Kristen Schuyten, the performing arts rehabilitation program coordinator at Michigan Medicine’s MedSport, is a physical therapy clinical specialist with board certification in sports.  Kristen is also a certified strength and conditioning specialist and performs staff training in the screening, evaluation, and treatment of musculoskeletal injuries for University of Michigan performing arts patients. She also coordinates and performs on-site triaging, backstage treatment services, and has established a referral network for U-M’s School of Music, Theatre, and Dance (SMTD) students. For the past decade, she has also coordinated the injury-risk screening for SMTD including analysis of individual screenings and customized exercise prescriptions.

We sat down to speak with her about her career, her concussion work within SMTD, and her return-to-performance protocols.

Michigan Concussion Center: Can you provide us with a summary of your career path?

Kristen Schuyten: I got my undergraduate degree from U-M before simultaneously completing my master’s and doctorate in physical therapy at Central Michigan University. I worked in the Grand Rapids area for a year before working with performing arts students at U-M MedSport. My background as a dance student during my undergraduate and graduate studies gave me a familiarity with this patient population. I understood their injuries and how to treat them effectively. I felt this was an obvious area of need in the world of physical therapy because the healthcare providers I saw for my injuries had a general sports background but didn’t understand how to help me progress through my dance-specific injuries. I am now treating these performing arts patients and continuously working to make myself more knowledgeable on dance injuries because research continues to be limited.

Dancers tend to have better balance, eye movement, and vestibular functions, so they are a unique population to assess and treat. Throughout my career, I have noticed that dance students and faculty share the same concerns as I did regarding their unique movement patterns, goals, and injury patterns. We were able to form a partnership with SMTD and develop screenings to decrease musculoskeletal injury risk. There were also concerns from a neurological perspective because of the challenge to accurately progress dancers when they presented at NeuroSport with a concussion.  There was no established baseline assessment to refer to prior to their head injury, and in working with our neurologists, athletic trainers, and PTs, we have formulated a comprehensive neurological baseline and return to dance protocol for them.

Additionally, I grew concerned about the lack of mandatory concussion education, training, and baseline assessment (unless they are involved with high school athletic associations or at the NCAA level). My work is novel at Michigan in trying to address this area of concern.

MCC: Is there a difference between a physical therapy clinical specialist and a regular physical therapist?

KS: Yes. A clinical specialist is a job position you apply and interview for with your colleagues and administration.  A clinical specialist is responsible for staff education, training, and helping with any clinical competencies, especially post-op patients. A clinical specialist also acts as a bridge, through communication and programming, between staff clinicians and administration, working to help with clinic flow and providing experience to guide newer clinicians and assist them as needed.  Over the past year, I’ve participated in multiple staff-wide presentations developed by our course committee, spoke at the Women in Sports Medicine and Rehabilitation Symposium, and helped assist various staff with professional development.

MCC: When people hear the term “concussion,” their first thought often goes to contact sports. However, you work with concussed performing arts students regularly. How did you get interested in this area of concussion and what should people know about this population?

KS: When patients would see me for physical therapy, they shared their concerns that their previous providers didn’t know how to handle their care. Additionally, I could only find case studies dealing with dance-specific concussion issues. As a result, we started concussion baseline testing five years ago, and it was at least six or seven years before that we started doing musculoskeletal baselines.

A majority of dance is partner or group work. Concussions can happen during improvisational dance where the dancers don’t necessarily know the patterns or choreography. For theater and drama students, concussions mainly occur during training where they miss their cue on a punch or sword fight and get hit. There is also a concern with the crew working backstage and all of the rigging, staging, and lights that could serve as equipment involved in concussion.

Sometimes concussions happen when they’re outside of practicing for class or a performance, whether it’s a slip and fall or car accident. I’ve had some patients get a concussion after getting up too quickly and hitting their heads on a dorm bunk. The after-effects are going to dictate what they can do for performance because of the amount of auditory, visual, and cognitive processing they do. There is no way they can escape it. A performer’s movement is deeply embedded in their class activities; their return-to-performance must be integrated. For example, an instrumentalist isn’t going to have as much cardiovascular exertional demand as if they were running sprints, but they have so much sensory processing information affected by a concussion because they are reading sheet music while playing an instrument.

MCC: What role do you play in concussion care and treatment?

KS: While I generally do more on the education side, I also look at the baseline assessments and get that information to the neurologists and doctors at NeuroSport so they can be prepared if the dancers present in our clinic.

