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Fall Injury Interventions
Playgrounds
Background
Playground injuries are a common source of injuries in children.11 Most of the data come from
public or school playgrounds and relatively little data are available on injuries
occurring on home playground equipment. Kotch and colleagues12 examined playground injuries occurring to children under the age of
five at home and in day care. They found that 2% of injuries in this age group occurring
at home and resulting in hospitalization occurred on playground equipment at home
compared to 36% of the injuries at day care. Falls accounted for 85% of the injuries
in this study. Trampolines were a frequent source of injury in their study, accounting
for 1/3 of the injuries. In other studies, slides are the most frequent cause of
injury for younger children and climbers for children over the age of six.13 Many studies have shown that falls off of playground equipment are
the most common injuries children sustain in day care centers.14 Blaxall4, Tinsworth, 2001, found that falls were the most common cause of injury resulting in hospitalization
to children under the age of 15 in the North Health Region of New Zealand. While
few of these injuries are fatal, fractures do occur as do an occasional head injury.11 Head injuries, however, account
for nearly one-third of admissions. These injuries are thus appropriate to prevent
The U.S. Consumer Product Safety Comm ission (CPSC) conducted a study of playground
equipment-related injuries treated in U.S. hospital emergency rooms in 1999. National
Electronic Injury Surveillance system (NEISS) data estimated that 205,850 public
playground and home playground injuries w e re treated. Age-specific incidence rates
are 29.1 injuries per 10,000 for children younger than 5 years, 34.8 per 10,000
for children 5-14 years, and 0.6 per 10,000 for those 15 years and older. Falls
account for the majority of injuries. Fractures were the most commonly reported
injury, with 80% of the fractures involving the wrists, lower arm and elbow. Over
75% of all injuries occurred on public playgrounds, the remainder occurred on home
equipment. However, only 30% of the 147 deaths reported to CP S C in the 10-year
period, 1990-2000, took place on public playgrounds. Deaths resulted from hanging,
primarily from ropes, cords, clothing strings or other items tied to or entangled
in the equipment (56%), falls, equipment collapse, entrapment or impact with moving
components (chiefly swings), Tinsworth, 2001.
Over the past 10 years there has been a substantial increase in trampoline related
injuries due to falls sustained on or off trampolines. Two-thirds of injured children
are between 5-14 years of age, (Committee on Injury
& Poison Prevention, Furnival 1999, Smith 1998). The most serious injuries are head and
cervical spine injuries that account for 9.8% of all trampoline-related injuries,(Committee on Injury & Poison Prevention, Brown
2000). During a 6 year period (1990-1995) an estimated 249,000 trampoline -
related injuries to children (95%CI, 166,300-332,500)18 years of age and younger
were treated in hospital emergency rooms in the U.S. Each year an estimated 1400
children (95%CI, 800-2000) are hospitalized. The largest proportion of these injuries
occur s on home trampolines,(Smith 1998). The American
Academy of Pediatrics has recommended that trampolines should never be used in the
home environment, routine physical education classes, or in outdoor playgrounds.
Use of trampolines should be limited to supervised training programs such as competitive
diving or gymnastics, (Committee on Injury & Poison Prevention).
Programs for prevention have included adding energy absorbing surfacing
materials, decreasing the height of playground equipment, having regular playground
inspections, and supervising children on playgrounds. Laboratory tests indicate
substantial differences in the energy absorbing potential of different surfacing
materials.15,16 The risk of injury is clearly related, by Newtonian mechanics, to
both the height of the equipment off of which a fall occurs, as well as the energy
absorbing potential of the material. Sacks
and colleagues17 found that equipment greater than 6 feet (1.8 meters) in height had
a higher rate of injuries than equipment less than 6 feet in height. Recent
studies indicate a maximum height of 1.5m (5 ft) results in fewer injuries.
This October, 2001 update includes 7 new studies evaluating effectiveness of various
types of playground surfaces and modifications of climbing structures.
Review of playground fall and injury prevention
studies:
Author | La Forest, 2001 |
Study design and target population | Cohort study design.
Children ages 1-14 injured on public playgrounds in Montreal,
Canada and receiving treatment at 2 pediatric emergency departments. |
Intervention | Evaluation of height of play equipment
& absorption level of playground surface. Questionnaire data from injured
children and inspection of playgrounds. |
Outcomes | Occurrence of injury depending on
equi pment height or surface.
