U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2250 Mail: Stop SSOP, Washington, DC 20402–0001

34-513 PDF 2007

S. HRG.110–133

DOD/VA COLLABORATION AND COOPERATION

TO MEET THE HEALTH CARE NEEDS OF

RETURNING SERVICEMEMBERS

HEARING

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

MARCH 27, 2007

Printed for the use of the Committee on Veterans’ Affairs

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 

(II)

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BARACK OBAMA, Illinois 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

LARRY E. CRAIG, Idaho, Ranking Member 

ARLEN SPECTER, Pennsylvania 

RICHARD M. BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

LINDSEY O. GRAHAM, South Carolina 

KAY BAILEY HUTCHISON, Texas 

JOHN ENSIGN, Nevada 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III)

C O N T E N T S 

MARCH 27, 2007

SENATORS 

Page 

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........................... 1

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 2

Craig, Hon. Larry E., Ranking Member, U.S. Senator from Idaho ..................... 4

Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia ........................ 6

Isakson, Hon. Johnny, U.S. Senator from Georgia ............................................... 7

Obama, Hon. Barack, U.S. Senator from Illinois .................................................. 8

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 10

Burr, Hon. Richard, U.S. Senator from North Carolina ....................................... 11

WITNESSES 

Duckworth, Major Ladda Tammy (Ret.), Director, Illinois Department

of Veterans Affairs ............................................................................................... 12

Prepared statement .......................................................................................... 15

Pruden, Jonathan D., Veteran, Operation Iraqi Freedom Veteran ..................... 16

Prepared statement .......................................................................................... 18

Response to written questions submitted by Hon. John D.

Rockefeller IV ................................................................................................ 21

Mettie, Denise, Representing the Wounded Warrior Project, and Mother of 

Army Spc. Evan Mettie ....................................................................................... 22

Prepared statement .......................................................................................... 25

Gans, Bruce M., M.D., Executive Vice President and Chief Medical Officer, 

Kessler Institute for Rehabilitation, New Jersey .............................................. 27

Prepared statement .......................................................................................... 29

Response to written questions submitted by Hon. John D.

Rockefeller IV ................................................................................................ 31

Attachment, National Institute for Disability and Rehabilitation 

Research (NIDRR): 

Model systems for Burn Rehabilitation ................................................... 32

Model systems for Traumatic Brain Injury Rehabilitation ................... 34

Model systems for Spinal Cord Injury Rehabilitation ............................ 38

List of Rehabilitation Research and Training Centers .......................... 44

List of Rehabilitation Engineering Research Centers ............................ 55

Attachment, List of National Center for Medical Rehabilitation Research (NCMRR) projects ............................................................................. 64

Kussman, Michael J., M.D., Executive-in-Charge, Veterans Health Administration, Department of Veterans Affairs ............................................................ 97

Prepared statement .......................................................................................... 99

Response to written questions submitted by: 

Hon. Daniel K. Akaka .................................................................................. 101

Hon. John D. Rockefeller IV ........................................................................ 111

Hon. Bernard Sanders .................................................................................. 113

Hon. Johnny Isakson .................................................................................... 115

Page

IV

Embrey, Ellen P., Deputy Assistant Secretary, Health Affairs/Force Health 

Protection and Readiness, Department of Defense ........................................... 115

Prepared statement .......................................................................................... 117

Response to written questions submitted by: 

Hon. Daniel K. Akaka .................................................................................. 124

Hon. Patty Murray ........................................................................................ 125

Hon. Bernard Sanders .................................................................................. 128

Hon. Johnny Isakson .................................................................................... 128

APPENDIX 

Response to written questions submitted to BVA from March 7, 2007 hearing 

on resources and TBI ........................................................................................... 137

Summary of the VA/DOD seamless transition study conducted by: 

Government Accountability Office .................................................................. 138

VA Office of Inspector General ........................................................................ 138

(1)

DOD/VA COLLABORATION AND COOPERATION 

TO MEET THE HEALTH CARE NEEDS OF

RETURNING SERVICEMEMBERS 

TUESDAY, MARCH 27, 2007

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 9:32 a.m., in Room 

SR–418, Russell Senate Office Building, Hon. Daniel K. Akaka, 

Chairman of the Committee, presiding. 

Present: Senators Akaka, Rockefeller, Murray, Obama, Brown, 

Tester, Craig, Burr, and Isakson. 

OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,

U.S. SENATOR FROM HAWAII 

Chairman AKAKA. The Committee on Veterans’ Affairs will come 

to order in this hearing on DOD/VA Collaboration and Cooperation 

to Meet the Health Care Needs of Returning Servicemembers. Good 

morning and aloha. 

This is the Committee’s second hearing in our series on seamless 

transition. The focus today is on how DOD and VA are working to 

meet the health care needs of those transitioning from service, especially those who have sustained serious trauma. There have been 

many hearings about Walter Reed since the story first broke about 

conditions there. This is not such a hearing. And yet, at one level, 

it is. 

The servicemembers who were staying in Building 18 at Walter 

Reed were in medical hold, awaiting a decision on their future. 

Many would soon be separated from the military and become veterans, and that is exactly what we are talking about today: how 

those leaving the service after being injured make the transition

to VA. 

With regard to the medical hold process, I realize that DOD must 

have time to make an informed decision on an injured 

servicemember’s future. However, as soon as it seems likely that an 

individual will be unable to return to service, DOD must work with 

VA to ensure that the servicemember gets the care he or she needs 

and that the actual transfer is carried out effectively. 

There is much talk about seamless transition, but it is far from 

clear that the talk is matched by effective action. This is not a new 

issue, but it seems that now more than ever, when the demand is 

so great, we find that there is more talk than action. 

2

We have entered the fifth year of this war. I cannot help but 

wonder why so many things are still being planned, still being discussed. Why is it that DOD and VA still cannot make the handoff 

of wounded servicemembers more effectively? Why do budgets still 

not reflect that caring for veterans is part of the cost of war? 

Another key element in easing the transition is making sure that 

servicemembers and their families have someone at both DOD and 

VA to whom they can turn and who has responsibility for making 

sure that they are getting the care and services they need. The 

Committee needs to know where DOD and VA stand on this. 

I remain resolute. For those seriously injured to transfer from 

DOD to VA without undue disruption to the wounded 

servicemember simply must happen. 

We have two panels of witnesses today. The first includes a number of witnesses who, unfortunately are living every day with the 

impact of serious traumas. I have asked Dr. Kussman and Ms. 

Embrey to hear the testimony of the first panel so that when they 

come forward, they will be able to address issues raised by the first 

panel. 

In closing, I note that each Senator will be provided summaries 

from the IG and GAO on their respective work on seamless transition, and a copy of these summaries will be in the record of today’s 

hearing. As you will see, many suggestions have been made already 

to VA and DOD on this issue. 

Now, I would like to yield to another leader of this Committee 

and of our side of the Senate, Senator Murray, for her opening 

statement. 

STATEMENT OF HON. PATTY MURRAY,

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Well, thank you very much, Mr. Chairman, for 

holding this really important hearing, and I really want to thank 

all of our witnesses who have come here today to join us, especially 

for your sacrifices and for coming here today to speak out. You are 

helping us get to the truth about what veterans are really facing 

and helping us change the system for the better for everyone else. 