I assist in creating a performing artist’s return-to-performance protocol by incorporating the available published research out there. Through collaboration with our multi-disciplinary team and in coordination with the SMTD Wellness Initiative, we have developed protocols, education, and provide information for the medical provider down to the student. 

MCC: How are the return-to-performance protocols you developed the same and different from those for athletes in traditional sports?

KS: Musical theater has components of dance embedded within it (along with the speech work and vocal needs). When you look at musical theater and dance specifically, the performer undergoes a lot of body rotation. The performer could be rotating in a transverse plane where they’re turning their head around and around with their body staying erect, or end-over-end if tumbling. The manner of rotational work is very different compared to most other sports. When spinning, there is the need for the head to whip around as fast as possible for the body to continue spinning and stay upright. This will challenge a performer’s vestibulo-ocular reflex, their spatial awareness, their proprioception, and their balance because they tend to balance on the ball of their foot or a ballerina on the few square inches of her pointe shoe box.

When we look at how the return-to-learn is embedded within their return-to-performance, this is the double-edged sword. When you see concussed athletes, there’s a separation of what they can do academically versus what they can do on the field. An athlete can work on increasing heart rates and exertion levels while not having any screen time or facing limited time in the classroom. Meanwhile, a performer has all those variables intertwined, which makes it more challenging for the student, faculty member, administration, and health care providers.

Let’s use a ballet dancer as an example. When I work on a return-to-performance protocol for a ballet dancer, the language I’m using is more universally accepted in the dance world and the progression can be less variable. First, dancers watch a class to see if they can handle the motions. If they can, we move onto the basic skill elements because we are trying to limit anything that could potentially increase any type of brain activity. There are stepwise progressions after that. Ballet dancers go from performing stationary movements to activities that cause their body elevation to change. They can fully participate in the ballet barre once they show no symptoms from that activity. Performers then move onto center work, where there is not the ability to hold onto something for balance. This also increases auditory and visual stimulation because they will be watching people dance around them.

If they can handle light center work without having any symptoms (e.g., headaches, nausea, or vomiting), they can move onto further solo activities before progressing to partner work. Bigger rotational activities get added in, starting with head movement and inversion activities. Finally, they might go through performance marking and motions before they are allowed to fully participate in live performances.

MCC: You will be presenting “Setting the Standard: Education, Baseline Assessment and Return after Concussion in Dancer” at the International Association of Dance Medicine and Science Symposium in October. Can you tell us a bit about what you are hoping the audience will learn from your talk?

KS: This current topic will focus on implementing our concussion baseline testing for performing arts students and how we are addressing the gap in knowledge and education at U-M.

For instance, I teach the UM dance department’s anatomy and physiology course. I usually spend a week mid-semester lecturing on concussions. Initially, there was a request by the administration to teach the topic at the beginning of the semester.  The first year I taught the course one of my students sustained a concussion and she immediately knew what to do. She knew what was happening in her brain and I was able to work that much closer with her for her return-to-learn because I was her instructor as well.

Even though it was an unfortunate situation, it is a good example of how much-needed that education is. In my course, the students get a basic anatomy lesson while understanding why we do the baseline assessments, what the concussion signs and symptoms are, and know what to do after someone sustains a concussion. However, this is only the dance department students and is not consistent throughout all departments in SMTD.

The presentation that I am giving in October will showcase the work we have done and continue to do at Michigan on an international stage, while also allowing for building connections with other clinicians and dance educators. 

 MCC: Talk about the collaborations you have with the Concussion Center and what excites you about being a member of the center.

KS: I’ve been thrilled to have been provided opportunities (and resources) for faculty to get involved more in concussion care and research at Michigan. I was able to help connect a couple of my former patients to the center to serve as part of their Concussion Champions program. Second, I was also able to give my opinion and advice on the return-to-learn policy that PhD student Allyssa Memmini is working towards.  Allyssa and I are working together on the development of faculty education through the implementation of surveys to the SMTD faculty and staff and look forward to working together to develop more widespread educational programming and return to learn and return to performance protocols in the future. 

The center has also helped me quite a bit. The staff and faculty expertise can further some of the performing arts initiatives and address some of the areas of need within the performing arts community at U-M, but nationally and internationally as well.  I am thankful for these connections and this center as I know the work done here will greatly help the University’s performing arts population, but also the performing arts community as a whole.