Trampoline use in homes and playgrounds

Trampolining was introduced in 1936 by George Nissen, a circus acrobat [1]–[7]. Since the 1950s, the recreational use of trampolines has increased dramatically, particularly in North America, Europe and Australia [1]. In the United States, backyard trampoline sales exceed 500,000 units annually [1]. Injuries resulting from the use of trampolines have been well documented in the medical literature for the past 50 years.[1],[2],[4]–[16] Trampoline injuries continue to increase over time.[1],[15],[17]–[19] One study [1] showed a 98% increase in trampoline injuries between 1990 and 1995. Many of these injuries require hospitalization with or without surgery, and result in permanent morbidity.[1],[2],[4]–[19] The vast majority of injuries are in the paediatric age group.[18]–[22] The present position statement reviews injuries sustained by children as a result of the recreational use of home trampolines, including the incidence, types and circumstances of injuries, as well as the disposition of children following injury. A literature review on trampoline injuries between 1966 and April 2006 was performed using MEDLINE. Canadian injury data were provided by the Public Health Agency of Canada. Recommendations regarding the recreational use of home trampolines by children are included. Injuries resulting from the use of trampolines in school physical education programs as part of training or competition for sport such as diving, gymnastics or trampolining, or the use of trampolines under the direct supervision of a therapist for the rehabilitation of an injury are not discussed. The prevalence of trampoline injuries in the paediatric age group appears to be rising. The main source of data on trampoline injuries in Canada is the Canadian Hospital Injury Reporting and Prevention Program (CHIRPP), a computerized information database that records injuries in patients from 14 emergency departments, including 10 children’s hospitals. The Public Health Agency of Canada has published numerous CHIRPP studies that are related to trampoline injuries. Between 1990 and 1998, there was almost a fourfold increase (from 149 in 1990 to 557 in 1998) in the number of injuries sustained by children from trampolines [18]. There was also a significant increase in the number of injuries between 1999 and 2003, particularly between 2002 and 2003 (Table 1) [19]. This is likely to be an underestimation of trampoline injuries because the database does not capture children with injuries presenting to a doctor’s office or a walk-in clinic, or to a hospital not included in the CHIRPP network. Fatal injuries are also under-represented because the CHIRPP database does not capture information on deaths occurring before reaching hospital or after hospitalization [18]. The CHIRPP data also do not reflect exposure rates and participation rates. Therefore, the increase in injury rates may be explained by an increase in trampoline utilization. Backyard trampoline injuries from the Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) database between 1999 and 2003 for children of all ages Backyard trampoline injuries from the Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) database between 1999 and 2003 for children of all ages The severity of trampoline injuries is also concerning. Using hospital admission rates as a measure of injury severity, trampoline injuries result in greater harm than injuries incurred in other sports or recreational activities. In Canada, despite the fact that trampoline injuries occur less often than other sport- and recreation-related injuries, perhaps reflecting lower participation rates, they result in a relatively greater frequency of hospital admissions (S McFaull, personal communication) (Table 2). The CHIRPP data also confirm that between 1990 and 2001, there was a 56% increase in the number of hospital admissions resulting from trampoline-related injuries.[19] Frequency of some sports and recreation (SPAR) injuries taken from the Canadian Hospital Injury Reporting and Prevention Program database between 1999 and 2003 for children one year of age and older Frequency of some sports and recreation (SPAR) injuries taken from the Canadian Hospital Injury Reporting and Prevention Program database between 1999 and 2003 for children one year of age and older The CHIRPP summary data for 1998 revealed that the majority of trampoline-related injuries occurred in the five- to 14-year age group (78.9%) and most (72.2%) occurred during home recreational use. Fractures were the most common injury (48.6%), often in the upper limb (57.7%), and they accounted for the majority of hospital admissions (86.3%). The overall hospital admission rate was 13.1%, compared with an overall admission rate of 6.8% for the entire CHIRPP database over the same time period. Of admitted patients, 82.2% were in the five- to 14-year age group. The most recent CHIRPP statistics reported on trampoline injuries between 1999 and 2003 (Table 1) [19]. The study included backyard trampolines only – mini, exercise and water trampolines, as well as incidents occurring at gymnastics clubs and schools, were excluded. Youth between 10 and 14 years of age accounted for 43.3% of these injuries, with