I also want to extend a special welcome to Denise Mettie. She is 

from Selah, Washington, and her son, Evan, who is receiving treatment for traumatic brain injury. I visited Denise and Evan at Bethesda Naval Station last February, a little more than a year ago, 

and since then he has faced not just medical problems but a bureaucratic system that has thrown up obstacles in his path toward 

recovery. Denise has been a tremendous advocate for her son. She 

had to quit her job so she could fight for Evan in a system that 

is failing for too many of our wounded veterans today. 

Denise, our country owes you and your son an apology. Your son 

fought a war for our country. You should not have had to fight 

every day to give him the care that he deserves. You and Evan deserve a lot better, and so do a lot of our men and women who have 

served us, and that is why your testimony, all of yours, is so important today, to help us hold the VA and the Pentagon accountable 

so that servicemembers never fall through the cracks and are never 

denied vital information and are never left in limbo when they 

3

need our help. And we have got a long way to go because what happened to Evan is really not an isolated case at all. 

Mr. Chairman, one of my biggest frustrations is that we have 

been unable, so far, to get all the facts we need to solve the problems. We hear stories of serious problems from veterans and their 

families, but then when we have tried to get answers from the Administration, we have run into a brick wall. We cannot get full answers on the number of servicemembers who are treated for TBI. 

We cannot get accurate projections on how many veterans will need 

inpatient mental health care. We cannot even get accurate information on the number of amputations. In fact, I am now hearing that 

the Administration is not counting as amputees veterans who lose 

a finger or a toe. That minimizes the scope of the problem, and it 

hides the true cost of this war. 

War is expensive, and if we do not face the full cost of the war, 

including caring for our veterans, we will never be able to have the 

resources and the right policies to be able to help families like 

Evan’s and the other ones that we’ll hear about today. We need the 

truth so we can have the right budget and the right policies. But 

if the Administration keeps hiding the ball, we will never be able 

to get this right for those who sacrifice for us. I really thank the 

witnesses for helping us today to get to the facts so we can solve 

this problem. 

Now, Mr. Chairman, I have to say that I have about had it with 

the Administration officials who keep assuring us that everything 

is taken care of. Two years ago, the VA told us everything was fine 

when it was, in fact, facing a $3 billion deficit. We are going to 

hear from two officials from the VA and the Pentagon on the next 

panel, and I want them to know—I know you have tough jobs, and 

I know you work very hard, but we are going to judge you by the 

results you get for our veterans, and we are going to hold you accountable for those results. 

Two months ago, as the Chairman said, we had a similar hearing 

on this Committee. Officials from the VA and the Pentagon told us 

about all the progress they were making. They were improving 

communication; they were setting up seamless transition programs. 

Everything was on track. Well, a month later we discovered that 

things were not fine when the Walter Reed story broke. 

It is easy to whitewash a moldy wall. It is a lot harder to make 

sure that our veterans are taken care of every step of the way. 

That is the challenge that we now face as a country, and that is 

why we are going to hold people accountable for the results, not 

just creating a new box in an organizational chart, but what the 

results are that we are getting for our servicemembers and our 

families. Are they getting benefits in a timely way? Are they getting fair disability ratings? Are they being screened and treated for 

both PTSD and TBI? Are they getting the best care? Are their medical records where they need to be? And are their families being informed? Because let me tell you, you can make adjustments to a 

bureaucracy decade after decade, but the real results are whether 

the men and women who have served us so well are telling us that 

things are changed for the better, and that is what we are going 

to be looking for. 

4

You know, I have to say that a lot of this misery could have been 

avoided. Many of us saw the warning signs years ago. We saw the 

VA was not planning for the full cost of this war, we saw that it 

was not using realistic projections, and we saw an overwhelmed 

and underfunded VA not getting itself on wartime footing. 

Well, we are not going to wait now for the President to fix the 

problem. We are facing the costs of this war, and we are putting 

the money where it is needed. 

Mr. Chairman, as you know, right now on the floor of the Senate is our supplemental bill. It includes $50 million to build new 

polytrauma centers, $100 million for mental health care, $201 million to treat recent veterans so they do not have to wait in waiting 

lines that delays their care, $30 million for research on the best 

prosthetics for our amputees, $870 million to fix problems that we 

have uncovered at VA facilities across this country now, and $46 

million to finally hire new claims processors so our veterans do not 

have to wait for years for their benefits. 

Those are the costs of war, and these families know it all too 

well. As a Nation, we have to pay for them, so we need to be honest 

about what it is going to take so that we can get it right and give 

our veterans, servicemembers, and their families the care and support they deserve. 

Mr. Chairman, as you know, I am managing the supplemental on 

the floor. I hope to stay for quite a bit of this hearing, but I want 

you to know when I leave, my staff will be here to get your testimony. I will have some more questions that I will probably submit 

for the second panel as well. But we want you to know we want 

to get this right. Your help in being here is our path to get there, 

and we all very much appreciate your testimony today. 

Thank you. 

Chairman AKAKA. Thank you, Senator Murray. 

I need to step away briefly, and I want to hand the gavel over 

to Senator Murray, and I shall return. 

Madam Chairman, the hearing is yours. 

Senator MURRAY [presiding]. Senator Craig, for your opening 

statement. 

STATEMENT OF LARRY E. CRAIG, RANKING MEMBER,

U.S. SENATOR FROM IDAHO 

Senator CRAIG. Thank you very much, Chairmen, Chairman and 

Madam Chairman. I want to thank you all for our distinguished 

panelists who are here today testifying on a critical and important 

issue. 

Those of you on the first panel in particular have traveled great 

distances, and I look forward to this hearing and your firsthand experiences in leaving the battlefield and transitioning back into civilian life. Ms. Duckworth, again, welcome to this Committee. This 

is not your first appearance here, and let me congratulate you on 

your new position. The veterans in Illinois will be served well with 

you at the helm, and so we look forward to your leadership in that 

capacity. 

I also look forward to hearing from our second panel because of 

their managerial experiences operating the transition process. We 

have all been concerned by recent news accounts suggesting that 

5

our returning servicemen and women are not experiencing optimum care at our Nation’s military and veterans’ hospitals. Like 

many Members of this Committee, I too have received complaints 

from some constituents who suggest that wait times are too long 

or quality of care is too poor. I have also received numerous reactions that it is the very best that could possibly be received. 

However, this Committee also knows of the recognition VA has 

received for quality and consumer services over the past few years. 

We know the VA has led the University of Michigan’s consumer 

satisfaction survey for the seventh year in a row. We also know 

that Time magazine’s cover story of how VA became the best health 

care in America also boasts of the quality of VA care. In fact, all 

of you here today have included in your written testimony very 

positive accounts of your experience at both military treatment facilities and VA hospitals. 

So some of us on this Committee are left to wonder why it often 

sounds like two different VAs are being discussed in the news, or 

you just heard the opening testimony, as the Ranking Democratic 

Member of the Committee, two stories being told here through two 

very different sets of glasses. 

I for one believe the answer lies in a simple reality. Medical care 

is very personal to all of us, including our veterans, and one person’s positive experience may be another person’s negative experience. I know the VA is the system of choice for millions of our veterans. I say ‘‘system of choice’’ because I know that over 3 million 

veterans have other options for health care, such as Medicare and 

TRICARE and private insurance, but they still choose VA. 

Unfortunately, a lot of our most deserving veterans, those with 

service-connected disabilities, do not have the power to choose to go 

somewhere else. VA is their only avenue to full health care. 

