 100% 1.00 100%

Duringdemiplié

Descent 1.00 100% 1.00 100%

Endofthemove 1.00 100% 0.48 90%

Ascent 1.00 100% 1.00 100%

Duringgrandplié

Descent 1.00 100% 0.82 97%

Endofthemove 0.80 95% 0.49 81%

Ascent 1.00 100% 1.00 100%

Kneealignedwith foot(2ndfeet position)

Duringdemiplié

Descent 1.00 100% 0.58 93%

Ascent 1.00 100% 0.76 97%

Duringgrandplié

Descent 1.00 100% 0.58 93%

Ascent 1.00 100% 0.58 93%

Stablemidfoot (1stfeetposition)

Duringdemiplié

Descent 0.59 85% 0.21 57%

Ascent 0.49 83% 0.21 60%

Duringgrandplié

Descent 0.78 90% 0.30 63%

Ascent 0.47 80% 0.33 63%

Stablemidfoot (2ndfeetposition)

Duringdemiplié

Descent 0.68 90% 0.10 55%

Ascent 0.61 87% 0.27 67%

Duringgrandplié

Descent 0.86 95% 0.17 57%

Ascent 0.90 97% 0.24 60%

AllKappavaluesweresignificant(p<0.05).

ofthe plié, exceptthe staticsteps of themove in which thekneeswereextendedandnowtakingintoaccountthe resultsobtained satisfactoryreproducibility for bothintra andinter-rater.

Given these results, the score sheet initially proposed (Appendix1)tovalidatetheMAADAMIneededtobe refor-mulated in order to display only the variables that had concordancebetweenthetwomethodsofassessmentand verificationofsatisfactoryresultsintherereproducibilityof theirtechnicalcriteria.Thus,inFig.4,wepresentthefinal versionoftheMAADAMIscoresheetindicatedtobeusedby thesameexaminerintheclinical,artisticorscientificway.

Discussion

The aimofthisstudywastopresent theresultsofallthe validationprocessesassociatedwiththedynamicevaluation methodoflowerlimbsjointalignment(MADAAMI)ofdancers duringtheexecutionoftheplié.Weshowedthatthe instru-ment is valid toevaluate all technicalcriteriathat guide thesuccessfulexecutionoftheplié,exceptforcriterion3, ‘‘Pelvicpositioning’’.

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Table 3 Values ofKappa coefficient (k) andconcordance (C)for intra-rater reproducibility (average ofresults from the threeresearchers:Res1×Res1;Res2×Res2; Res3×Res3),andinter-raterreproducibility(averageoftheresultsofeachtwo researchers:Res1×Res2;Res1×Res3;Res2×Res3)oftheevaluativeMADAAMIcriteriaregarding‘‘DescriptionofPelvisPosition’’.

Descriptionof pelvisposition (1stfeetposition)

Duringdemiplié

Descent 0.67 87% 0.34 68%

Ascent 0.70 88% 0.25 65%

Duringgrandplié

Descent 0.67 88% 0.32 68%

Ascent 0.67 88% 0.31 68%

Descriptionof pelvisposition (2ndfeetposition)

Duringdemiplié

Descent 0.84 93% 0.25 63%

Ascent 0.62 87% 0.24 67%

Duringgrandplié

Descent 0.96 98% 0.33 70%

Ascent 0.96 98% 0.43 73%

AllKappavaluesweresignificant(p<0.05).

importanceofthepliéinclassicaldance(Vaganova,1945; Gantz, 1989; Howse and Hancock, 1992), it is clearly a necessary tool that would also serve as the basis for the development of other studies that can expand on alternativesassessmentforthismove.Accordingtothe lit-erature,the plié,ifrepeatedincorrectly countless times, can result in several injuries of the lower limbs (Gantz, 1989; Bordier, 1975; Guimarães and Simas, 2001), and

thisjustifies the aim of this study, which wasto develop a tool capable of evaluating the plié methodologically. The MADAAMI is characterized as an instrument that can directly assist both dance teachers, in the development oftheirteaching---learning---traininginballetclassrooms,as well as other professionals involved in the well-being of dancers,includingphysiotherapists,physicaleducatorsand physicians. We understand the MADAAMI as an important

Table4 Resultsregardingtothe validationagreement ofthecriterion 1(‘‘Midfootstability’’)showing thepercentage of agreement(C),thevaluesoftheKappacoefficient(k)anditssignificancelevel(p)forallstepsoftheplié(n=20).

