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APPENDIX A Recommendations for an Injury Research and Training Agenda The body of this report describes research issues and needs in various stages of the injury process: preven- tion, biomechanical response, treatment, rehabilitation, surveillance, and longitudinal follow-up. Current research in each of these subjects is often done without consideration of the overlap with others. In addition, each type of injury is treated as a separate problem, without integration of research results. Surveillance systems for motor-vehicle injuries, injuries associated with consumer products, and occupational injuries are operated separately at a greater cost than would be necessary for a general injury surveillance system, which would have the additional advantage of including injuries not followed in any current system. For such a system to have maximal benefit, it must include data that speak to the questions important in each stage of the injury process. Data on the causal factors that form the basis for choices among preventive approaches must be included. The system must make it possible to relate biomechanical research in the laboratory to the variety of persons and circumstances involved in actual injuries. Acute- trea~ment facilities must be organized to provide the necessary data without disruption of the treatment process. Follow-up data that lead to understanding of the implications of acute treatment for rehabilitation can be included only if experts in rehabilitation are involved. Preventive strategies that do not take into account the limits of human beings to perceive and respond to motion are unlikely to be successful. Sim- ilarly, modifications of the environment or products to reduce severity of injury that are undertaken without knowledge of human tolerance and biomechanical responses will be less than maximally effective. Understanding of 139

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140 biomechanical functioning of the human organism can be used in planning movement of patients in emergency medical systems and in restoration and rehabilitation of function in acute- and long-term-care facilities. This appendix contains examples of the many neglected problems and presents the committee's recommendations for addressing them. It is not intended to be either an - exhaustive or rank-ordered research and training agenda. Although discussed separately, these problems are part of a pattern that must be approached in an interdisciplinary, holistic program for maximal impact. SURVEILLANCE AND DATA COLLECTION PROBLEM With the exception of injury related to motor-vehicle and aircraft crashes, data on the incidence and severity of injury are not adequately detailed. In the motor-vehicle data, identification of cases is based on police reports, despite the fact that research on medically treated injury victims in various areas of the United States and elsewhere in the world has shown that police reports underestimate the problem by 20 percent or more. The discrepancy between police-reported and actual assaultive injuries is probably much greater than that in the case of motor-vehicle in juries. To the extent that factors that contribute to injury are correlated with reporting, inference of causation can be distorted sub- stantially by the selective reporting of cases to police. The Consumer Product Safety Commission (CPSC) maintains a system for gathering data from selected hospital emer- gency rooms, but the cases reported exclude intentionally inflicted injuries and are limited to injuries from one or more of the products in the regulatory jur isdiction of CPSC. Th is system could form the teas is of a comprehen- sive injury surveillance system. Many states now have computer-coded data on all hospital discharges, but the specific cause of injury is not included. Its inclusion would greatly increase the value of those data for research and the development of control strategies. RECOMMENDATION The federal government should establish a nationally representative random sample of the nation's hospital admissions, discharges, and emergency room cases. A system of continuous surveillance of injury incidence and severity, contributing factors (including specific vehicles and vectors), populations at high risk, and costs

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141 of the injuries of patients treated in those facilities should be established. This program should be supplemented by the collection of comparable information on fatal cases not handled in medical facilities, but reported on death certificates. (The details of the minimal information needed are presented in Chapter 2.) PROBLEM The distribution and use of motor vehicles are documented to an extent that permits some measures of exposure to them, but the amounts and types of exposure of various segments of the population to most hazards are unknown. For example, we do not know whether the decrease in injuries associated with particular toys and household products among children as they grow up results from improvement in the ability to handle these items as a function of development, learning, or reduced exposure. These potential explanations lead to different possi- bilities for intervention during the periods of life in which specific types of injur ies are prevalent. RECOMMENDATION Data on exposure to various products and types of energy, identif fed in clinical surveillance as often involved in injury, and the characteristics of the populations exposed should be gathered systematically. The goal should be to link incidence, severity, and exposure in particular populations, to identify points at which intervention is most appropriate. The identification of abilities and limits of specific populations in the use of particular forms of energy and products should be a high priority in stab research. PROBLEM Knowledge of the chronic effects of injury on personal abilities in occupations, recreation, and social and psychologic functioning is lack ing . The eventual results of damage to the brain and nervous system and to sensory organs and of loss of limbs and organs have been investigated in only a few projects, which were severely limited by sample size and time constraints. This knowledge can be gained only through longitudinal studies of the outcome of injury in populations stratified by type and severity of injury. REC - MENDATION Support should be generated for longitudinal studies of injured persons and otherwise comparable noninjured persons, to assess the eventual consequences attributable to injury.