There are the veterans who choose to be able to say loud and 

clear, ‘‘I earned the right to be cared for by this Nation.’’ At the 

same time, I think they should also have the power to say, ‘‘If you 

do not treat me right or if someone else can provide me with a better medical service, I will go elsewhere.’’ And I have introduced legislation that would provide our service-connected disabled veterans 

with that power. 

I am not sure nor am I confident that the solution that you have 

just heard from Senator Murray of pouring billions and billions 

more dollars at the current system is the best solution. When I introduced the legislation I am talking about, I said that in many 

ways the bill was about my confidence in the VA health care system. If veterans have the ability to choose and they choose to stay 

right where they are in the VA system, well, then, we have learned 

something about this system, because right now there is no internal polling or ‘‘voting with one’s feet’’ because the option simply 

does not exist. But I also said that if the veterans leave in droves, 

then we have learned something else that is awfully important. 

Mr. Chairman, our hearing today is a follow-up on January’s 

hearing of seamless transition and a series of hearings that I held 

with your cooperation two years ago as Chairman on these very important issues. In fact, this is hearing number four or five on the 

issue of seamless transition. We have identified specific treatment 

challenges and the need for early intervention for mental health 

6

care and outreach to those still in need of family therapy services. 

As I said in January, I do have concern that DOD’s efforts to take 

care of its own disabled personnel are complicating efforts by DOD 

and VA to coordinate care and benefits. I am hopeful that the 

President’s new Interagency Task Force on Returning Global War 

on Terror Heroes will help us determine what changes, legislation 

or otherwise, are needed to make us meet these challenges as they 

relate to our young veterans of today. 

I also hope this hearing will shed some light on true personal 

struggles that some of our military families are facing today. Nothing is more important to this Committee than ensuring that our 

servicemembers return to civilian life, that they receive the very 

best possible care and services, and I acknowledge all of you here 

today and look forward to your testimony. 

Thank you, Madam Chairman. 

Senator MURRAY. Thank you, Senator Craig. 

We will recognize each one of our Senators for an opening statement before we go to our panelists in seniority order. Senator 

Rockefeller, you are next. 

STATEMENT OF HON. JOHN D. ROCKEFELLER IV,

U.S. SENATOR FROM WEST VIRGINIA 

Senator ROCKEFELLER. Thank you, Madam Chairman. I will be 

very brief. 

Actually, I think this is the first day in quite a few months that 

all four of the Committees I am on meet, many of them at the same 

time, so I have to go off, too, but I will be here for a while. 

I think it is long past the time when we think of the warfighter 

and then we think of veterans who are physically wounded, mentally wounded. I think all is part of the cost of war. Veterans are 

as much a part of the cost of war as are Humvees, as are 

warfighters out there in the desert in 120 degrees. There is no difference. I say directly to the Ranking Member that I do not think 

Senator Patty Murray, Chairman Murray was talking on two 

tracks. I think she was talking on one track. I think what she was 

saying is that veterans for the most part will say that the treatment they get from their doctors in VA hospitals, from their rehab 

people, from their counselors, from the professionals who work with 

them on a medical basis, day in and day out, is very good. I think 

the complaint comes about the Administration, and not in all VA 

hospitals, but I know in my own State, the case is so clear and it 

is so easy to pick out the difference between the two. Part of the 

reason is they are all in different VISNs, so, you know, they are 

going in all directions, and I regret that. But this is the cost of war. 

It is not some kind of special effort. 

Just going over the testimony, I really like the idea, Mr. Pruden, 

to offer rehabilitation in substance abuse to veterans who request 

it. I also think that Dr. Gans’ testimony about using private rehabilitation centers may make good sense. I have discussed with the 

Ranking Member the idea that I know personally of hundreds of 

physicians, some of whom practice alternative medicine, which is 

a—when you walk into a Vet Center and there are five people 

standing there in gray suits, they look like they have come to audit 

the Vet Center. You ask them what they are doing there. They are 

7

there for PTSD treatment. And so there are so many. All of these 

people come back wounded particularly from this war, more so 

than any other war in terms of the psychology, the uranium additions to the IEDs, and all the rest of it, which are unremovable, 

agony for the rest of your life. 

So my thought, and I have discussed this with the Ranking 

Member, is that there are hundreds of specialists who have—

maybe they are orthopedic surgeons, there are all kinds of people— 

discovered that there are other ways of helping. It is alternative 

medicine in a friendly sense, not alternative medicine in a strange 

sense. It is not invasive. It works. I have seen it work on PTSD 

with Gulf War I veterans. I have seen it work in a very short period of time. I think that the time has come for us to think about 

enlarging that capacity within the VA. Go to the private sector for 

some things, go to the private sector for some pro bono—everybody 

that I have talked to, it is all pro bono. We will go anywhere in 

the country. We will go to San Diego. We will go to Florida. We 

will go to West Virginia, anywhere you want. But we want to show 

that we can be helpful and, believe me, they can be. I just want 

to introduce that thought into this hearing because we are not 

throwing money at a problem. Chairman Murray bailed us out 2 

years ago, and we are doing a little bit better this year. But this 

is not a fight between Republicans and Democrats. This is the 

treatment of veterans on the same par as we treat our warfighters, 

and maybe better. 

Thank you. 

Senator MURRAY. Thank you, Senator Rockefeller. 

Senator Isakson? 

STATEMENT OF HON. JOHNNY ISAKSON,

U.S. SENATOR FROM GEORGIA 

Senator ISAKSON. Thank you very much, Senator Murray. I appreciate very much your calling this hearing, and I particularly 

want to welcome Jonathan Pruden, who we claim to be a Georgian. 

I know he is a North Carolinian, but he spent 2 years at Fort Stewart, and that allows you permanent citizenship, as far as we are 

concerned. Captain, we appreciate your service to the country and 

your being here today. 

I also have to tell you that I sat on a mat at Walter Reed with 

Tammy Duckworth. She probably does not remember me, but I go 

out to Walter Reed whenever there is a wounded Georgia soldier 

there in rehabilitation. And there were a couple there that day, and 

I saw Tammy with that magnetic smile of hers, and her courageous 

recovery was taking place. So I sat on the mat with her for a while 

and talked to her about her experience, and I appreciate her service now to the VA—I guess in Illinois. Is that correct? Congratulations, Director. We are proud of you. And I want to apologize as 

I slip out for a minute. I am chairing with Senator Kennedy the 

card check hearing today, so we have got two extremely important 

hearings. I am going to have to bounce back and forth. 

For just a second, when we talk about the transition from DOD 

to Veterans and Veterans to DOD, I think it is really important for 

us to be focusing. And I do not disagree with any of the comments 

that I heard said by Senator Rockefeller. We want to see to it that 

8

the treatment of a veteran, active duty or a retired veteran, is the 

best that I can be. And to that end, although there has been a lot 

of negatives lately generated with the beginning of Building 18, we 

cannot forget the miracles that are done every day at Walter Reed 

and the hospitals around the country. I have a young man at Walter Reed now, Steven Pearson, whose father I called after I visited 

Steven to just tell him, ‘‘Here is my number, if there is anything 

I can do while you are in Georgia and he is there recovering, let 

me know.’’ And he said, ‘‘Well, I will.’’ And he said, ‘‘One thing you 

can do is tell everybody. I stayed the first 10 days with my son at 

Walter Reed, and I have never seen a quality of care equal to that 

anywhere.’’ So that is a good testimony from someone that is there 

receiving it today. 