Severity of injury (>-AIS 2 vs. mild)
Shock absorbing properties of surfaces measured by determining
surface absorption level (g-max) deceleration. |
Results | Risk of injury 3 times greater (95%CI,
1.5-6.4) for fall onto a surface with g-max of 200g compared to 150g.
Injury risk 2.6 times greater on equipment higher than 2m (6.4ft),
compared to 1.5m or lower.
Falling onto non-recommended type of surface increases risk
of injury 2.3 times. |
Study quality and conclusions | Risk of injury determined by height
of equipment and surface resilience. Recommended types of surface material decrease
risk of injury severity.
Maximum equipment height, 2m (6.4 ft)
Sand is recommended surface. |
Author | Sibert, 2001 |
Study design and target population | Ecological study
Cardiff, Wales, UK
5 playgrounds improved; 14 control playgrounds; 18 month surveillance
before and after changes. |
Intervention | Playground improvements following surveillance program.
Bark surface depth increased to 60cm (24"); horizontal
monkey bars replaced with a rope climbing frame. |
Outcomes | Injury rate per observed child. |
Results | Significant decrease in injury rates in 5 intervention playgrounds
compared to control playgrounds p<0.003.
Playground use unchanged. |
Study quality and conclusions | Good quality study. Adjusted for exposure before and after
intervention. Illustrates benefits of partnership between health services surveillance
and local authorities. |
Author | Macarthur, 2000 |
Study design and target population | Case control study design.
Playground falls resulting in emergency department visits to a pediatric
trauma center in Toronto, Canada 1995-1996.
Cases: severe injuries AIS 2 or greater (n=67)
Controls: minor injuries AIS 0 or 1 (n=59). |
Intervention | No intervention. |
Outcomes | Injury type, location & AIS score.
Information obtained from medical record, mail and telephone
questionnaire and playground inspection. |
Results | Cases had extremity fractures; controls facial lacerations.
73% of cases fell from height >1.5 m (5 ft) vs. 54% of
controls (p=0.03). |
Study quality and conclusions | Height of fall and type of undersurface are important risk
factors for playground injuries.
Falls of greater than 1.5 m were associated with a 2-fold
increased of severe injury compared with falls from 1.5 m (5 ft) or less.
Depth of impact absorbing surface below recommended safety
standards. |
Author | Roseveare, 1999 |
Study design and target population | Randomized controlled trial.
12 intervention (I) school playgrounds.
12 control (C) school playgrounds.
Wellington, New Zealand. |
Intervention | I=Community in tervention including hazard report, engineer's
report, regular contact & assistance obtaining funding.
C=hazard information only. |
Outcomes | Reduction in number of hazards from baseline measures. |
Results | Significant reduction of all hazards in I compared to C schools
19 months after intervention, p<0.03.
52% reduction in height hazards (I) vs 8% reduction in C schools
p<0.02. |
Study quality and conclusions | Use of control group adjusted for secular trend. Provision
of information ineffective. Long term commitment and comprehensive programs
necessary. Must also address financial barriers faced by schools. |
Author | Mowat, 1998 |
Study design and target population | Case control study design.
Cases: children treated in emergency departments (ED) for playground
injuries (n=59).
Controls: 1) children seen in ED for non-playground injuries
(n=61).
2) children seen for any type of non-injury medical care.(n=68)
Kingston, Ontario, Canada. |
Intervention | Playground surface, depth of surface materials, presence of
handrails or guardrails according to Canadian and US safety guidelines.
Surveillance of injuries at 117 public playgrounds. |
Outcomes | Any injury treated in hospital emergency rooms.
Injuries identified from CHIRPP database.
Cases matched by age, sex, day seen in ED. |
Results | Multivariate analysis used.
Increased risk of injury, OR=21.0, 95%CI 3.4, 128) for use of improper
surface compared to proper surface.
Increased risk of injury for falls onto appropriate surface
with insufficient depth (OR=18.2 95%CI 3.3, 99.9).
Increased risk of injury if guardrails inadequate (OR=6.7
95%CI 2.6, 17.5). |
Study quality and conclusions | Guidelines for playground surface materials, surface depth
and use of hand rails reduce injuries.
Compliance with guidelines will reduce injuries. |
Author | Mott, 1997 |
Study design and target population | Case control study design.
