Literature Review

Annotated Circus Injury Bibliography July 2020 for the Performing Arts SIG of the Academy of Orthopedic Physical Therapy

Circus Medicine Bibliography (updated April 2020)

Below you can find summaries of the medical literature and how it applies to your training.

Acute Injury Care: RICE is no longer the standard
Aerobic Conditioning
NSAIDS / Circus Candy
Warm Ups

Please contact Emily if you have topics you’d like to see reviewed or updated.


Dynamic stretching should occur prior to activity after a cardiovascular warm up to specifically warm up joint motion, increase blood flow, improve range of motion, and possibly muscular performance. Static stretching is tool to increase flexibility and should be performed following strength or dynamic activities, ie circus training. Static stretching has been shown to reduce optimal muscular firing for at least 10 minutes afterwards and possibly longer with prolonged (>5 min) stretching. With the high demands of circus arts both in mid and end ranges of motion, I can not recommend static stretching prior to training. Overall, stretching does not appear to be protective against injury as many previously thought.

Stretching References

Acute Injury Care (Not RICE)

When an ankle is sprained or a knee banged up we all recall our first aid training and the acronym R.I.C.E. The RICE protocol developed in 1978 by Dr. Mirkin. Since then, he (among many others) have spoken out against it. Specifically, rest is a much smaller component of the consensus on treatment. Inflammation, lymph fluid, is how we get nutrients to injured tissues. The key is managing the swelling so that fresh nutrients are being pumped into the system as the used fluids are returned to the system.

Relative rest is the new term. We want to use the injured tissue as much as is tolerated without increasing pain and symptoms. This improves blood flow and the circulation of lymph fluid (swelling). Both blood flow and lymph fluids are GOOD! They bring nutrients to the damaged tissues so that they are able to heal and as they cycle they move away the damage and waste products of the reactions. MOVEMENT is key.

Even in the acute short term, movement is shown to shorten healing time.Get the injured area moving with gently range of motion exercises as tolerated to improve early ligament healing. Also, do some general aerobic exercise, not involving the injured tissue, to keep these fluids moving and improve lymph and blood flow. For example, you can go for a walk or a run with a sprained wrist.

Ice should be used in limited amounts for pain management. Duration of application time is about 10 minutes.

Acute Injury References

Aerobic Conditioning

​Aerobic conditioning is an important component of fitness. Circus performers train individual skills and need endurance to put them all together into an act. Though there is no current literature on circus performers, dancers have a similar pattern of intermittent training and the lack of aerobic conditioning is evident. If anyone is looking to do some research…. this is a great place to investigate.

Aerobic References

NSAIDS / “Circus Candy”

NSAIDs/Ibuprofen should be used selectively as they increase the risks of heart attack and strokes even in healthy populations. NSAIDs should be used in the lowest dose and for the shortest duration of time. Taking NSAIDs for long periods of time should only be considered in consultation with a physician. Avoid NSAIDS for common muscle soreness. (note: follow your physician’s instructions. This is information for your education only)

NSAIDS References

Warm Ups

Warm Up References