Second, I want to mention and commend General Schoomaker, 

who is now at Walter Reed and was called upon to take that duty 

over. Before he came to Walter Reed, he was at the Eisenhower 

Medical Center in Georgia, in Augusta. And it has been a best-kept 

secret about what he had done there. And I see you are nodding 

your head, Jonathan, so you may know what he has done there. 

But what he has done there is he decided that veterans’ facility 

ought to be a facility that could seamlessly transfer active DOD soldiers into that facility, rehab them and turn them around so you 

would have utilization by both active DOD troops and the Veterans’ 

Administration service provided. 

Dr. Hollings at that Augusta VA Medical Center is the head of 

that Center, and he and his employees have done a phenomenal 

job. They have a capacity of 30 at any one time. Walter Reed amputees are now being transferred directly to the VA medical center 

at Augusta for their immediate treatment. Since January of 2007, 

431 soldiers, sailors, airmen, and Marines have received rehab 

services at the Augusta unit of the veterans medical center; 26 percent of them have been treated and have returned to active duty. 

So it is a great story about how collaboration and coordination 

and this idea of a seamless transition from Veterans to DOD and 

back again, if you will, can work. 

I appreciate very much Dr. Hollings at Augusta for the leadership that he is showing and all those employees. I am a big fan of 

General Schoomaker, and I think he is going to make a big difference in the lives of veterans everywhere because of the attention 

he will give. And I particularly, again, appreciate the service and 

commitment of Tammy Duckworth and Jonathan Pruden. Thank 

you both for being here today. 

Senator MURRAY. Thank you, Senator Isakson. 

Senator Obama? 

STATEMENT OF HON. BARACK OBAMA,

U.S. SENATOR FROM ILLINOIS 

Senator OBAMA. Thank you, Madam Chairman, Ranking Member 

Craig. 

Let me start by saying I am so pleased to see Director Tammy 

Duckworth, who is a dear friend as well as a hero, and who is 

doing great work back in Illinois. It is nice to see you again. I 

thank all of the other panelists for their outstanding work on behalf of our veterans. 

9

I know this is the second hearing on seamless transition issues 

facing the Department of Veterans Affairs and Department of Defense during this session. I want to join my colleagues in recognizing that although Building 18 raised awareness in the general 

public, folks on this Committee I think have been concerned with 

how we are approaching these problems for quite some time. The 

question of how we care for our returning servicemembers and 

their families has gained greater significance given recent revelations. But what we know is that given the increasingly complex injuries resulting from fighting in Afghanistan and Iraq, it is clear 

that our current DOD and VA health and rehabilitation resource 

investments are inadequate. 

When it comes to providing the needed health care and support 

services to heal our wounded warriors, we owe them and their families the very best. Later today, I will be offering an amendment 

to the Iraq War supplemental to address many of these systematic 

problems uncovered at Walter Reed. The problems may affect 

DOD’s military health care system, but also exacerbate many of the 

ongoing challenges to the VA’s health system. And my amendment 

would boost the number of caseworkers and mental health counselors and make it far easier for our troops and family members 

to navigate the complex disability review process within DOD. 

I think all of us are in agreement that we need to make the DOD 

process less complex and better coordinated with the VA process. 

As Tammy has pointed out in her testimony, we need a more robust national engagement with our State VA programs as well. 

I look forward to working with the Chairman and this Committee as well as DOD, VA, and our private rehabilitation centers 

to ensure we are providing the health care and rehabilitation worthy of the sacrifices so many servicemembers and family members 

have made. And I just want to make one last point. I know that 

there was some back and forth with respect to the amount of 

money that is needed. Senator Craig, I do not think anybody disagrees with the notion that we should not be wasting money, and 

if we can find ways to do things that are more efficient and more 

cost-effective, they should be by all means pursued. 

But I do think it is important to note that for quite some time, 

at least since I have been on this Committee, the VA has underestimated both the amount of money and the amount of time required to get this right. I think DOD, when we start talking about 

creating what we would think would be relatively simple issues, 

such as setting up medical technology systems that allow military 

records to go from DOD to the VA, it seems like it keeps on stalling. And so on the one hand, I do not want to waste money. On 

the other hand, I do not want us to shortchange people who have 

made the extraordinary sacrifices on our behalf. I know you do not 

either. And I think it is important for us to recognize that, as Senator Rockefeller stated, this is part and parcel of the costs of going 

to war. And I am fearful that we have continually shortchanged the 

back-end costs that are involved.

10

Thank you, Madam Chairman. 

Senator MURRAY. Thank you, Senator Obama. 

Senator Tester? 

STATEMENT OF HON. JON TESTER,

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Madam Chairman. I appreciate the 

opportunity. Thank you, guests, for your testimony. I am going to 

make this quick. I do have some comments I want to make after 

the first panel. When I was elected to this position—and maybe it 

is because of this Committee—I thought the last thing that I would 

be doing is talking with veterans about problems within the medical care system for our veterans when they come home from the 

field of battle. 

That has not been the case. I have been going home every weekend, and about half of those weekends, I have been having hearings with veterans throughout the State of Montana. And I can tell 

you what I have been hearing is this: Once you get in the system, 

the care is excellent in the VA. But to quote one veteran, and I 

hear this over and over and over again—‘‘Sometimes it appears as 

if the VA is trying to outlive me’’—and not letting that person 

through the door. That is a huge problem. Veterans should not 

have to fight for their benefits. They should be granted those benefits for the service that they gave to this country. 

From a DOD perspective, I will just tell you that I have also 

heard that the care is very, very good, but the administrative runaround and red tape is almost unbearable. And for a lot of these 

folks that have been injured on the field, they do not have the ability to be their own advocates. Unless they have a wife or a father 

or a mother or a daughter or a son that is there to help them 

through this process, it becomes unbearable. 

Let me give you just one example. A fellow from Shelby, Montana, who is over at Walter Reed, they put him back together and 

did a heck of a job, and he would attest to that fact, too. Went in 

to get his medical records at Walter Reed. Couldn’t get them. They 

pushed him to another person. That person pushed him to another 

person. That person pushed him to another person. That person 

pushed him to another person, who pushed him right back to the 

first person that he talked to, 4 hours later, 41⁄2 hours later. That 

is ridiculous, and it is not something that our military people 

should have to put up with. And that is the essence of what I like 

about this hearing, seamless transition between active military and 

the VA, and to put on something that Senator Obama talked about. 

The fact that the Department of Defense still has paper records, 

still has paper medical records, and you can use all the excuses of 

the courts or whatever, and the second panel may want to respond 

to this, it is ridiculous. This is 2007. It is not 1960 anymore. And 

the VA has made that transition—I applaud them for that—to electronic medical records. The DOD needs to do the same thing. 

Thank you, Madam Chairman. 

Senator MURRAY. Thank you, Senator Tester. 

Senator Burr, opening comments? 

11

STATEMENT OF HON. RICHARD M. BURR,

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Thank you, Madam Chairman, and to our witnesses, let me thank you for your willingness to come in and share 

your insight, your experience, and your stories. 

