Spit It Out! How saliva may provide the key to sports-related concussion

concussionSRxA’s Word on Health has reported several times on the problems of concussion among football players and cheerleaders. So we couldn’t help but sit up and take notice of an article in our local newspaper about some cutting edge research taking place yards from our front door.

The third floor of Bull Run Hall on George Mason University’s Prince William campus plays host to plenty of mind-bending science projects – laser capture microdissection, protein electronics and high-resolution mass spectrometry to name but a few.

Yet the most complex and potentially influential findings to emerge from the school’s College of Science might come down to a kid spitting in a cup after football practice.

Once a week athletic trainers collect saliva samples from the 12- and 13-year-old kids playing for the Jets, an A-League football team in the Central Loudoun Youth Football League. Then they send them to Dr. Shane Caswell, a George Mason professor and pioneer of the world’s first salivary biobank designed for concussion research in athletes.

Caswell stores the saliva in a freezer he dubs the “spit repository.” He eventually extracts the samples and runs them through sophisticated machinery to determine changes in protein variance. By comparing each kid’s spit samples to previous submissions, he hopes to uncover a handful of proteins that can detect concussions.

George Mason scientistsWorking alongside Caswell is Dr. Chip Petricoin. Long accustomed to studying protein biomarkers for cancer research, Petricoin never imagined he’d wind up plying his trade for studies on traumatic brain injury and concussions.  But the seed was planted six years ago, when he was called up to Fort Detrick to conduct a site review for a company that had been given a grant from the army to do concussion research. Petricoin admired their efforts, but he realized that his own work with cancer biomarkers could reap significant benefits for the concussion research that remained in its nascent stages.

A year later he found himself working in the same building as Caswell, whose extensive background in athletic training was getting him increasingly involved with concussion research. The two discussed their respective endeavors and quickly realized they could join forces.

The university’s College of Science and College of Education and Human Development began funding their efforts last year. Since then, Caswell and Petricoin have begun to explore the vast quantities of information stored in athletes’ salivary biomarkers.

Think about the biomarker content of a sample like an iceberg,” said Petricoin, co-director of the university’s Center for Applied Proteomics and Molecular Medicine. “The concept of what you see is only the tip of the iceberg? That’s kind of like biomarker research. Things that have been seen before are just the tip of what really is there. If we could go all the way down and see everything, you’d see a whole new iceberg. So we’re kind of going a mile deep now in the iceberg biomarker research.”

athlete spittingIndeed, the depth of these largely uncharted waters became apparent when the duo began their work with the Jets this fall using eight saliva samples. A few weeks after collecting those baseline samples, they used the nanotechnology at their disposal to examine new samples from four of the same kids who had recently suffered concussions. After compiling a list of proteins, they found that 60% of their list featured proteins that had never been described.

The process generates an information archive that’s larger than anyone’s ever seen before in saliva,” Petricoin said.

Caswell and Petricoin are currently working on 37 concussion cases, a total that increases every week with new samples arriving from different sources. They’re collaborating with Prince William County Public Schools, as well as intercollegiate athletics at Marymount University and George Mason.

The Jets’ head coach, Rob Scola, says his team has so far adapted nicely to the study. George Mason sends a certified athletic trainer to the field to provide care and to collect data on hits the players endure. The trainer tapes every game and practice, something that allows coaches to see what they’re doing right and wrong in their efforts to teach proper heads-up tackling techniques. Players also wear helmets with sensors that detect the force and location of impacts sustained in practices and games.

It’s all part of an effort to determine what measures coaches should take to minimize players’ risk of head trauma on the football field, where the rate of brain injuries is higher than in any other youth sport.

It’s very hard to get information from a very small team in a very small league and then extrapolate that,” Scola said. “I think that as Mason starts to expand the study, I think there will be some really interesting pieces of information that come from that, which I believe can be helpful to the league and football as a whole. I think it’s a phenomenal first step.”

Part of the project’s appeal lies in its lack of hassle. Biomarker work has traditionally come from blood and spinal fluid samples, which are rooted in far more invasive processes than simply spitting in a cup.

If I were to go out on the field and say, ‘Hold on a second. I want to take your child’s blood or their cerebral spinal fluid.’ That’s game over. We can’t move forward,” Caswell said. “This is a non-invasive tool that is rapidly deployable. There’s no threat of infection, it’s easily done and it provides a great deal of information.”