a median age of 10.1 years. Fractures were most common (47.2%), with 62.5% in the upper extremities. The hospital admission rate was 12.4%, more than double the admission rate (5.9%) for all injuries in the CHIRPP database for the same time period. Approximately one-half of patients (52.4%) were injured on the trampoline mat, and 14.3% were injured when multiple people were on the trampoline mat at the same time[19]. A regional Canadian study [6] found similar results. Black and Amadeo reviewed orthopedic injuries in children resulting from the recreational use of a trampoline in Winnipeg, Manitoba. The majority of these injuries occurred in children between five and nine years of age (49%). Sixty-five per cent of the children were injured on the trampoline mat, while 30% were injured when they fell off the trampoline mat. Thirty-five per cent of children were injured when there were multiple children on the mat at the same time. The most common injury was a fracture or fracture dislocation (75%), with the upper extremities most often involved (forearm 45%, humerus and elbow 35%). There was one fracture dislocation of the cervical spine with paralysis in an eight-year-old boy who fell off the trampoline mat. There were no reported deaths. Ten per cent of cases occurred under adult supervision [6]. A number of studies from other countries have also reviewed trampoline injuries in children [1],[2],[4],[6],[7],[13]–[19],[21],[22]. A review of these papers, including the previously stated Canadian data, is summarized as follows: Ages most at risk: The majority of trampoline injuries occurred in the five- to 14-year age group, with the average age between seven and 10 years [1],[6],[7],[13]–[15],[17]–[19],[22]. This age group also had the most trampoline-related hospital admissions [4],[18]. Most common injuries: The majority of studies [1],[4],[6],[13],[15],[17],[18],[19],[21],[22] found fractures were the most common injury (32% to 75%) and the most frequent reason for hospital admission.[1],[17],[18],[21],[22] Two small retrospective studies [2],[14] found that sprains and strains were the most common trampoline-related injuries. Most common site of injury: The extremities, especially the upper limbs, were injured in 30% to 80% of cases.[1],[4],[6],[7],[13],[17],[18],[19],[21],[22] Two small retrospective studies [2],[14] found that the lower limbs were involved more often. Circumstances: Most trampoline injuries (71% to 99%) occurred at home or at a neighbour’s house.[1],[2],[4],[7],[15],[17],[18],[21],[22] Up to 83% of injuries happened when there was more than one child on the trampoline at the same time.[6],[7],[13],[15],[17],[19] The majority occurred as a result of falling on the trampoline mat (52% to 66%).[6],[7],[13],[15],[17],[19] With the exception of one study (4), which found that 80% of injuries occurred as a result of falling off the trampoline, falls off the trampoline accounted for 30% or less of injuries.[6],[7],[13],[15] Less common circumstances resulting in injury included attempting stunts such as somersaults or flips [7],[15],[19], and imaginative play such as jumping off a ladder onto the trampoline mat.[15] Seasonal injury peaks occurred in the spring and summer months, when backyard trampolines are mostly in use.[1],[6],[7],[13],[15],[18],[19],[21],[22] Disposition of children: Most children were discharged home following evaluation of their injuries in the emergency department.[18],[22] Hospital admission rates ranged from 3% to 17%.[1],[2],[7],[13],[15],[17],[18],[19],[21] One New Zealand study [4] showed an increase in hospital admission rates for trampoline injuries from 3.1 to 9.3 per 100,000 persons per year between 1979 and 1988, with the highest admission rate in the five to nine-year age group (30.3 per 100,000 persons per year). The majority of admissions resulted from fractures [1],[6],[17],[18],[21],[22], with 6% to 17% of children requiring surgery.[7],[13],[15],[17] Serious injury: There have been reports of rare, but serious, injuries resulting in significant morbidity associated with trampolines, including cervical spine injuries,[5],[6],[8]–[10],[15],[16],[19] vertebral artery dissection [23], significant knee ligamentous injuries [9],[24], popliteal artery thrombosis [25] and ulnar nerve injury.[26] Cervical spine injuries are perhaps the most concerning because of the potential for significant long-term morbidity. One study [15] in children found 12% of injuries were spinal injuries, including seven cervical or thoracic fractures and one with C7 paraplegia. Torg and Das [5],[11] and Torg [12] reviewed 114 catastrophic cervical spine injuries resulting in quadriplegia associated with trampolining. The majority of these injuries occurred in highly trained athletes during training sessions, indicating that training with experienced supervision does not prevent these catastrophic injuries.