I think we all share the same feelings that we want to have a 

system that is perfect, and that should be our goal. And the reality 

is I hear about stories that Senator Tester said about an individual, and I hear Senator Obama talk about the transfer of medical data and health IT. I look outside the DOD world and the veterans’ world and realize that the private system that we have got 

is deficient on everything that we are deficient in in these systems. 

So my concern is that our focus stay on how do we make the system better. How do we make sure that we are able to provide the 

level of care that our veterans deserve and that we set out in legislation to achieve? But also realize that things in health care happen in real time and that what we designed 2 years ago has significant challenges today because of the change in the make-up of who 

walks in the door, the types of problems that they have, the demographic shift that happens in America as it relates to the VA. 

I happen to represent a State that is the number one choice of 

military retirees. I know in real time exactly what that does to a 

health care system, and the challenge to get ahead of the curve and 

to be able to offer and provide the level of health care that they 

deserve and that this Committee, in a bipartisan way, expects is 

challenging. 

I hope that all of you understand that we are attempting to get 

to the bottom of where our problems are and in a bipartisan way 

fix those problems. Our goal is to be perfect, but we will never 

reach it. But it is also to make sure that the stories of the runarounds, the stories of the lines, the stories of the inability to 

transfer medical data, that we fix these things. It is unacceptable. 

But it is also to realize that this is not just the VA health care system and the DOD health care system. We have got this bigger animal in America. It is Medicare and Medicaid and private pay, and 

they do not do these things very well either. And they have a tremendous influence on, in fact, these two systems that we are looking at today. 

My hope is that as Members attempt to wade through this to 

learn and to fix, we will also realize that we have got challenges 

on the private sector side that if, in fact, we do not fix those, we 

will find it impossible for the VA and for the DOD pieces to work 

as we expect them to work without those changes. 

So, once again, I thank our witnesses for being here. I thank the 

Chair for scheduling this. I look forward to hearing from the witnesses. 

Chairman AKAKA [presiding]. I want to thank our Members for 

their opening statements, and I also want to thank Senator Murray 

for being the Chair. 

I welcome our first panel of witnesses. We have brought each of 

you here for your unique perspectives on VA and DOD and this 

kind of care, especially for serious traumas. 

First, I welcome back Tammy Duckworth. Since she testified in 

2005, she has been named the Director of Veterans’ Affairs for the 

12

State of Illinois. Director Duckworth has a firsthand perspective on 

Walter Reed, and she can also share what her office is doing to 

help veterans. 

Jonathan Pruden sustained serious injuries in Iraq. He, too, has 

firsthand knowledge about the various health care systems for returning servicemembers and veterans. 

I welcome as well Ms. Denise Mettie, whose son, Evan, sustained 

a very serious brain injury in Iraq last year. I understand that you 

are a wonderful advocate for your son. 

Finally, I have asked Dr. Bruce Gans from the renowned Kessler 

Institute for Rehabilitation to give us the perspective of a private 

provider dealing with the same sorts of injuries so many of our 

servicemembers are experiencing. Dr. Gans, as you summarize 

your testimony, it would be most helpful if you could build upon 

what the witnesses before you have said. 

I want to thank each of you for being here. Your full statements 

will appear in the record of the Committee, and I would like to first 

call on Director Duckworth for your statement. 

STATEMENT OF MAJOR LADDA TAMMY DUCKWORTH (RET.), 

DIRECTOR, ILLINOIS DEPARTMENT OF VETERANS AFFAIRS 

Ms. DUCKWORTH. Thank you, Mr. Chairman, Ranking Member 

Craig, Members. It is such a pleasure to be here today. Two years 

ago when I testified, I was still an inpatient at Walter Reed. I came 

here in my wheelchair, did not have my legs yet, and I want to tell 

you that I owe the medical personnel at Walter Reed my life. I owe 

them a debt of gratitude I can never, ever repay. And as we think 

about what is happening at Walter Reed, I hope people do remember that, that the personnel there are amazing. 

I would like to talk to you about three main things. First, I 

would like to talk about the state of readiness of the VA system 

and specific programs within the VA, such as the prosthetics program. I would also like to speak about information sharing between 

the DOD, the USDVA, and the need also to coordinate with the 

State VA agencies. And then I would like to make some recommendations on some testing that should be done universally 

across the Nation for all of our veterans coming home. 

Since I have entered the VA system, I must say that the transition from Walter Reed to Hines VA that I experienced was very, 

very easy for me. We have a wonderful lady at Walter Reed—her 

name is Brenda Foss—who is the VA coordinator there, and she 

had reached out to the local VA hospital from Walter Reed and had 

everything coordinated for me even before I left. I even got a tour 

of Hines VA Center from the OIF/OEF coordinator at Hines even 

before I checked into Hines itself. So that transition was quite 

smooth. They are certainly working with one another, and that 

went very well. 

Where I am experiencing problems is not the major clinics within 

Hines. It is with the prosthetics program. I do not know how it is 

across the Nation, but if I am talking to my comrades, my fellow 

wounded warriors, the prosthetics program within the VA is simply 

not ready to handle the high functioning level of the current war 

wounded that are coming home today. They are doing a wonderful 

job of taking care of our older veterans who are losing limbs to diaVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
13

betes, who are ill, whose goal is to get a prosthetic device and be 

able to walk around their home and maybe make it out to the car. 

They are not ready for veterans who want to go rock climbing and 

running marathons. Many of the veterans coming out of Walter 

Reed want to join the Paralympics program. We are going to rock 

the Paralympics program at the next Olympics because we have so 

many of our young veterans entering that. We are going to really, 

I think, win a majority of those Gold Medals for the United States. 

But the VA system is simply not ready, and they do not have time 

to catch up. They simply do not have time to take some of those 

wonderful men and women who work in the prosthetics program 

and send them back for the year-long training that they need to 

work on the high-tech levels of prosthetics that we wear. If you do 

that, those prosthetists then are not available to take care of the 

veterans who are already in the system, and then you will be hurting and harming the veterans of previous wars who need access to 

the lower levels of prosthetic devices. Those of us who need carbon 

fiber running legs—and I am getting my scuba legs this week from 

Walter Reed. I have a prosthetist down in Florida who is making 

me a flying leg so I can get back in a cockpit again. We need to 

be able to access that level of care. 

So I was so pleased, Senator Craig, to hear you say that it would 

be wonderful for us to be able to go to outside sources. That is important. That is important because the VA simply does not have 

time to catch up when it comes to the prosthetics program. 

Once the war is over and the critical first 2 years of an amputee’s life are behind us, then we have time to wait for a prosthetist 

to learn to fit us. But in the first 2 years, we simply do not have 

time, and that is why it is critical for those patients to be able to 

access the prosthetist that we need to access to get the care that 

we need. 

However, I do think that additional funds are needed for the VA 

system. It simply is underfunded, and the problems that we have 

with the VA right now come from the fact that while the personnel 

are excellent, they want to work hard, they want to do the best job 

for us, they cannot because they do not have the funding for it. And 

so that is why the supplemental, the additional spending, will really be a boon to the VA so that they can indeed do the job that they 

need to do. 

I would like to give you an example. My physical therapist at 

Hines wanted to come with me here this week to Walter Reed to 

coordinate and to learn to care for me better with my latest artificial limbs and simply was not able to because there is no funding 

for the plane ticket for him to come from Chicago here to Walter 

Reed to do that. That is not acceptable. 