Evaluationcriteria Phasesofthemove Movementstep Validationofagreement

k p C

Midfootstability (1stfeetposition)

Withkneesextended Static 0.64 0.002 95%

Duringdemiplié

Descent 0.45 0.015 90%

Endofthemove 0.14 0.209 65%

Ascent 0.31 0.144 85%

Midfootstability (2ndfeetposition)

Duringdemiplié

Descent 0.64 0.002 95%

Ascent 0.64 0.002 95%

Duringgrandplié

Descent 0.44 0.047 90%

Ascent 0.46 0.002 90%

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Table5 Resultsregardingtothevalidationagreementofthecriterion2(‘‘Pelvicpositioning’’),showingthepercentageof agreement(C),thevaluesoftheKappacoefficient(k)anditssignificancelevel(p)forallstepsoftheplié(n=18).

k p C

Descriptionof pelvisposition (1stfeetposition)

Duringdemiplié Endofthemove 0.50 0.019 78%

Duringgrandplié Endofthemove 0.30 0.060 72%

Descriptionof pelvisposition (2ndfeetposition)

Duringdemiplié Endofthemove 0.04 0.822 61%

Duringgrandplié Endofthemove 0.15 0.436 67%

Table6 Resultsregarding tothe validation agreement ofthe criterion3 (‘‘Pelvic stability’’),showing the percentageof agreement(C),thevaluesoftheKappacoefficient(k)anditssignificancelevel(p)forallstepsoftheplié(n=18).

k p C

Pelvicstability (1stfeetposition)

Duringdemiplié Descent_Ascent 0.60_0.60 0.005_0.009 89%_83%

Duringgrandplié Descent 0.60 0.005 89%

Ascent 0.72 0.001 89%

Pelvicstability (2ndfeetposition)

Duringdemiplié Descent_Ascent 0.87_0.82 0.001_0.001 94%_94%

Duringgrandplié Descent_Ascent 1.00_1.00 0.001_0.001 100%_100%

interdisciplinaryinstrument,abletobeusedinboth rehabil-itationandpreventionofinjuriesassociatedwithincorrect performanceof plié(Hincapié etal.,2008; Barnesetal., 2000; Kadel, 2006; Nilsson et al., 2001). Therefore, the

MADAAMI canbe usedby severalhealth professionals and danceteacherswhichareinterestedinanalyzingthemotion of plié and its negative effect on the body when poorly executed.

Table7 Resultsregardingtothevalidationagreementofthecriterion4(‘‘Alignmentbetweenkneeandfootipsilateral’’), showingthepercentageofagreement(C),thevaluesoftheKappacoefficient(k)anditssignificancelevel(p)forallstepsof theplié(n=13).

k p C

Kneealignedwithfoot (1stfeetposition)

Duringdemiplié

Descent 0.62 0.010 92%

Ascent 0.62 0.010 92%

Duringgrandplié

Descent 1.00 0.001 100%

Ascent 1.00 0.001 100%

Kneealignedwithfoot (2ndfeetposition)

Duringdemiplié

Descent 0.62 0.010 92%

Ascent 0.62 0.010 92%

Duringgrandplié

Descent 1.00 0.001 100%

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Steps Criteria Evaluation

1st_Position

(evaluate the right foot)

With knees extended Static Midfoot stability E ( ) G ( ) R ( ) I ( )

During demi plié

Descent

Pelvic stability E ( ) G ( ) R ( ) I ( ) Knee aligned with foot E ( ) G ( ) R ( ) I ( ) Midfoot stability E ( ) G ( ) R ( ) I ( )

End of the move Knee aligned with foot E ( ) G ( ) R ( ) I ( ) Midfoot stability E ( ) G ( ) R ( ) I ( )

Ascent

During grand plié

Descent Pelvic stability E ( ) G ( ) R ( ) I ( )

Knee aligned with foot E ( ) G ( ) R ( ) I ( ) End of the move Knee aligned with foot E ( ) G ( ) R ( ) I ( )

Ascent Pelvic stability E ( ) G ( ) R ( ) I ( )

Knee aligned with foot E ( ) G ( ) R ( ) I ( )

2nd_Position

(evaluate the right foot)

During demi plié

Descent

Ascent

WithKnees extended Static Midfoot stability E ( ) G ( ) R ( ) I ( )

During grand plié

Descent

Ascent

Position of

the foot Phases of plié

Figure4 MADAAMIscoresheetinitsfinalversionaftervalidationproceduresofagreementandevaluationofintraandinter-rater reproducibility.Caption:E,excellent;G,good;R,regular;I,insufficient.

Itshouldbenotedthatinthepresentstudy,itwas occa-sionallynotpossibletocompareMADAAMIand3Dkinematic evaluation, with regardsto the assessment of criterion 1 (‘‘Midfootstability’’)instepsof‘‘descent’’,‘‘ascent’’and ‘‘endof themove’’ motionphase‘‘Duringgrand plié’’in thefirstpositionofthefeet(Table3).Weknowthat, tech-nically,duringthesestepsofthepliéthereislossofcontact between the heels and the ground (Vaganova, 1945). So, giventhefactthattherewerenoreferencesinthe litera-turetonumericaltechniquesthatrepresentsan instability ofthemidfootwhenitisnotincontactwiththeground,it wasnotpossibleforustodefinethekinematicparameters thatwouldbeabletoverifythis.