Cardiff, UK
N=300 kids ages 0-14. |
Intervention | Risk factors for hazards identified. |
Outcomes | Injuries treated in ED. Injury rates per observed number of
children on different surfaces, types and heights of equipment. |
Results | Concrete surface increases risk of injury compared to rubber
type surfaces. RR=5.l 95%CI (2.1-12.5) Risk of injury or fracture due to falls
from monkey bars was twice that for climbing frames and 7 times that for swings
or slides. |
Study quality and conclusions | Safety standards should be based on epidemiological data. Recommend
removing monkey bars; keeping height of equipment to 2.5m (8 ft) and use of
rubber or bark type surfacing. |
Author | Witheaneachi, 1997 |
Study design and target population | Cross sectional survey.
Random sample of 240 playgrounds selected from 4 metropolitan and
4 rural public health units.
Sydney, Australia. |
Intervention | Safety guidelines. |
Outcomes | Compliance wi th guidelines for 1) fall height (2.5m).
2) type & depth of surfacing, 3) safe fall zone.
Determined by inspection. |
Results | 45.4% of equipment had recommended undersurface. 72% of equipment
proper height, but only 1.8% of equipment met both height and undersurface guidelines. |
Study quality and conclusions | Representative sample of playgrounds surveyed.
Poor compliance with safety guidelines.
None of the 240 playgrounds complied fully with guidelines. |
Author | Chalmers, 1996 |
Study design and target population | Case control study.
Children <15 years in New Zealand.
Cases: children treated for fall injuries from playground
equipment, N=110.
Controls: children who also fell from playground equipment
but did not require medical attention. |
Intervention | Height and surface standards for playgrounds.
Maximum fall height 2.5m (8 ft); impact absorbing surfaces. |
Outcomes | Injuries requiring ED visit. |
Results | Increased risk of fall injury where equipment didn't meet standards.
Falling from greater than 1.5 m (5 ft) compared to lower heights,
OR=4.1 95%CI (2.3-7.6)-Falling on to hard surface compared to impact absorbing
surface. OR=2.3 95%CI (1.0-5.0) Odds ratio adjusted for multiple confounders. |
Study quality and conclusions | Good quality study using logistic regression to examine fall
height and surface type.
Height and surfacing requirements of NZ standard are effective in
preventing injury in falls from playground equipment.
Recommend maximum fall height be reduced to 1.5 m (5 ft),
from current 2.5 m ( 8 ft). |
|
Author | Sacks et al., 1992 |
Study design and target population | Randomized controlled study
Child Care Centers
66 of 71 randomly selected child care centers in intervention
group and 71 randomly selected centers in the control group |
Intervention | Identifying playground hazards, giving
this information to the center director, providing playground safety information |
Outcomes | Mean and median number of hazards
per center and playground |
Results | Median of 7 hazards per playground.
Intervention sites had 1.3 more hazards unrelated to equipment (p=0.18) and
2.2 more equipment related hazards (p=0.16) than control playgrounds.
25% of intervention playgrounds and 32% of control playgrounds
were hazardous OR=0.71, 0.39-1.29 |
Study quality and conclusions | Good quality RCT
Inspections and provision of information did not decrease
playground hazards |
Author | Sosin et al., 1993 |
Study design and target population | Cohort study
Approximately 90% of K-6 grade students in state of Utah |
Intervention | None per se
Examined rates of injuries by type of surface and height of equipment |
Outcomes | Injuries severe enough to cause at
least day of school absence or medical care
Incidence density rates calculated per equipment and surface |
Results | Incidence rate was lowest for equipment
over sand. Relative to sand, rate ratio for injuries were: mats=2.2 (1.38-3.58),
gravel=2.1 (1.36-3.21), grass=1.7 (0.96-3.15), asphalt = 6.2 (3.27-11.87). |
Study quality and conclusions | No multivariate analysis; analysis
assumes equal exposure in each school for all pieces of equipment.
Sand appears to be the surfacing material with the most energy absorbing
potential and the lowest risk of injury. Wood chips were not evaluated. |
Author | Davidson et al., 1994 |
Study design and target population | Interrupted time series study
Children 5 to 16 years of age in Central Harlem compared to
Washington Heights, NY |
Intervention | Multi-faceted community intervention
(starting in 1989) including: repair of all playgrounds, major capital improvements
in 5 playgrounds and parks, painting of building murals, development of recreational
programs for target age group, traffic safety programs and bicycle helmet promotion |
Outcomes | Severe injuries (injuries resulting
in death or hospitalization) during the intervention period (1989-1991) compared
to pre-intervention period (1983-1988) |
Results | Decrease in the risk of all injuries
in the target age group in Central Harlem (RR = 0.74, 0.62-0.89) and in Washington
Heights (RR=0.70, 0.59-0.83).