I also would like to talk about information sharing. We need to 

make sure that there is adequate information being shared between DOD and USDVA. That is starting to happen. Secretary 

Nicholson introduced a new program in Florida where seven people 

participated, where soldiers voluntarily allowed the DOD to transfer their personal contact information to the local USDVA. 

There are a lot of State programs available that we cannot tell 

the wounded servicemembers that these programs exist unless we 

know that they are coming home to us. If they are part of the NaVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00017 Fmt 6633 Sfmt 6633 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
14

tional Guard, we can reach out and touch them. But if they are 

coming home as a soldier, for example, serving with the 10th 

Mountain Division in New York, coming home to Illinois, I have no 

way of knowing that that individual soldier is coming home. And 

I have no way of telling him that here in Illinois, Governor 

Blagojevich has instituted a supplemental health care program, 

health insurance for veterans, or that he just recently signed a bill 

into law that gives all employers a $600 tax rebate next year on 

every OIF, OEF, and Persian Gulf War veteran that they hired in 

2007. What a great thing to be able to write on your resume, that 

if you hire me, you get $600 back on your taxes next year. But I 

cannot even tell those vets that because I do not even know that 

they have come home. 

So this seamless transition needs to happen down to the State 

agency level as well, and there is actually an organization of State 

Directors of Veterans Affairs, whom you addressed, Senator Akaka, 

just recently, who can help facilitate that so that we truly do work 

together, red States, blue States, Federal, local levels, to really do 

what we need to do for our veterans. 

I would also like to talk about some universal testing needs. We 

need to test universally all wounded veterans for PTSD, for traumatic brain injury, for hearing loss, and for vision loss. That is not 

being done uniformly across the VA system. Hines VA right now 

is testing for vision loss all of the patients that come through its 

traumatic brain injury unit, and it is finding that 60 percent of 

those patients in their polytrauma center at Hines have some form 

of functional vision loss. Vision loss will affect your scores on a 

traumatic brain injury test. Hines VA is the only VA hospital in 

the entire Nation that is testing for vision loss as a universal thing 

that is done for all polytrauma patients. That is very important because the veteran may be thinking that he is not understanding 

what is going on, maybe he has worse TBI than he really has, because he cannot read the test, he cannot pass some of the vision 

aspects of it. So that is important. 

I would like to finish by talking about the need for additional 

funding and coming back to that. One of the things that I have not 

heard people talk about are the Vietnam era veterans. We have 

been talking about this large influx of wounded warriors coming 

out of this war who are coming home, who are entering the VA system, and the fact that we need to take care of them. And this is 

where the additional spending is so critical. 

What people do not realize is that the Vietnam veterans have 

now reached an age, in their mid-60’s, that they need additional 

medical care. They are reaching a point in their lives where they 

are accessing greater levels of medical care. In fact, in Illinois, the 

first Vietnam veterans have entered our nursing homes. 

Our VAs are now entering a stage where we talk about the sandwich generation of people who are taking care of their children and 

their parents at the same time. The VA is entering that stage within the next 5 to 10 years. We will have a large influx of Vietnam 

veterans in the next 5 to 10 years demanding greater access to VA 

health care at precisely the same time that you have all of the Iraq 

and Afghan vets coming in also accessing it. The VA simply is not 

ready. 

15

So I thank you for continuing to do this. It is such a pleasure 

to see you, Senator Akaka, as the Chairman of this Committee. 

You are one of us. You served, and we are so proud to be here. 

And, again, thank you so very much for having me here, and I 

know that Captain Pruden will have wonderful things to say as 

well. 

[The prepared statement of Major Duckworth follows:]

PREPARED STATEMENT OF MAJOR LADDA TAMMY DUCKWORTH (RET.), DIRECTOR, 

ILLINOIS DEPARTMENT OF VETERANS AFFAIRS

Mr. Chairman, Members of the Committee. It is indeed a pleasure to be here to 

testify. I am honored to have the opportunity to follow up on my March 2005 testimony on the Seamless Transition from DOD to VA healthcare. 

When I last appeared before this Committee, I was newly injured and still an inpatient at Walter Reed Army Medical Center. The care that I received and continue 

to receive at Walter Reed is above the best. The personnel there are incredibly talented and dedicated. It is unfortunate that they are not given adequate resources 

to support our Wounded Warriors. 

Since my last appearance, I have undergone the transition from DOD to VA 

healthcare and have had an overall positive experience. However, compared to the 

experiences of other servicemembers, I know that mine is not uniform across the 

Nation. Even before I left Walter Reed, the USDVA representative had reached out 

to me and coordinated with the OIF/OEF coordinator at Hines VA Hospital. I had 

an early tour of the facility and met my future physicians. The one negative experience was the prosthetics department, which, while eager to meet my needs, was 

many decades behind in prosthetics technology. I now receive care at Hines but also 

continue to return to Walter Reed. The staff at Hines have been very helpful, and 

shown great initiative. For example, even though my physical therapist at Hines 

had not treated a high-functioning amputee like myself before, he prepared for my 

treatment by reaching out and coordinating with my Physical Therapist at Walter 

Reed. Both therapists did this of their own initiative. 

I continue to return to Walter Reed for its prosthetics program. I also travel to 

a specialist in Florida for state-of-the-art care. Recently, Hines sent a prosthetist 

with me to Florida to learn about the high-tech artificial legs that I obtain from the 

private practitioner there. He was overwhelmed by the technology. The USDVA is 

absolutely not ready to treat amputee patients at the high tech levels set at Walter 

Reed. Much of the technology is expensive and most of the VA personnel are not 

trained on equipment that has been on the market for several years, let alone the 

state-of-the-art innovations that occur almost monthly in this field. I recommend 

that the VA expand its existing SHARE program that allows patients to access private prosthetic practitioners. There is simply not enough time for USDVA to catch 

up in the field in time to adequately serve the new amputees from OIF/OEF during 

these critical first 2 years following amputation. Perhaps after the end of the current wars in Iraq and Afghanistan, the VA will have time to advance its prosthetics 

program. 

In addition to medical treatment, Seamless Transition is also the passing from 

one administrative program to another. The Seamless Transition initiative needs to 

be expanded to each state’s VA, and more importantly, local counties and municipalities. The current model for Seamless Transition focuses on transition from the 

DOD to the USDVA entities within the state. It is also important to involve each 

state’s VA agency as there are many state programs that are unique to the state. 

For example, in Illinois we provide Veterans’ Care, a health insurance plan for veterans. We also provide additional funds for accessibility modifications to disabled 

veterans’ homes. New benefits are added at the state level more quickly than can 

be tracked by the USDVA. For example, as of January this year, Illinois gives up 

to a $600 rebate on employer’s state taxes for each Persian Gulf War, OIF or OEF 

veteran, that they hire. 

One of the greatest difficulties for state VA agencies is the tracking of returning 

servicemembers who come home from active duty status. We at the states only find 

out about these individuals if they self-report to our agency. It appears that a significant difficulty with the Seamless Transition between DOD and USDVA is the 

sharing of servicemember’s information. The DOD and USDVA are still negotiating 

a Memorandum of Agreement (MOA) for this process. Recently, the USDVA announced a new program that was pilot-tested in Florida called the Florida Seamless 

Transition Program. This program for sharing information between USDVA and 

16

state VA agencies is just now being expanded to other states. It basically allows 

wounded servicemembers at DOD medical facilities to voluntarily give permission 

to have their contact information forwarded to their home state’s VA agency. Only 

seven servicemembers chose to participate, but this is an excellent start. 