Caswell and Petricoin’s work with the Jets has opened the door to broader studies that extend to the entire lifespan of an athlete’s career. The hope is that parents will have their children give samples when they begin participating in youth football, ice hockey, soccer, or whatever sport they choose to play. They can then follow that up by giving more samples as they pursue the sport in high school, college and beyond.

“You are then able to track at various time points throughout someone’s career and identify how their marker is changing and then maybe one day compare it to a database that could help inform decisions about whether or not that individual should retire from play, whether that individual is suffering any adverse consequences from their participation,” Caswell said.

blue mouthgardEven more ambitious is their ultimate goal of implementing the biomarkers into a clinical diagnostic device. Petricoin envisions a mouthguard that turns from clear to blue when a concussion is detected. The technology, he says, is there – impregnating the nanoparticles into the mouth guard, binding the biomarkers and producing a color shift are concepts that have already been engineered.

The hard part is nailing down the biomarkers. For the moment, all Caswell and Petricoin are trying to do is identify what’s in the saliva. As the data mounts, they hope to reveal protein distribution patterns that coincide with repeated head trauma.

Caswell, a former hockey player who once returned to the ice minutes after suffering a concussion only to realize minutes later that he wasn’t carrying his stick, believes those patterns will come and that his team is well-positioned to make meaningful discoveries that could impact concussion policies on a greater scale.

If and when they do, we’ll be sure to let you know.

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Is Your Student Safe?

teacher-running-with-aedThe beginning of another school year means the beginning of school sports including football, soccer, cross country and swimming. All too often, school sports result in injuries to athletes and, in some cases, incidents of sudden cardiac arrest (SCA). Although SCA in athletes makes the headlines, it’s important to know that SCA can happen to anyone including a seemingly healthy child.

Sudden cardiac arrest in a young person usually stems from a structural defect in the heart or a problem with the heart’s electrical circuitry. The most frequent cause, accounting for about 40% of all cases, is hypertrophic cardiomyopathy or HCM.

HCM is a genetic heart condition that affects 1: 500 individuals, including men, women and children of all ages. HCM is characterized by a thickening of the heart muscle and can lead to sudden cardiac arrest.

sca incidenceApproximately 50% of individuals with HCM experience no symptoms, and don’t even know they have the condition, until tragically, sudden cardiac arrest occurs.  In 9:10 cases the outcome is fatal, resulting in unimaginable grief for families and fellow students.  Yet better outcomes can be achieved with early electrical stimulation of the heart – delivered by a small, fully automated, easy to use box.

Given that educational institutions house more than 20% of the American population every day, you’d think they would be fully prepared for this eventually. But sadly, they are not.

At the time of writing, only 19: 50 states in the U.S. require that at least some of their schools have automated external defibrillators [AED’s].  In some states, AEDs are required in public, but not private schools. In other states, AEDs are required in high schools, but not elementary schools. Some states require AEDs only in schools offering athletics. Only two states – Hawaii and Oregon – require AEDs in colleges.

To find out whether your state requires AEDs in schools, click here to view an interactive map.

Chain of Survival full sizeAlthough schools and colleges are ideal and obvious locations for AED deployment, concerns regarding legal liability and litigation have been perceived as a barrier to purchasing and deploying AEDs.  Fortunately this is slowly changing.  Recognition of the need to protect youth from sudden cardiac arrest is gaining momentum in many states:

In Pennsylvania, Sen. Andrew Dinniman has sponsored Senate Bill 606, Aidan’s Law, named for Aidan Silva, a seven-year-old Chester County resident who succumbed to SCA in September 2010.  Aidan had no symptoms of a heart condition prior to his death. Aidan’s Law will help ensure that every public school in Pennsylvania has an AED that is up to date and ready to use.

Rep. Connie Pillich, of Cincinnati, has introduced a bill focused on SCA in student athletes. House Bill 180 requires the Ohio Department of Health and the Ohio Department of Education to jointly develop guidelines and materials to educate students, parents and coaches about SCA. The measure bans a student from participating in a school-sponsored athletic activity until the student submits a signed form acknowledging receipt of the guidelines and materials created by the health and education departments. Individuals would not be allowed to coach a school-sponsored athletic activity unless the individual has completed, within the previous year, a sudden cardiac arrest training course approved by the health department.

