For example, we might define an exposure ... meaning that injuries are twice as likely to occur on .... Ontario, Canada complied with national standards (Pickett et.
Playground surfacing and playground injuries Jennifer A. Himmelsbach, MS and Martyn R. Shorten, PhD BioMechanica, LLC, Portland, Oregon, USA
Reference:
Himmelsbach, J.A. and Shorten M.R. (2003) Playground surfacing and playground injuries Pp 71-88 in Sports Surfaces (Eds. B.M. Nigg, G.K. Cole, D.J. Stefanyshyn) Calgary, University of Calgary
Playground surfacing and playground injuries Jennifer A. Himmelsbach MS and Martyn R. Shorten PhD BioMechanica LLC, Portland, Oregon, USA.
Introduction The challenges offered by active, exploratory play are important contributors to a child’s physical, mental and social development. Adventurous play also carries risks. In the USA, playground related deaths occur more than once per month on average. Each day, hundreds of children require emergency room treatment or hospitalization for playground-related activities. Since many deaths and severe injuries are the result of falls from playground equipment to the underlying surface, the shock attenuation performance of playground surfacing is expected to have a significant effect on injury risk. Materials that are typically used in playground surfacing include organic loose fills, (e.g. wood chips, bark dust, engineered wood fiber) inorganic loose fills (e.g. gravel, sand, crushed marble) and manufactured products (poured in place rubber/urethane compounds, rubber tiles, etc.). In the USA, awareness of the importance of shock attenuating surfacing in playgrounds is increasing, especially since minimum shock attenuation performance requirements were recently included in the regulations associated with the Americans with Disabilities Act. This paper reviews recent injury statistics and research related to playground injuries and the role that appropriately designed surfacing can play in the prevention of severe injuries and death due to falls.
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Playground Injury and Death Statistics Measurements and Statistics Some care is required when interpreting injury and death statistics, especially when comparing the results of different studies. Different definitions of “injury” and different statistical reporting techniques may make direct comparisons misleading. In order to distinguish between different measures of injury risk, some definitions are useful. • Exposure:
A baseline for measuring risk, including an accounting of the population exposed to injury. For example, we might define an exposure as one child visiting one playground. A measure of exposure is required to determine the both injury risk and relative risk.
• Injury Rate:
The number of injuries occurring over a period of time, without reference to exposures.
• Injury Risk:
Injury rates relative to an exposure baseline. For example, “One injury per 1000 exposures”
• Relative Risk: A ratio comparing two injury risks. For example, if the injury risk is 0.6 per thousand exposures on the average playground and 1.2 per thousand exposures on playground A then playground A has a relative risk of 2; meaning that injuries are twice as likely to occur on playground A. Measurements of risk and relative risk provide the most useful and comprehensive documentation of injury data. However, most playground injury statistics do not have exposure baselines, because of the difficulty and expense of collecting
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exposure information. The criteria used to define an injury must also be considered when interpreting injury statistics. For example, the US Consumer Product Safety Commission’s nationwide surveys of playground equipment-related injuries use emergency room visits as the criterion for recording an injury. Minor injuries treated in Doctor’s offices and those not requiring medical attention are therefore not included in these statistics. Playground Deaths The US Consumer Product Safety Commission (CPSC) recorded 147 playground equipment-related deaths reported between January 1990 and August 2000 (Tinsworth and McDonald 2001). The CPSC’s data included fall-related deaths from only a few states for most years of the survey. Therefore, the fatalities reported can be expected to underestimate the true number. While the exposure baseline of the CPSC’s data is not known, the data are valuable nonetheless, since they show the relative frequencies of different kinds of fatal events and can be used to identify sources of risk, if not their relative importance. Of the reported deaths, 90 (61%) are known to have occurred on playground equipment installed in homes rather than in public playgrounds. The majority of victims were less than ten years old. Younger children were more frequently victims in home settings; older children were more likely to be killed in accidents at public facilities. The primary cause of playground equipment-related deaths is hanging due entrapment or entanglement with materials tied to the equipment or around the child’s neck. Falls accounted for 21% of the recorded deaths, most of which (3/4ths) involved catastrophic head injury. Since new playground equipment is specifically designed to minimize the risk of entrapment and entanglement, the proportion of hanging deaths is expected to decrease over time and fall-related deaths can be expected to
