The show must go on

From career-altering injuries to debilitating psychological problems, UCL is tackling the dire need for specialist medical care for performing artists.

By Sasha Arms | UCL Communications

A performer at Gifford’s Circus © Steven Kaack

Emily Prior-Willeard is a bioveterinary scientist, a circus performer — and a Master’s student of Performing Arts Medicine at UCL.

While helping with the horses at Giffords Circus — a traditional English circus from the Cotswolds — Prior-Willeard was able to put her joint hypermobility to new uses. Although she already knew her joints could move beyond the usual range of motion, her exposure to circus life subsequently allowed her to experiment with aerial hoop, contortion, silks, corde lisse and static trapeze. “I’m a dislocator,” she says. “One of the acts I do is to go through a tennis racket. You’re bending to such extreme limits: flexibility comes down to your muscles, your ligaments, your tendons, the way you’re built, hip and shoulder socket depth.”

Emily Prior-Willeard

Prior-Willeard’s life and passion is now the circus, and she can be found in the Giffords Circus UK tour every summer. Yet it’s an under-recognised side of the life of a performer that has led her to UCL. “As performers, a lot of our identity and our self-value is external; we often find it hard to internally validate our success. So we are always pushing to be better and more amazing, to the point that we are doing such risk-taking acts to draw in the crowds. It’s down to us as performers to provide that entertainment, but with these risks obviously come injuries.”

The entertainment-seeking crowds rarely consider the injuries of performing artists. Yet it casts a constant shadow over the lifestyles, livelihoods and identities of performers. Prior-Willeard says: “We don’t get injured, we can’t get injured, and we don’t want our employers to know that we are injured.” But of course, performers do get injured, and regularly. She goes on to say: “I’ve had four concussions and broken my nose twice in the last two years, incurred from performing and training. You keep going regardless.”

Kata Kiss performing with her ankle in a cast.

A colleague of Prior-Willeard’s, aerialist and hula hoop performer Kata Kiss, sustained a serious injury to her ankle mid-season while on tour. Despite being in a plaster cast and in significant pain, she continued performing two shows a day for the rest of the season with a modified act.

Performing arts medicine

Emily Prior-Willeard’s experiences in the circus uncover an under-recognised side to performing that rarely makes it into the limelight. “There has been a specific requirement for a number of years to look after performers’ particular needs,” says Dr Hara Touli, UCL’s Performing Arts Medicine MSc leader. “We’re talking about injuries, diseases that affect their careers, and psychological and mental health issues that affect these kinds of professionals, who are quite a unique group of patients.”

Performing arts medicine is thus an emerging specialism in the medical field, to provide defined care for performers, including musicians, instrumentalists, singers and dancers. However, the health issues that can arise for different types of performers are vast.

Upper string musicians may be at risk of over-use syndromes, for example, while guitarists may suffer spinal deformities, and the distinctive muscle activity of pianists can cause injuries throughout their hands. Performers are also susceptible to less visible health issues, such as eating disorders and performance anxiety.

The support gap

One of the key issues performers face is that medical provision specifically for performing artists is scarce. Typically, it’s only the large organisations such as The Royal Ballet and Cirque du Soleil who employ teams of specialist medics, physiotherapists, rehabilitation specialists and occupational psychologists.

Specialist organisations such as British Association for Performing Arts Medicine (BAPAM) are starting to emerge, but the artists at smaller performance companies, part time performers and street performers don’t have anywhere near the same access to specialist levels of treatment as those who work for the largest companies.

Performing arts is a booming sector. In 2014–15, London & Partners and the Society of London Theatres (SOLT) estimated that 14.7 million people watched theatre performances in London alone, with gross revenues of £624 million. There are close to 20,000 performances a year in the 42 West End theatres that make up the membership of SOLT. But just a fraction of performers have access to specialist medical attention.

Performers and the relatively few performing arts medics out there believe part of the reason for the support mismatch for performers stems from a wider debate about whether performers are artists or athletes, often concluding that they are both.