A related aspect of information sharing between DOD, USDVA and state VA 

agencies is the technical aspect of data sharing. The USDVA and DOD each have 

their own excellent medical records keeping system. Unfortunately, most state agencies that operate health facilities such as long-term care facilities do not have electronic records keeping due to the prohibitive costs. At the very least, the USDVA 

and the DOD should be able to electronically share data so that the wounded 

servicemembers’ medical records can simply be transmitted electronically once they 

enter the USDVA healthcare system. If there are issues of patient privacy, the 

records could be given to the servicemember on a CD–ROM, to be turned over at 

the patient’s discretion once they begin seeing their USDVA healthcare provider. 

Any Seamless transition program must also include comprehensive screening for 

Traumatic Brain Injury (TBI), Post Traumatic Stress Disorder (PTSD) and vision 

loss by both the DOD and the USDVA Health Care systems. I know that efforts are 

underway to strengthen these assessments by both the DOD and the USDVA. However, there is no standard procedure in place to ensure that all war wounded are 

screened nationwide. 

Currently, there is an issue with TBI screenings. Some servicemembers who are 

not screened for TBI, are being identified as suffering only from PTSD. However, 

it is possible to have both PTSD and TBI or either condition alone. My concern is 

that servicemembers with TBI are not diagnosed and then return to civilian life 

without this medical condition noted on their records. The symptoms of TBI can result in inability to work or even aggression that results in homelessness and entry 

into the criminal justice system. At that time, these veterans are then often diagnosed as having PTSD and treated for PTSD even though the main injury is TBI. 

What is significant about this situation is that TBI and PTSD have many treatment 

methods that are the exact opposites. 

One additional screening criteria that is critical is testing for vision loss. At the 

Hines USDVA Hospital, all polytrauma patients are routinely screened for vision 

loss as soon as they enter the facility. The result of these screenings is that 60 percent of the polytrauma patients at Hines have been found to have some form of 

functional vision loss. Vision loss, an acute injury on its own terms, can also negatively affect how patients perform on tests for TBI, which are heavily reliant on vision. Hines is the only USDVA facility in the Nation that conducts routine screening 

of patients in its polytrauma centers. This is because it is the initiative of the excellent Blind Rehabilitation program at Hines. 

I would like to close by saying that I have had a surprisingly positive transition 

to the VA system. I also understand that this may not be the same across the board 

for all returning servicemembers. There are problems that can be resolved such as 

the establishment of standard screening criteria for major injuries such as TBI, 

PTSD and vision loss. I would also strongly urge this Committee to consider eliminating the 2-year window for free VA care for OIF/OEF veterans. This is a new time 

limit that will limit veterans’ ability to access care for injuries such as PTSD, which 

may not become evident until over 2 years after their service. We have more work 

ahead of us, but much of it can be resolved through information sharing, use of patient advocates, and a willingness to access private healthcare specialists.

Chairman AKAKA. Thank you so much for your testimony. 

And now Jonathan Pruden. 

STATEMENT OF JONATHAN D. PRUDEN,

OPERATION IRAQI FREEDOM VETERAN 

Mr. PRUDEN. Mr. Chairman, Members of the Committee, good 

morning. It is an honor to be here. I strongly agree with Major 

Duckworth’s assessment of VA prosthetics and have experienced 

similar challenges in receiving adequate prosthetic care. I had my 

legs made at a private clinic down in Gainesville, Florida. 

Part of the problem here may be that VA care has predominantly 

become geriatric care, and this is only right given that most of the 

veterans are over the age of 50 right now. VA physicians and clinicians have become very good at diagnosing and treating chronic 

diseases associated with this aging population. However, they have 

17

little experience with blast injuries and young patients. At facilities 

I have been asked at least a dozen times if I lost my leg to diabetes 

or vascular disease. While re-establishing ADLs for an 80-year-old 

veteran is certainly an admirable goal, these young OIF/OEF veterans, as Major Duckworth said, want to go on and live fuller lives. 

They want to go run marathons and climb rocks, and they need a 

higher level of care. 

On July 1, 2003, I was wounded in Baghdad. Over the next 3 

years, I had 20 operations, including the amputation of my right 

leg. At Army, Navy, and VA hospitals, I encountered caring and 

competent individuals willing to go the extra mile to care for 

servicemembers and veterans. 

I understand that steps are being taken already to remedy a lot 

of the issues that we are discussing here today, but I also understand that a lot of times there is a substantive gap between policy 

change here and the effects on the ground for the guys implementing it. 

Our severely wounded men and women should receive the best 

medical care, regardless of the cost. One of my favorite soldiers, 

Corporal Robert Bartlet was critically wounded in Iraq on May 3, 

2005. He lost his left eye; the bones and soft tissue on the left side 

of his face and his jaw were all blown away or pulverized; both his 

hands have nerve damage; he suffers from PTSD and has a mild 

TBI. He is about to go in for his 30th surgery on April 13th. 

Currently, Corporal Bartlet must go back and forth between Walter Reed and Johns Hopkins for separate dental and plastic surgery care because TRICARE will not authorize dental care at Johns 

Hopkins. This is inexcusable. He will have to endure an extra 8 

months of surgeries because TRICARE will not allow his plastic 

surgeon and a dental surgeon to tag team and do two surgeries at 

once. The practice of tag teaming is very common. They did that 

on me a lot at Walter Reed. I would have vascular, ortho, and 

neuro all working on me at once, so instead of having three surgeries at separate times and having long recoveries, they piled it 

all into one. This reduces recovery times and risks associated with 

anesthesia and so forth. Military physicians caring for our severely 

wounded must be able to base their treatment decisions solely on 

what is best for the patient, not TRICARE authorizations. 

Rob is a very positive, inspiring individual who wants to get on 

with his life and his education. He should not be facing numerous 

extra surgeries and putting his life on hold for lack of a TRICARE 

authorization. He and other servicemembers like him have already 

sacrificed enough. 

We also must ensure that servicemembers have advocates who 

know the system and can help them and their families navigate the 

incredibly complex MEB/PEB process and the VA’s benefits process. When I went to my local VA to apply for benefits when I was 

medically retired in December of 2005, I discovered that, despite 

what I had been told, an earlier application for a vehicle adaptive 

grant had been filed as my disability claim. My disability claim did 

not even include the amputation of my right leg. So I tried to stop 

the disability claim and find out what was going on. No one at the 

Gainesville VA or anyone I could talk to could get through to the 

18

regional office to stop the claim or, you know, add my amputated 

leg to my disability claim. 

Finally, I contacted someone up here in VA Central Office who 

contacted someone in benefits who contacted St. Pete, and then 

they called me. And it worked out in the end, but you should not 

have to work the system like that to make this happen. And a lot 

of these individuals do not have the wherewithal because of injuries and medications and so forth to do that, to work the system, 

or they do not have the contacts. You should not have to do that 

to get your benefits straight. This is something we really need to 

work on. 

For over 5 years, VA and DOD have been promising IT miracles 

that will connect military treatment facilities one to another, inside 

DOD, and DOD to the VA. I am wondering when it is all going to 

get fixed. 