John Ellsessar, whose son Michael died during an Oxford High School football game in 2010 from cardiac arrest, believes automated external defibrillators should be as readily available at school settings as fire extinguishers.

Ellsessar, is pushing for legislation to require all schools to have defibrillators, said he and his wife were horrified when they learned that at most schools that have the medical devices, but they are locked away in nurses’ offices, instead of being ready for emergencies.

CPR-AED-lgAnd in Rhode Island, high school seniors will be required to be trained in CPR and the use of a defibrillator before they can graduate. Under the legislation signed into law by Gov. Lincoln Chafee, students will receive training that includes a hands-on course in cardiopulmonary resuscitation and an overview of the use of an AED.

The National Parent Teacher Association has also adopted a resolution calling for public schools to develop emergency response plans that include summoning help, performing CPR and using automated external defibrillators to save lives. The PTA also called for ongoing CPR-AED training in schools and legislation that would fund placement of AEDs in every school, while providing immunity for people who use the lifesaving devices in good faith.

To learn more about sudden cardiac arrest and how you can help please visit http://www.sca-aware.org

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Heads Up on i-Concussion

NAU footballThere is a new face at Northern Arizona University (NAU) football games this fall.  No – not a new quarterback or coach – but a robot on wheels!

Making its debut at the season kick-off game against the University of Arizona in Tucson last Friday, the robot has the ability to assess a player for symptoms and signs of a concussion and to consult with sideline medical personnel thanks to a specialized camera system, remotely operated by a Mayo Clinic neurologist.

teleconcussion robot Mayo Clinic will be working with NAU to test the feasibility of using a telemedicine robot to assess athletes with suspected concussions during football games as part of a research study. With sophisticated robotic technology, use of a specialized remote controlled camera system allows patients to be “seen” by the neurology specialist, miles away, in real time.

Athletes at professional and collegiate levels have lobbied for access to neurologic expertise on the sideline. As we seek new and innovative ways to provide the highest level of concussion care and expertise, we hope that teleconcussion can meet this need and give athletes at all levels immediate access to concussion experts,” said Bert Vargas, M.D., a neurologist at Mayo Clinic who is heading up the research.

This study is the first to explore whether a remote neurological assessment is as accurate as a face-to-face evaluation in identifying concussion symptoms and making return to play decisions. Mayo Clinic physicians will not provide medical consultations during the study, they will only assess the feasibility of using the technology.

But, if it appears feasible, this may open the door for countless schools, athletic teams, and organizations without access to specialized care to use similar portable technology for sideline assessments.

teleconcussion robot 2As nearly 60% of U.S. high schools do not have access to an athletic trainer, youth athletes, who are more susceptible to concussion and its after-effects, have the fewest safeguards in place to identify possible concussion signs and symptoms at the time of injury. Teleconcussion is one way to bridge this gap regardless of when or where they may be playing.” Says Dr Vargas.

Others involved collegiate sports agree.

At NAU, our primary goal is to provide an outstanding student-athlete experience culminating in graduation,” says Dr. Lisa Campos, vice president for Intercollegiate Athletics at Northern Arizona University. “We charge our staff to research the most current and best practices to ensure the safety and care of our students. Partnering with the Mayo Clinic in its telemedicine study will further this research and potentially improve diagnosis for rural areas that may not have access to team doctors or neurologists. The study allows the NAU Sports Medicine Staff and team doctors to continue to make all diagnoses and return to play decisions for our students, while investigating the effectiveness and efficiencies of telemedicine. We are excited to have the teleconcussion robot on our sideline this fall.”

concussion_footballThere were a number of examples last football season where college football players clearly demonstrating concussion-like symptoms were quickly thrown back in games or weren’t even taken out of the game for an evaluation,” said Ramogi Huma, executive director of the National College Players Association. “College football players are in desperate need for independent concussion experts on the sidelines, and this study could help make that safeguard a reality.”

Telemedicine is not new to the Mayo Clinic in Arizona.  They first used the technology with the telestroke program in 2007, when statistics revealed that 40% of residents in Arizona did not live in an area where they were availed of stroke expertise. Since the telestroke program began nearly 3,000 emergency consultations for neurological emergencies have taken place.

