Injury prevention in people with disabilitiesBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7292.940 (Published 21 April 2001) Cite this as: BMJ 2001;322:940
Risks can be minimised without unduly restricting activities
- Samuel N Forjuoh, associate professor and director of research,
- Bernard Guyer, professor and chair
- Department of Family and Community Medicine, Scott and White Memorial Hospital and Foundation, Texas A&M University System HSC College of Medicine 1402 West Avenue H, Temple, TX 75604, USA
- Department of Population and Family Health Sciences, Johns Hopkins School of Hygiene and Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
Clinical review p 975
Some risk of injury exists for almost every human activity, and this risk may be increased for people with impairments, disabilities, or other special healthcare needs. The mechanism of injury is insensitive to the presence or type of disability, whether the injury involves transfer of excessive kinetic energy to the body, as in physical trauma, or deprivation of an essential element such as oxygen, as in submersion. However, the additional risk associated with the underlying condition changes the dynamics of the injury process. Epidemiological studies have, for example, found that people with epilepsy have a greater risk of drowning and burns than those without the disease1–3 and that individuals with a sensory deficit are at greater risk of pedestrian injury.4 Besag's description in this week's BMJ of the death by drowning of a 14 year old boy who suffered from tonic seizures (p 975)5 raises questions about injury prevention strategies in an area where there is not much evidence. The instinctive reaction of restricting the activities of people with disabilities would, however, be wrong.
Several aspects of Besag's case, along with his analysis,5 deserve comment. The observation that seizures result in expulsion of air from the lungs, thereby increasing the density of the body and promoting submersion, makes logical sense, even though there may be no research. Besag rightly points out the implications for both risk and prevention. Unsupervised swimming in “murky” water may be particularly dangerous, and Besag quotes the boy's parents, who asked what is meant by proper supervision. It is easy to lay blame in such situations on inadequate supervision without paying attention to the components of such oversight. How would “supervision” have made a difference?
Injury prevention is the multidisciplinary science of averting damage to body tissues6 by identifying the host, agent, and environmental factors that interact to create the risk of injury. Successful injury prevention strategies have resulted from careful observations followed by formal research using the principles of epidemiology and biomechanics. These approaches have been used to develop interventions like car seat belts, poison prevention packaging, and helmets for motorcyclists. Additionally, injury prevention strategies often involve combinations of education to improve safe behaviour, better engineering of environments and products, and legal requirements to regulate both the engineering and the behaviour. All strategies, however, require evaluation and re-evaluation over time.
Besag's case study illustrates several of these injury prevention issues. Firstly, the level of understanding of the underlying condition among patients, their families, their primary care physicians, and other responsible adults must be assessed. Many people with epilepsy may not know much about their condition and its inherent risks,7 and those entrusted with their care may also be ignorant. In a study of epilepsy awareness among schoolteachers in Thailand 38% reported that they had never heard or read about epilepsy.8
Secondly, this case emphasises the host-environment interactions in injury risk. As Besag points out, the child was in an unfamiliar setting, a body of murky water. The parents, who had previously supervised his swimming, were not present. Rather, a group of schoolteachers, who may have been unfamiliar with both the condition and the risks of the setting, were in attendance. There appears to have been no preparation for the dangers. Injuries are predictable and occur to people at high risk, in high risk settings.
Thirdly, what would have constituted adequate supervision in this case? It might have begun with preparation for the school trip, for example by ensuring adequate medication to prevent seizures and making sure that the people in charge of the trip knew about triggering events or stressors and their management. Besag makes excellent suggestions about supervising the actual swimming activity. Perhaps some consideration should also be given to the routine wearing of a flotation vest in such cases, even though this might be considered restrictive. Unfortunately, there is little research in this subject, so it is difficult to design a package of protections with confidence.
Finally, what is the role of educating the individual with the seizure disorder, in this case a 14 year old child, about risks and prevention strategies? Smith believes that teaching water skills to children is an important measure in preventing drowning9 and cites the research of Asher et al10 as providing the first comprehensive evidence that teaching swimming and water skills may usefully supplement other strategies such as fencing pools. Barss, however, disagreed and argued that more definitive studies are needed to assess the benefit of such programmes.11 No specific studies have been done among children with disabilities.
Though we need to assess and minimise risk, at the same time every effort should be made to integrate individuals with special healthcare needs into society. Thus swimming should not be discouraged in people with epilepsy or any other physical disability. But practical precautions can and ought to be taken to minimise their risk of injury or death until research brings forth proved preventive strategies. Despite the dramatic nature of such cases, they are still rare.