No decrease in outdoor fall injuries in the target age group
in Harlem (RR=1.35, 95% 0.75-2.42) or in Washington Heights (RR=0.89, 0.49-1.54)
No decrease in all injuries in the younger (non-target) age
group in Central Harlem (RR=1.06, 0.83-1.35) or in Washington Heights (RR=0.96,
0.77-1.19). |
Study quality and conclusions | High quality study using objectively
collected data. Timing of intervention vs. data collection is not clear. No
specific data given for playground falls.
Intervention did not appear to decrease risk of outside falls. |
Summary of playground injury studies:
Falls from playground equipment are responsible for 60-80% of all medically-attended
playground injuries (Macarthur, 2000) Two studies recommended reducing
the maximum fall height of equipment from 2.5 to 1.5 meters (Chalmers
1996; Macarthur, 2000), while a third study
(Laforest 2001) recommended 2.0 meters.. Replacing
monkey bars (jungle gyms) with rope climb ing frames was shown to be a successful
injury reduction strategy in two studies. (Mott, 1997;
Siebert, 2000) The combination of lower fall height
and impact absorbing surfaces will reduce injuries.
Surfacing materials appear to play an important role in the risk
of playground injuries. Laboratory tests indicate a substantial difference in the
energy absorbing potential of surfacing materials. In the dry, non-frozen state,
wood chips have better energy absorbing potential than sand, grass and synthetic
matting.16 When wet, wood chips were better than sand and matting.15 The Sosin study provides real
life data to back up the laboratory studies. These studies are fairly consistent
in that sand and wood chips, to a depth of 9-12 inches (23-31cm), is the best material
for decreasing the costs of injuries. Sand is by far the cheapest surfacing material;
chips cost three times more than sand. The Laforest study reported an innovative
method of obtaining information about the relationship between risk of injury, surface
resilience, and height of equipment as well as between type of material and severity
of injury by measuring playgrounds where children were injured. The Mowat study
indicated that Canadian Standards Association guidelines for appropriate playground
surfaces, adequate surface depth and guard or hand rails substantially reduce fall
injuries.
The most important factor for the prevention of playground injuries, however, is
the use of safe surface materials and the maintenance over time of the surfaces
and equipment. While playground standards have been developed based on research
findings, the existence of standards does not mean that they will be followed, (Consumer
Federation of America 1998, Mott 1997, MMWR
1999,Witheaneachi, 1997). One study cited above found
no effect of an inspection program. A New Zealand study demonstrated that an intensive
multi-faceted community intervention was more effective in reducing playground hazards
than providing hazard information alone. (Roseveare 1999).
The most important factor for the prevention of playground injuries,
however, is the use of these materials and the maintenance over time of the surfaces
and equipment. One study cited above18 found no effect of an inspection
program.
Recommendations on playground injury interventions:
Surfacing materials such as sand or wood chips to a depth of 9-12
inches (23-31cm) can be recommended as effective injury prevention strategies. These
must be regularly maintained. Optimal equipment height is 1.5cm (5ft).
A number of guides are available for community groups, agencies
and parents on playground design:
US Consumer Product Safety Commission. Handbook for Public Playground Safety. Washington,
DC: US Government Printing Office, 1991.( revised 1997)
US Consumer Product Safety Commission. Playground surfacing: technical information
guide. US Government Printing Office, 1990.
- American Society for Testing and Materials (1991). Standard specifications
for impact attenuation of surface systems under and around playground equipment.
ASTM F1292- 91. Philadelphia, PA.
- Morrison ML, Fise ME (1992). Report and model law on public playground
equipment and areas. Consumer Federation of America. 1424 16th Street, NW, Suite
604, Washington, DC 20036 (202) 387-6121.
- US Consumer Product Safety Commission. Handbook for Public Playground
Safety. Washington, DC: US Government Printing Office, 1991
- US Consumer Product Safety Commission. Playground surfacing:
technical information guide. US Government Printing Office, 1990.
- American Society for Testing and Materials (1999). ASTMF 1918
Standard consumer safety performance specification for soft contained play equipment.
West Conshohocken, PA.
Recommendations for future research:
Programs designed to improve community implementation of playground
standards, including regular maintenance, need to be tested. Multi-faceted community
programs have been successful in other areas. Innovative programs that address barriers
(particularly financial barriers) to implementing playground standards need to be
developed and tested.
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