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increase proportionately. Playground Injury Rates The CPSC tracks consumer product-related injuries in the National Electronic Injury Surveillance System (NEISS) database which is based on a sample of 100 hospital emergency rooms located around the USA.. The most recent CPSC report of playground equipment-related injuries and deaths looks at injuries during 1999 (Tinsworth and McDonald 2001). As before, the data do not have an exposure baseline and consequently cannot be used to determine absolute injury risk or relative risk. Nevertheless, the database contains some valuable information about potential sources of risk and the relative frequencies of different kinds of injurious events. During 1999, an estimated 205,850 playground equipment related injuries were treated at hospital emergency rooms, equivalent to one emergency room visit every 1.3 minutes during daylight hours or 7.5 injuries per 10,000 children in the US. Children aged 5-14 were at greatest risk. While fatal events were most likely to occur on home playground equipment, 75% of injuries occurred in public facilities and only 24% on equipment intended for home use. Accident and Injury Types About 10% of all accidental injuries to children occur during sport or recreation (Danseco et al 2000;Kersting-Durrwachter and Mielck 2001). Estimates of the proportion of total injuries accounted for by playground accidents varies. (Boyce et al )(1984) found that playground injuries account for only about 4% of the total but these injuries were 1.6 times more likely to be rated “severe” than those caused by other activities. (Bijur et al 1995) found that playgrounds accounted for 13% of the total injuries in children aged 5-9, while 9.6% of injuries to kindergarden children in Southern Germany were from playground falls (Kersting-Durrwachter and Mielck 2001). Studies that restrict their scope to the school environment have found that playground injuries accounted for 61% - 74% of all
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school injuries (Junkins, Jr. et al 1999; Lenaway et al 1992; Alkon et al 1999). Recent surveys of playground injury types (Table 1) show that arm and leg fractures are the most common major injury. While head injuries are less common, accounting for 10% of injuries overall, their potential consequences are far more severe. Table 1: Summary of recent surveys of playground injuries, classified by injury type Source
Injury Type
First Author
Year
n
Head Injury
Limb Fracture
Cut, bruise
Macarthur
1999
126
Mayr
1995
338
Lillis
1997
Waltzman
1999
Pickett Chalmers
Sprain, Strain
4.8%
47.6%
43.6%
3.0%
5.5%
40.8%
37.0%
13.0%
3.7%
289
3.0%
28.0%
43.0%
7.0%
10.0%
204
5.0%
61.0%
18.0%
8.0%
6.0%
1996
120
2.7%
20.0%
65.0%
3.3%
11.7%
1996
246
3.7%
26.4%
44.3%
7.7%
18.0%
Mack
1997
1868
12.4%
20.5%
Laforest
2000
930
12.0%
55.0%
Bermado
2001
234
42.0%
----- 53.2% ----19.0%
11.0%
Other
13.9% 4.0%
33.0%
Table 2: Summary of recent surveys of playground injuries, classified by accident type Source First Year Author Mayr Mott Mowat Pickett Bermado
1995 1997 1998 1996 2001
n
Fall
103 330 45 120 234
72.4% 65.0% 80.0% 76.7% 73.0%
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Accident Type Collision Jump
13.9% 21.0% 13.3% 11.7%
5%
Other
8.7% 14.0% 7.7% 11.6%
Playground Hazards The CPSC’s study (Tinsworth and McDonald 2001) reported that 79% of injuries on public playground equipment and 81% of the injuries on home equipment were related to falls. Most injuries (68%) occurred during falls to the surface beneath the equipment, but some (10%) were the result of falling on to other parts of the play structure. A survey of other recently published studies also shows that a majority of injuries (70% on average) are due to falls (Table 2). Equipment height correlates significantly with severity of injury from falls. Climbing apparatus, slides and swings are associated with more frequent and more severe injuries than other play equipment. Younger children (