Furthermore,it isimportanttohighlight thatMADAAMI havebeenclassifiedasa‘‘RejectedInstrument’’toassess thecriterion‘‘PelvicPositioning’’staticatallphases,both beforeandafterthe‘‘descent’’and‘‘ascent’’attheend

ofdemipliésandgrandpliés(Table5).Itisspeculatedthat thenon-complianceofthedataobtainedbybothmethods underliesthedifficultiesthatthehumaneyehasto evalu-atethepositioningofthepelvisaccurately,withrespectto theclassificationofthispositionangles.Thisisbecausethe pelvicangle variationisverylow,only3◦ ₍_Kapandji,_2000; Tribastone,2001) which without the aid of specific tech-nology,preventsthehumaneye,eveniftrained,tocheck theangles correspondingtothe pelvisratings ‘‘neutral’’, ‘‘retroversion’’ or ‘‘anteversion’’. Thus, based on prede-finedcriteriainthisstudy,MADAAMIissuitableforevaluating alignmentofthepelvicpositioningonlyinthedynamicsteps ofthe plié. Therefore,it is suitable for evaluatingpelvic stabilityonly.

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stepsinwhich theknees wereextended (Table7).This is likelyduetoalimitationinthemethodologyofthisstudy: positionsthatallowreferenceinmathematicalroutinesto identifyinternalandorexternalrotationofthefemur rela-tivetotheexternalrotationofthetibia,werenotcollected. Incontrast,thehumaneyewasabletoidentifytheposition ofthepatellainrelationtothesecondtoeipsilateralwhen thekneesremainedextended.

It is believed that assessment of the four techni-cal criteria that guide the successful execution of plié in classical ballet (Vaganova, 1945; Howse and Hancock, 1992; Clippinger, 2007; Fitt, 1996) enables dance teach-ers to track and assess whether their students are followingthesecriteriaorperformingcompensatory move-ments predictive of musculoskeletal injuries during the teaching---learning---training process. Whereas the imple-mentation of these compensatory movements such as misalignmentbetweenthekneesandthefeet,holding insuf-ficient external rotation of hip (en dehors) accompanied bycompensatorytibialexternaltorsion,footpronationand eversion to reach 180◦ _maximum _en _dehors_, _appears _in

parallel withan increase in injuries in joints and regions that comprise the lower limbs (Wohlfahrt and Bullock, 1982; Gantz, 1989; Bordier, 1975; Kushner et al., 1990; Hincapié et al., 2008; Barnes et al., 2000; Kadel, 2006; Nilsson et al., 2001). This highlights the importance of a simple method, easy to use, valid, reproducible and abletoassessmethodicallyandspecificallyeachandevery stepofthe move advocated bythe techniqueof classical ballet.

Golomer andFéry (2001) claimthatinjuries caused by thepractice of classical balletare relatedto the techni-cal guidance given during the teaching---learning---training process,whichmustrely,indispensably,tofixthe compensa-tionsdescribedabove.Theauthorsstatedfurtherthatthe practiceof this type of dance, even ifbased on physical andbiomechanicalscientificallycorrectfoundations,ifnot welltargetedandexecuted,canbecomeacauseof inconve-niencetothegoodimplementation,performanceandeven thehealthofpractitioners.Itisofgreatimportanceto mon-itor,evaluateandtocontinuallyreassessthewayinwhich thepliéisimplemented,regardlessofthetechnicallevelof thedancers,becausethebestwaytopreventchangesand injuriesistomaintain‘‘puretechnique’’withthenecessary intelligencethatallowsittoadapttoanatomicaland physi-ologicalpeculiaritiesofeachdancer(notthereverse)(Pozo Municio,1993).

WethereforeconcludethattheMADAAMI,which consti-tutesa checklist to the dance area,is a new assessment tool that allows for the identification and monitoring of individualizedtechnicalexecution of the plié, being suit-ablefor usebythe sameexaminer. Someof thepractical applications of MADAAMI include its use in the detec-tion of levels of proficiency of classical ballet by dance teachers, and as an evaluation instrument for diagnos-tic of joint misalignments and monitor the rehabilitation process of musculoskeletal injuries by healthcare pro-fessionals. Thus, we believe that the MADAAMI is an interdisciplinarytoolwitheasyanddirectlanguage,which besides being used in teaching---learning---training process can also be used in primary care and rehabilitation of dancers.

Funding

ThisstudywasfundedbyCAPES(graduatestudentstipend mode).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Appendix

A. Supplementary

data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.rbce. 2016.02.016.

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