We’ll be following the results of this study and will let you know the results as soon as they’re in.

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Not so Chilling News for Runners

ice bath 2As a former marathon runner, I vividly remember having to endure ice-cold baths after heavy training sessions and competitive events in an attempt to reduce inflammation and speed up my recovery.  i also recall that this process was not only time consuming but also bone-chillingly painful.  While I enjoyed race running and even embraced the hours of pavement pounding leading up to competition, I loathed this recovery.  Each time as I sat shivering, I’d miserably moan to anybody who would listen that I’d be better off with a glass of wine, a nap in the sun, a hot bath and an early night!

So it was with mixed emotions I read about a new study that found ice baths aren’t all that effective.  And while I’m glad for the next generation of athletes, I can’t help but wish this has been published 20 years earlier.

The study, published in the European Journal of Applied Physiology, showed no mitigation of post-exercise strength loss or decreased soreness in subjects who engaged in post-exercise cryotheraphy, or ice baths, compared to a control group.

It doesn’t help you feel better and it doesn’t help you perform better,” says lead researcher Naomi Crystal. “Ice baths are very popular as a treatment, but the research is really mixed as to whether they’re beneficial. They’re miserable. If it doesn’t work, you don’t want to waste your time.”

The researchers had 20 active college-age men run downhill at a grade of 10% for 40 minutes. Half the subjects then submitted to a 20-minute ice bath, standing in a tall recycling bin filled with thigh-high ice water cooled to a chilly five degrees Celsius (40 degrees F).

cryotherapy researchThey then measured the ice bath’s effect on soreness, strength, swelling and inflammation by conducting three post-exercise measures taken at intervals from one hour to three days:

  • the subjects’ perceived soreness while walking down stairs
  • quadriceps strength on a resistance machine
  • thigh circumference
  • concentration of plasma chemokine ligand 2 (CCL2), a marker for inflammation

The results showed no difference in strength or perceived soreness between the subjects who took ice baths and the control group. Thigh circumference did not change significantly for any of the subjects after the run.

Difference between the two groups’ CCL2 concentrations, while not statistically significant, showed a trend toward lower concentrations in the cryotherapy subjects, although this measure varied greatly between the subjects.

icebathThe lack of difference between the control and the cryotherapy group surprised the researchers. “I expected to see an improvement in soreness, an improvement in strength with the ice bath,” says Crystal.

Although the researchers conclude that their study does not support the use of cryotherapy for recovery from exercise, Crystal’s personal view is more moderate. “I’m not convinced that it doesn’t help at all,” she says. “Use them sparingly. Use them in tournament situations, use them with an athlete who has done something extraordinary. But for day-to-day athletes, I wouldn’t recommend them. They’re painful, and they’re time consuming.”

Amen Sister, amen!

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The Sobering Buzz on School Buses

School_BusAs the summer draws to a close and the new school years approaches, now’s the time for parents to sit down with their kids and have “the talk”.

No, not that one!  We’re talking about school bus safety.  According to the National Highway Traffic and Safety Administration, an average of 19 kids die each year as a result of school bus related accidents.

To help reduce this terrible statistic, Susan Laurence, injury prevention coordinator, at Cincinnati Children’s Hospital believes such a talk will help ensure a safe, enjoyable start to the school year for everyone. According to Laurence, many injuries happen when children are boarding or exiting the bus. “A blind spot extends about ten feet in front of the bus, obstructing the driver’s view. Often times, children are not aware of this blind spot and might mistakenly believe that if they can see the bus, the bus driver can see them.”

Laurence offers the following suggestions to parents on how they can ensure their child is safe before, during and after their school bus ride.

school bus safetyWhile Waiting for the Bus 

  • arrive at the bus stop at least five minutes before the bus arrives
  • avoid horseplay while waiting for the bus
  • do not go into the street while waiting for the bus

During the Bus Ride

  • remove loose drawstrings or ties from the child’s jacket and sweatshirt because they can snag on bus handrails
  • when boarding or leaving the bus, children should always walk in a single file line and use the handrail to avoid falls.
  • while on the bus, the child needs to remain seated, forward facing at all times and keep the aisle clear of his feet and his backpack
  • do not shout while on the bus or distract the driver unnecessarily
  • keep head and arms inside the bus at all times

School Bus AccidentAfter the Bus Ride

  • wait for a signal from the bus driver before crossing the street
  • look left, right, left before stepping into the street to make sure there are no cars passing the bus
  • cross the street at least 10 feet (or 5 giant steps) in front of the bus
  • wait until the bus comes to a complete stop before exiting
  • exit from the front of the bus
  • ask the bus driver for help if anything is dropped while entering or exiting the bus
  • do not talk to strangers when walking to and from bus stop

Simple, sensible advice for all parents. Let’s make sure we keep the wheels on the bus this school year and prevent children from ending up under them.