Performers at Giffords Circus © Andrew Rees

“When you are looking at a violinist playing a virtuosic piece, they are having to work their fingers so quickly and so intensely that I think it involves athletic skill and training,” says Emily Prior-Willeard. “Circus artists create an emotion in their audience, but at the same time they are performing enormously physical feats with Olympian strength and incredible balance. They are such a unique breed of athlete in that they are both an athlete and a performer.”

Bridging the gap at UCL

The Performing Arts Medicine MSc is unique to UCL, as it’s the first and only postgraduate degree in the discipline in the world.

Given the course’s unique positioning, it’s attracting a huge range of people from across the globe, including GPs, physiotherapists, chiropractors and osteopaths, as well as musicians and other performers themselves.

“This Master’s teaches us everything from the muscular and skeletal injuries that you commonly see in performers, all the way through to the vocal user, the training and music and dance conservatoires, the common problems seen at them and the areas that we need to progress, develop and be aware of,” says Prior-Willeard.

The MSc is also starting to attract more psychologists, particularly following the introduction of a postgraduate certificate, which offers the same breadth as the MSc, minus the clinical modules.

Emily Prior-Willeard

In turn, these UCL students take their expertise away with them, back to their countries and workplaces. They expand their own practices, become doctors for orchestras or dance companies, and work for organisations that run clinics for performing artists only, such as BAPAM.

Ultimately, they disseminate their knowledge about performing arts medicine care, which is crucial for the growing recognition of the specialism.

“Performing arts medicine is an emerging medical discipline,” says course leader Dr Hara Trouli. “When our students enrol in the first weeks of term, we find that they always have the same issues in explaining their degree to the rest of the student body. Even when I talk about it in medical circles, people are confused.”

Why isn’t general medical provision enough?

Despite the emergence of UCL’s Performing Arts Medicine MSc and specialist organisations such as BAPAM, there is still a lot of confusion in medical and sports science fields about the necessity for performing arts medicine.

Dr Trouli explains: “You often hear from performers that they’ve had an injury, visited a doctor or physiotherapist, and although these professionals have had the best of intentions, they’ve lacked the knowledge.”

She goes on to say: “Approaching a performer is never one-sided; you never interview a performer as if they’ve just fallen or they have a headache. You have to look at the wider picture of the individual.”

Emily Prior-Willeard

A common response performers hear when visiting non-specialist medics is to rest for a certain number of weeks, or to stop performing completely. “We tend to hide our injuries and push through them, until it gets to a point that they are so bad that we have to do something about them,” Emily Prior-Willeard says.

“Then, a health professional tells us to stop doing what we’re doing. As performing artists, if we were to do that, we would lose our identity. People who have trained for a huge proportion of their lives cannot be told to do desk jobs instead. It leads to psychological problems and depression. It exposes incredibly artistic, creative minds to dark places. We need to protect our performers, we need to keep them going, and we don’t want them to be scared of admitting to injury.”

Psychological problems can be part and parcel of the lives of performers, but again is an aspect that is under-represented in the medical field. A survey of actors by BAPAM and EQUITY in 2014–15 found that 57% of the performers questioned were experiencing ‘general worry’, and 39% said that a mental health issue had had some impact on their career at some point.

“Performing is a field where opportunities can be hard to come by, it can be badly rewarded and it’s a place where talent alone does not lead to success,” says Dr Carol Chapman, Counselling Psychologist and honorary lecturer in Performing Arts Medicine for UCL. “Coping with periods of intense work and complete lack of work can be difficult to manage for actors, and dancers may often have to work their way back to full fitness following injuries and strains.”

Emily Prior-Willeard

In addition, working anti-social hours and long stretches of time spent travelling can be disruptive for family life and relationships, leading to distress and ill health. Dance musician Moby recently told The Guardian (Drugs, sleeplessness, isolation: the downside of being a dance musician) that he’s never been on tour without experiencing anxiety, depression and insomnia.

