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OCR for page 139
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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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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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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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.
Representative terms from entire chapter:
sustained research