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Pediatricians Propose Policy to help Hollaback Girls

It’s official!  Cheerleading – love it or hate it –  isn’t just about short skirts, big smiles and pompom waving.  According to a new policy statement from the American Academy of Pediatrics (AAP), cheerleading is just as athletic and potentially as dangerous as a sport and should be designated as one.

In addition, to making it a sport, the AAP urges coaches, parents and school officials to follow injury-prevention guidelines, develop emergency plans and ensure cheerleading programs have access to the same level of qualified coaches, medical care and injury surveillance as other sports. They also recommend better supervision including on-site athletic trainers, limits on practice time and better qualified coaches.

Not everyone is fully aware of how cheerleading has evolved over the last couple of decades. It used to be just standing on the sidelines and doing cheers and maybe a few jumps,” said Cynthia LaBella MD, a sports medicine specialist at Chicago’s Lurie Children’s Hospital.

Injuries have increased as cheerleading has become more popular.  Over the last two decades, the number of cheerleaders injured has climbed dramatically. Hardly surprising given that cheerleaders engage in stunts such as creating human pyramids that reach 15 feet high or more.  Common injuries include severe sprains, broken arms and legs, neck injuries and concussions.

Last year alone, there were almost 37,000 documented emergency room visits for cheerleading injuries among girls aged 6 to 22.  That’s a 400% increase from the 1980.  And while the overall injury rate in high school cheerleading is lower than in other girls sports, such as gymnastics, soccer and field hockey, the rate of catastrophic injuries like skull fractures and spinal paralysis is higher.  In fact, cheerleading accounts for 66% of all catastrophic injuries in high school female athletes.

Data suggest there are more than 3 million cheerleaders nationwide, most of them girls.  While most belong to traditional cheerleading squads that support schools’ athletic teams, many schools have also created competitive cheering teams.
Some schools and state high school sports associations already consider cheerleading a sport and require the kind of safety oversight that the academy is recommending. But many do not, says Jim Lord, executive director of the American Association of Cheerleading Coaches & Administrators.

Lord and the AAP agree on a number of safety recommendations including limiting the height of human pyramids in high school cheerleading to just two people and banning routines that include pyramids, tumbling or tosses from being performed on hard surfaces.

Lisa Kluchorosky, a sports medicine specialist who works with the academy and the National Athletic Trainers Association, believes the new policy will not only help to reduce injuries but also help erase misconceptions that cheerleading is not very athletic.

What do you think?

The Peak Time for Everything

Not enough hours in your day?  So much to do…so little time?  If you’re anything like me, these will be familiar expressions.

And in which case, you should be interested to learn that maybe, just maybe, you could pack more into each day if you did everything at the optimal time?

A growing body of research suggests that paying attention to your body clock, and its effects on energy and alertness, can help pinpoint the different times of day when it’s best to perform at specific tasks.

Most people organize their time around everything but the body’s natural rhythms.

But workday demands such as commuting, social events and kids’ schedules inevitably end up clashing with the body’s natural circadian rhythms of waking and sleeping.

And as difficult as it may be to align your schedule with your body clock, it may be worth a try, because there are significant potential health benefits.

Disruption of circadian rhythms has been linked to problems such as diabetes, depression, dementia and obesity.

When it comes to doing cognitive work, for example, most adults perform best in the late morning, says Dr. Steve Kay, a professor of molecular and computational biology at the University of Southern California.  As body temperature starts to rise just before awakening in the morning and continues to increase through midday, working memory, alertness and concentration gradually improve. Taking a warm morning shower can jump-start the process.

The ability to focus and concentrate typically starts to slide soon thereafter. Most people are more easily distracted from noon to 4 p.m.