[5],[9],[10]–[12] Trampolining is a high-risk activity with the potential for significant injury, especially in children and youth. Multiple authors and organizations, including the American Academy of Pediatrics (AAP) and Safe Kids Canada, have called for the elimination of trampolines in the home environment as recreational play equipment [1]–[4],[7],[8],[14],[17],[27] or for an outright ban on trampolines under any circumstances for the paediatric age group [5],[9],[10],[11],[12],[15],[16] (Table 3). Others, including Health Canada and the American Academy of Orthopedic Surgeons, have advocated for specific paediatric limitations, including no participation by children younger than six years of age, only one child on the trampoline mat at a time, parental supervision and no flips or tricks while on the trampoline.[6],[7],[13],[21],[22],[28]–[31] Policy regarding trampoline use by children Policy regarding trampoline use by children Regarding the limited use of trampolines in supervised competitive training programs, such as trampolining, diving and gymnastics, the AAP [17] and the Victorian Injury Surveillance System [21],[22] have recommended that the following safety measures be strictly adhered to: the use of safety pads covering the frame and springs of the trampoline, as well as the surface surrounding the trampoline; the presence of competent spotters trained in trampoline safety at all times when the trampoline is in use; only one person on the trampoline at a time at the centre of the mat; avoidance of manoeuvres beyond the athlete’s skill level; and the use of safety harnesses when learning or practicing more advanced skills. Despite these safety recommendations, significant trampoline-related injuries in children continue to occur. For instance, in Australia, despite the existence of clear recommendations for the safe use of trampolines since 1992 [21], there were 1355 trampoline-related injuries in children younger than 15 years of age presenting to emergency departments in Victoria between 1995 and 1999, 16% of whom required hospital admission.[22] Trampoline injuries occur frequently in the paediatric age group. The majority of injuries and hospital admissions occur in the five- to 14-year age group. There has been an alarming increase in the rate of hospital admissions in Canada resulting from trampoline-related injuries, mostly for fractures of the upper extremities. The majority of trampoline injuries occur on backyard trampolines as a result of falls on the trampoline mat, negating the notion that spotters around the outside of the trampoline, parental supervision or even safety enclosures can eliminate injuries. Many injuries occur when there are multiple users on the trampoline at the same time and when there is inadequate supervision. Numerous authors and organizations, such as the AAP, have made recommendations against the use of trampolines by children. Other organizations, such as the American Academy of Orthopedic Surgeons, Health Canada and the Consumer Product Safety Commission have recommended specific restrictions on the use of trampolines in the paediatric age group. Despite these warnings, however, trampoline injury rates continue to rise. The use of trampolines is a high-risk activity with the potential for serious injury. The rapid increase in injuries related to the recreational use of trampolines by children is evidence that current preventive strategies are ineffective to prevent the majority of injuries. Therefore, the Canadian Paediatric Society and the Canadian Academy of Sport and Exercise Medicine recommend that: Trampolines should not be used for recreational purposes at home (including cottages and temporary summer residences) by children or adolescents. Health care professionals, including family physicians and paediatricians, should warn parents of the dangers of trampolines as a recreational toy at routine health care visits. Parents should be advised to avoid the purchase of trampolines for the home because enclosures and adequate supervision are no guarantee against injury. Trampolines should not be regarded as play equipment and should not be part of outdoor playgrounds. Physicians should advocate for legislation to require warnings of trampoline dangers to be put on product labels. More research on trampoline injuries sustained in supervised settings, such as schools, gym clubs and training programs, should be conducted to assess the risk of injury in these settings. The authors thank Steven McFaull, Senior Research Analyst, Injury and Child Maltreatment Section (Health Surveillance and Epidemiology Division, Public Health Agency of Canada), for his invaluable assistance in obtaining Canadian Hospital Injury Reporting and Prevention Program data on trampoline-related injuries. Members: Claire LeBlanc MD (chair); Tracy Bridger MD; Stan Lipnowski MD; Peter Nieman MD; Tom Warshawski MD Liaison: Laura Purcell MD, Canadian Paediatric Society, Paediatric Sport and Exercise Medicine Section Members: Lynne Warda MD (chair); John Philpott MD; Ann Hawkins MD; Richard Stanwick MD; Charmaine Van Schaik MD Liaisons: Laurel Chauvin-Kimoff MD, Canadian Paediatric Society, Emergency Medicine Section; Allyson Hewitt, Safe Kids Canada; Gail Salminen, Health Canada Members of Working Group: Laura Purcell MD (chair); John Philpott MD (vice-chair); Elaine Joughin MD; Claire LeBlanc MD; Bill Mackie MD; Merrilee Zetaruk MD Principal Authors: Laura Purcell MD London, Ontario; John Philpott MD Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.

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