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142 PREVENTION PROBLEM Relatively small-scale special studies of in jur ies concentrated in space and time, such as fatal falls of children in New York, have resulted in speci- f ication of factors that can be modif fed to reduce inci- dence and sever ity. With the exception of investigation of air crashes and a few other disasters by the National Transportation Safety Board and the military services, there is no federal response to most types of injury comparable with the response to diseases, such as the response to the deaths of legionnaires following a convention a few years ago, or the current emphasis on acquired immune deficiency syndrome. This lack of response is due at least partly to the previously mentioned lack of surveillance, which would reveal the concentration of particular types of cases in space and time. RECOMMENDATION Teams of injury epidemiologists should be established with a mission of investi- gating the causes of concentrations of specific types of in jury in space and time, and recommending points in the injury process where intervention programs could be introduced by federal, state, or local authorities or by private individuals and groups. PROBLEM The enormous contribution of kinetic energy to injury and the substantial reductions in crashes related to modest changes in motor-vehicle lighting and improvement in road definition suggest that subtle problems in the perception of motion relative to the ability to react are important in injury causation. The psychologic propensity for perception of personal invulnerability and physical limits on perception and reaction are little understood. Discovery of injury- reducing changes in vehicles and the environment to improve perception of hazard and ability to react has been mostly fortuitous, rather than based on fundamental understanding of perception and reactive abilities. REC - MENDATTON. Support should be initiated for a program of research signed at understanding the physical limits and abilities of people to perceive motion of themselves and others in a variety of environments, particularly those in which injuries occur most frequently. The nature of personal perception of hazard, relative to

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143 subjective perception of ability to avoid harm from the hazard and objective assessment of that ability, should be included in the research efforts, which should compare groups with high and low incidences of injury. The effect of environ- mental insults to the nervous system, such as those caused by industr ial solvents and lead from motor-vehicle exhaust and paint chips, on hazard perception and ability to react should also be included in the research. PROBLEM Preliminary evidence indicates that physiologic, as well as psychologic, contributors are involved in assaultive behavior. Research on large differences in hormone concentrations between assaultive and nonassaultive persons has not been replicated or followed up--a situation that would be unlikely if a disease, such as cancer, were involved, rather than injury. The parallel in age and sex distribution of persons involved in some types of unintentional and assaultive injuries suggests the possibility that similar mechanisms con tr ibute to both . RECO~DATION A program of research in physiologic factors in assaultive and other injuries associated with persons in similar age and sex categor ies should receive support. PROBLEM Various efforts aimed at injury control are adopted with little or no experimentation regarding effectiveness. In some cases, evaluation has found programs ineffective or harmful. But most programs are never evaluated. RECOMMENDATION Support should be increased for research programs of randomized experimental- control studies of the effect of injury-control efforts on injury rates and severity. Where experimental-control studies are not pass ible-- e.g., in the case of laws--evaluation using quasiexperimental and other research designs should be supper ted . PROBI`EM Testing of the in jury potential of mater ials and products before the ir marketing is sparse. Large businesses have the resources to undertake such research, but it may be necessary to provide test facilities for r esearch on the products of small bus inesses, perhaps on a cost-char ing basis, depending on the costs of the

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144 research relative to the assets of a business. The consequences both to the injured and to the businesses, when large lawsuits jeopardize their existence, could be avoided in many instances by prior research on injury potential and appropriate improvements in products as they are developed. RECOMMENDATION The federal government should require researab on the injury potential of materials and products before marketing to the public, preferably by researchers who have no financial interest in the business enterprises that intend to market the materials or products BIOMECHANICS . PROBLEM Scientists have understood the physics and chemistry of most of the forms of energy by which people are injured much longer than they have understood bac- teria and viruses, but research on injurious encounters with energy has lagged far behind research on biologic infection. As discussed in detail in Chapter 4, design of less injurious environments depends at least partly on knowledge of the effects of specific energy exposures on specific human tissues. Although we know the approximate limits of forces that can be tolerated by healthy persons in rapid deceleration, we do not have refined data on effects on nervous tissues and tissues outside particular size and structural ranges. RECOMMENDATION Research on the mechanisms of injury associated with mechanical energy should receive increased support. PROBLEM The extent of reversibility of damage to tis- sues that have experienced specific loadings of environ- mental energy is poorly understood. The technology of culturing skin cells for burn patients is an exciting result of advancement of knowledge. Research on the response of tissue to mechanical loads could lead to analogous technology for other types of tissue. RECOMMENDATION Sustained support should be generated for research on the responses of various tissues to mechanical and other forms of energy. PROBLEM Design of environments and protective equipment depends partly on knowledge of the variations in tolerance to hazards among the persons who will live,