Dr Chapman estimates 60% of the performers she comes across in her own work suffer from anxiety problems, describing them as being “psychologically distressed.”

“A lot of injuries — physical or mental — can be career stopping, so prevention is key,” says Dr Hara Trouli. The BAPAM study found that 77% of respondents said the best aid to helping with psychological issues would be to have direct access to skilled clinicians and therapists.

Sport and performing arts on a level playing field

UCL’s Performing Arts Medicine MSc is being run through the Institute of Sport & Exercise Health (ISEH), of which UCL is one of five high-profile partners. This marks an important step towards performing arts medicine being classified on a level playing field with sports medicine.

The ISEH is all about combining clinical expertise with education, achieved via the partnership model between UCL, UCLH hospitals, the British Olympic Association (BOA), the English Institute of Sport and HCA Hospitals.

Injured athletes can visit the ISEH to see specialist medics in their field. One of the specialists based at the ISEH is Dr Kalpesh Parmar, the club doctor for Leicester Tigers Rugby, also a specialist in medical issues originating from other sports such as cage fighting.

“When it comes to top athletes, the quicker they can be seen, the quicker the problem can be dealt with,” says Matt James, Development Director at the ISEH. The long-term vision is that the ISEH will have a network of centres across the UK, and that performing arts medicine will become increasingly integrated.

As well as practical medical provision, the ISEH is important in terms of research, where UCL particularly adds value. “Increasing the performance of athletes, even by the tiniest of margins, makes the difference between having a medal and not having a medal at Olympic level or at the Commonwealth Games,” said Matt James.

There is a constant flow of research coming out of the centre across sport and performing arts medicine, from preventing injury in breakdancers, to the impact of low oxygen environments, with the help of the on-site hypoxic chambers.

And finally, the ISEH ensures the expertise originating from the centre has a positive knock-on effect on non-athletes. This involves community projects aimed at improving population health, such as the building of exercise facilities in Camden, collaborative work with the Youth Sports Trust, and regular 5k and 10k runs in Regent’s Park.

Giving performing artists back their lives

It’s the collaboration and multi-faceted approach originating from the ISEH that has the potential to put performing arts medicine firmly on the map of the medical landscape.

Gifford’s Circus

“I really believe I’m going to be able to make a difference with the help of all the people at UCL and the related institutions,” says Emily Prior-Willeard. “It’s amazing, because hopefully we are going to help a very frustrated, scared population to not be frustrated and scared anymore.”

Modifying the approach to medical issues faced by performing artists, rather than telling them to stop performing, is also crucial.

“One of the messages this Master’s is putting across is that you can still perform, but you may just need to modify,” says Prior-Willeard. “We’re starting to see things like custom chin rests on violins, or flutes becoming less asymmetrical so they’re better for the body. It’s about challenging ideas and giving performers back their lives in exchange for our entertainment.”

Performers at Giffords Circus © Gem Hall

More awareness is clearly needed among medical practitioners on the issues facing performers and why they require specialist help. This doesn’t just mean physically; mental health is a key factor too. And when specialist provision for performing artists does become more readily available, continuity of care must be considered for performers who have unique timetables and work schedules.

“When you’re on the road, you can’t just pop into a local doctor,” says Prior-Willeard. “And if you do, they’ll typically see you and then say: ‘Ok, I’ll see you again in six weeks!’ That’s just not practical for performers.”

“It would be an amazing thought that, no matter where you go on tour, there’s a performance arts-based medical team who will see you whether you’re a circus performer, a musician, or a singer,” says Prior-Willeard.

“It would be life-changing to know there’s someone who will be there to support you every step of the way, who could communicate with a network of medics to provide national and international support. We need more awareness, but I feel positive that with the help of institutions such as UCL, that’s exactly where we’re heading.”


Sasha Arms is Digital Engagement Manager for UCL Communications.

The Institute of Sport Exercise & Health takes NHS and private referrals.

Find out more about the UCL MSc in Performing Arts Medicine.

Find out more about Gifford’s Circus on their website.