Alertness tends to slump after eating a meal, and sleepiness tends to peak around 2 p.m.  But you may want to rethink taking a nap at your desk.  It turns out, somewhat surprisingly, that fatigue may boost creative powers.

For most adults, problems that require open-ended thinking are often best tackled in the evening when they are tired. According to a 2011 study when students were asked to solve a series of two types of problems, requiring either analytical or novel thinking, their performance on the second type was best when they were tired.

Mareike Wieth, an assistant professor of psychological sciences at Albion College in Michigan who led the study says, “Fatigue may allow the mind to wander more freely to explore alternative solutions.”

Of course, not everyone’s body clock is the same. Morning people tend to wake up and go to sleep earlier and to be most productive early in the day. Evening people tend to wake up later, start more slowly and peak in the evening.

Communicating with friends and colleagues online has its own optimal cycles, research shows. Sending emails early in the day helps beat the inbox rush.  6 a.m. messages are most likely to be read.

Reading Twitter at 8 a.m. or 9 a.m. can start your day on a cheery note. That’s when users are most likely to tweet upbeat, enthusiastic messages, and least likely to send downbeat tweets steeped in fear, distress, anger or guilt.

Other social networking is better done later in the day. If you want your tweets to be re-tweeted, post them between 3 p.m. and 6 p.m., when many people lack energy to share their own tweets and turn to relaying others’ instead. And posts to Facebook  at about 8 p.m. tend to get the most “likes,” after people get home from work or finish dinner.

When choosing a time of day to exercise, paying attention to your body clock can also improve results. Physical performance is usually best, and the risk of injury least, from about 3 p.m. to 6 p.m.

Muscle strength tends to peak between 2 p.m. and 6 p.m. as does lung function which is almost 18% more efficient at 5 p.m. than at midday.

Is there a best time to eat? Experts suggest limiting food consumption to hours of peak activity to keep from packing on pounds.  Perhaps we are not only what we eat, we are when we eat!

We’d Like to Bounce Something Off You…

In 1945, George Nissen, a competitive gymnast, patented the modern trampoline as a “tumbling device. Initially intended as a training tool for acrobats and gymnasts it was subsequently used for military aviator training.

More recently, at least if my neighborhood backyards are anything to go by, the main use of trampolines, is recreational. Driven perhaps, by parents concerns that their kids are becoming more sedentary, along with a family-friendly price tag, it seems there are few family gardens in suburban Northern America that don’t have a trampoline

All this despite the fact that the American Academy of Pediatrics and other lofty medical organizations such as the American Academy of Orthopedic Surgeons, the Canadian Pediatric Society and the Canadian Academy of Sports Medicine have issued guidelines discouraging the use of trampolines in homes and playgrounds..

In fact, with each new set of guidelines comes an increase in the numbers of trampolines in the home setting.

And an increase in injuries…

In 2009, the rate of trampoline-associated injuries was 160 per 100,000 among 5-14 year olds. And approximately 75% of these injuries occurred when more than one person was on the trampoline at the same time.

The most common site of trampoline injury, is the lower leg accounting for 34% – 50% of injuries and >60% involved the ankle,  Upper extremities are injured in 24% – 36% of cases. Most commonly, when people fall off the trampoline. Of these, approximately 60% are fractures.

Head and Neck Injuries account for 10% to 17% of all trampoline-related injuries and 0.5% of these, result in permanent neurologic damage.

And before, you succumb to your precious little angel’s demands, or are tempted by fall yard sale trampoline bargains you may also want to consider the following:

  • The potential for severe and devastating injury is high.
  • Enclosures and padding may provide a false sense of security and do not prevent the large numbers of injuries that occur on the trampoline mat itself.
  • Many injuries occur even with reported adult supervision.
  • Multiple jumpers increase injury risk, particularly to the smallest participants; so trampoline use should be restricted to a single jumper at any given time
  • Individuals 5 years and younger appear to be at increased risk of fractures and dislocations from trampoline-related injuries.
  • Somersaulting, flipping, and falls put jumpers at increased risk of head and cervical spine injury with potentially permanent and devastating consequences. These maneuvers should not be performed in the recreational setting.
  • Active supervision by adults familiar with the above recommendations should occur at all times. Mere presence of an adult is not sufficient.

Have you got a trampoline story to tell? SRxA’s Word on Health is looking forward to hearing from you.