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145 work, and play in those environments. Adequate research in injury mechanisms and human tolerance has not been developed, because of the lack of sustained research support of teams to integrate knowledge of physics, anatomy, physiology, and function. Indeed, the haphazard availability of scarce funds results in the periodic assembly and disassembly of research groups, which pre- vents sustained development of knowledge and expertise. It also results in an inadequate research base and in expenditures that in the long run are greater than those which would be necessary in sustained research efforts. RECOMMENDATION Programs should be established for sustained research on the tolerance of tissue to mechanical and other forms of energy in differ- ent rates and amounts to which humans are commonly exposed. TREATMENT PROBLEM Speed of response and training of emergency medical personnel have improved, but we do not know the optimal combination of resources to allocate to the initial phase of injury. Conditions in different areas of the country suggest that no system is ideal for all areas. The opportunity remains to experiment with new system= and to compare those in use, to find the optimal combinations for local conditions. RECoMMENDATION Research on the effects of extant and experimental emergency response systems on survival and disability should be increased. PROBLEM The lack of knowledge of acute treatment vis-a-vis eventual outcome is outlined in Chapter 5. Research is particularly needed on stabilization of the injured, control of shock, neuroendocrine responses, metabolism, and prevention and control of postinjury infection. REO~ENDATTON Sustained support 'should be provided for research on the various biologic systems involved in the response to in jury. The short- and long-term effects of attempts to control the numerous injury response systems should be investigated more intensively. Protocols for research on treatment for injury should meet the same standards for experimentally demonstrated efficacy as research on treatment for diseases.

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146 PROBLEM The best treatment for injury is often available only in specialized emergency facilities. The organization of emergency response systems and treatment facilities may have as much bearing on outcomes as their availability. Local and regional systems that result in each injury patient's being in the most appropriate facility for treatment should be the goal. RECOMMENDATION Research in the organization and delivery of emergency response to and acute care of the injured should be supported. PROBLEM Damage to the spinal cord is sometimes exacerbated by inappropriate movement of the injured patient, reducing the potential for normal function or rehabilitation. RECOMMENDATION Research on the stabilization of the spinal cord, transport and diagnosis of the spinal-cord-in jured , development of technology, and training of emergency personnel to minimize damage to the spinal cord should be increased. PROBLEM Contracture from burn injuries limits functional body movement, and resulting disfigurement leads to social withdrawal and accompanying problems. RECOMMENDATION Research on the pathophys iol- ogy of burn injury should be increased, with an eye to reducing the degree of contracture and disf inurement. PROBLEM Smoke and gas inhalation in fires results in sears in lung tissue and pulmonary insufficiency. RECOMMENDATION Support for research on the treatment and rehabilitation of persons with damaged lungs 'should be increased. REHABILITATION PROBLEM Evidence is increasing that injury, especially injury to the nervous system, has long-term adverse conse- quences, not only for the obviously disabled, but also for those who seem to have recovered. As noted in Chapter 6, the development of aids and the provision of services for the disabled are often undertaken without adequate study of the contribution of the efforts to recovery or adaptation. -

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147 RECOMMENDATION Research on the outcomes of physical and psychologic rehabilitation efforts should be increased. Such research should focus on the identification of the optimal combinations of factors that contribute to restoration of as nearly normal function as possible, including removal of architectural and social barriers. Reduction of adverse consequences in the patient's family and friends and in persons whose actions might have contributed to injury should be included in such research. PROBLEM Research on treatment for long-term disability is fragmented. For example, surgical procedures commonly do not now take into account the fitting of prostheses, disfigurement, and self-image. RECOMMENDATION Interdisciplinary teams of investigators should be supported to find ways of integrating treatment and long-term rehabilitation in the interest of the total functioning of the injury patient. PROBLEM Preventable pressure sores occur frequently in injured (and other immobilized) patients. RECOMMENDATION. Support for research on technology and training for long-term-care personnel to prevent pressure sores should be increased. TRAINING AND ORGANIZATION FOR INJURY CONTROL PROBLEM Given the neglect of injury in academic training centers and the small number of researchers who have developed the knowledge and skills to produce competent science in the field, it is unlikely that all the identified research tasks could be undertaken immedi- ately even if funding for such efforts were available. This is partly a chicken-and-egg problem, in that the best research training occurs in settings where sustained research programs are in progress. Support of research in academic settings will indirectly contribute to training of researchers. Without funds for scholarships and faculty support, however , such training cannot grow to meet the need. RECOMMENDATION The numbers of researchers and teaching personnel should be monitored, to

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148 show the need for expertise in each of the specified fields of research. Follow-up study of the production and productivity of researchers should be included, to permit assessment of the extent to which research and training programs are accomplishing their goals. The funds needed to reach the research and training goals in specific periods should be estimated. PROBLEM Present organizational arrangements have proved incapable of allocating resources or activating and managing the needed epidemiologic, preventive, biomechanical, clinical, and rehabilitative research and development needed for rational programs to prevent injury and treat and rehabilitate its ViCtiB. Injury research is fragmented, diffuse, and insufficiently organized and administered. Resources are not allocated on the basis of any overall assessment of need and feasibility of achieving new knowledge and technology. The potential is high for duplication of effort. There is no leadership or oversight to avoid inappropriate duplication. RECOMMENDATION. A new agency of the federal government, the Center for Injury Control (CIC), should be established in the Centers for Disease Control (Cl)C) to administer the planning, solici- tation, funding, and evaluation of coordinated research and development directed at control of injury. CIC should be directed by a scientist with a broad interdisciplinary view of the problem. The director should be authorized to convene a council of scientists from other agencies that administer injury research, to coordinate the total federal effort. The budget for CIC should be a clearly identified part of the CDC authorization.