Last summer, GAO reported that two VA polytrauma centers 

they visited could not access DOD electronic records. I have encountered this time and again. When I filled out a post-deployment 

health assessment at Walter Reed, I thought that would be the one 

time I had to fill it out. I wound up filling that out five different 

times at five different medical facilities because never did another 

facility have a record of me filling out this post-deployment health 

assessment at any other facility. And to date, the VA still does not 

have a record of me having filled out this assessment, which is supposed to help screen for various health conditions. 

We can do better than this. I know a lot is being done. I appreciate what this Committee is trying to do, and I appreciate the very 

caring and competent people in the VA and DOD and the work 

that they are doing. 

Thank you all very much for having me here today. 

[The prepared statement of Mr. Pruden follows:]

PREPARED STATEMENT OF JONATHAN D. PRUDEN,

OPERATION IRAQI FREEDOM VETERAN

Mr. Chairman and Members of the Committee, good morning. It is an honor to 

be here today. 

On July 1, 2003, I was wounded in Baghdad. Over the next 3 years I had 20 operations, including the amputation of my right leg. At Army, Navy, and VA hospitals 

I encountered caring and competent individuals working diligently to help wounded 

servicemembers and veterans heal. There have been some obstacles along the way, 

but most of my care and the care of my wounded soldiers has been first rate. This 

is as it should be. 

Our men and women in uniform deserve nothing but the best care we can provide 

when they are wounded in the service of our Nation. Anything less is not acceptable. 

Although I will express a number of concerns about our current system of care, I 

think we all need to be very careful when pointing fingers. The vast majority of VA 

and DOD employees are extraordinary men and women, willing to go the extra mile 

to care for servicemembers and veterans. Individuals like Lieutenant Colonel 

Gajewski at Walter Reed, Jim Mayer in VA Outreach, and Karen Myers at the 

Gainesville VA have influenced my life and the lives of countless others in profoundly positive ways. 

As this Committee well knows, VA and DOD provide outstanding medical care 

and benefits to millions of servicemembers and veterans each year. The dedicated 

public servants who provide this care deserve our utmost respect. That being said, 

there are still areas that need improvement to ensure truly seamless care for our 

wounded warriors. I understand that steps are already being taken to remedy some 

of these issues but I also know that there can be quite a chasm between policy 

change and substantive changes ‘‘on the ground.’’

19

IN NEED OF AN ADVOCATE

I’ve found that soldiers will often ‘‘suck it up’’ and not complain about challenges 

they face or seek the help they need. At times they are stymied by an overly complex system that can be challenging to negotiate even without mental and physical 

obstacles created by their wounds or medications. The following cases are a few examples of issues faced by men I’ve worked with.

• I caught one of my men dragging his nerve damaged foot and asked him why 

he wasn’t wearing a much needed Ankle-foot orthosis (AFO). He told me that the 

Sergeant at the orthopedics clinic didn’t have one in his size. • One if my old Scout’s was seriously wounded and his entire squad was Killed 

in Action (KIA) or Wounded In Action (WIA). He denied having any PTSD and believed those who claimed to have it were faking. Meanwhile he was consuming ever 

greater quantities of alcohol and was having trouble controlling his anger. • Another soldier; a bilateral amputee, was rendered unconscious for an undetermined amount of time by a blast that killed the driver of his vehicle and grievously 

wounded the other occupant. His mother reported he has great difficulty remembering things but he was not screened for a TBI in nearly 2 years by DOD. This 

is likely because his TBI symptoms were masked by symptoms of significant PTSD 

and substance abuse.

There was no reason for these men to suffer. In each of cases resources were 

available and could have been used to help these men. Often problems arise, not 

because of a lack of resources, but a lack of information. These soldiers all needed 

more information and an advocate to ensure they received the services they needed. 

NOT AUTHORIZED BY TRICARE

Our severely wounded men and women should receive the best medical care regardless of the cost. One of my favorite soldiers, Corporal Robert Bartlet, was critically wounded in Iraq on May 3, 2005. He lost his left eye, the bones and soft tissue 

of the left side of his face were pulverized or blown away, both his hands have nerve 

and tissue damage, he suffers from PTSD, and a mild TBI. He is about to go in 

for his 30th surgery on April 13, 2007. 

Currently, Corporal Bartlet must go back and forth between Walter Reed and 

Johns Hopkins for separate dental and plastic surgery care. This is inexcusable. 

He will have to endure an extra year of surgeries and time away from his wife 

because TRICARE will not pay for dental care at Johns Hopkins that would allow 

his plastic surgeon and dental surgeons to ‘‘tag-team’’ and do two surgeries at once. 

The practice of ‘‘tag-teaming’’ is very common and prevents patients from having to 

endure extra surgeries, longer recoveries, and increased health risks associated with 

multiple surgeries. 

Walter Reed has the dental surgeon but not the plastic surgeons to work on Rob. 

So he will continue to endure, needless, extra surgeries as he bounces between Walter Reed and Johns Hopkins. Despite repeated requests, TRICARE will not allow 

him to receive dental care at Johns Hopkins. 

This is completely unacceptable. Military physicians caring for our severely 

wounded must be able to base their treatment decisions on what is best for the patient not on TRICARE authorizations. Rob is a very positive, inspiring individual 

who wants to get on with his life and his education. He should not be facing numerous extra surgeries, pain, and recoveries while his life is put on hold in order to 

save the government a few dollars. 

He and other soldiers in similar situations have already sacrificed enough. 

THE JEC

In recent Congressional committee hearings representatives repeatedly expressed 

great concern about the complex and confusing quagmire that the wounded must 

attempt to navigate as they transition from DOD to VA care. In light of these concerns it seems important that Congress consider the actions of the Joint Executive 

Council (JEC), the only significant entity that straddles the divide between DOD 

and the VA. 

Unfortunately this year, Congress will not be receiving its annual report on the 

JEC from the Government Accountability Office (GAO) as it has each March for the 

past 3 years. The 2003 NDAA required GAO to present an annual report on the 

JEC to Congress. According to Laurie Ekstrand, of GAO’s healthcare team, ‘‘GAO 

asked to have the annual reporting changed. Given the array of issues we have to 

cover it seems more reasonable to report on an as-needed basis and to have reporting about the JEC considered in relation to the relative importance of the rest of 

our requested workload.’’

20

The JEC provides its own annual report to Congress but they have a vested interest in highlighting the ‘‘good news stories’’ and minimizing the focus on areas in 

need of improvement. Allowing agencies to self report without the objective oversight provided by GAO reports may have contributed to the problems at Walter 

Reed. Army Leadership was so focused on all the good that was being done that 

they failed to look for, or acknowledge, the bad. In recent Congressional hearings 

General Schoomaker, the Army Chief of Staff, addressed the Army’s propensity to 

believe its own good press about Walter Reed and acknowledged, ‘‘we have been 

drinking our own bathwater.’’

A COMPLEX PROCESS

We must ensure that wounded servicemembers have advocates who know the system and can help them and their families navigate the incredibly complex MEB/

PEB process and the VA benefits process. Secretary Nicholson’s hiring of 100 patient advocates and 400 benefits personnel is a step in the right direction but much 

more needs to be done. 

The problems with the current system have been highlighted by the MED HOLD 

situation at Walter Reed. One of my old troops lived in Building 18 last year. Neither he nor the others I’ve been working with complained about their accommodations. Rather, they were frustrated by the way they were treated by NCOs, social 

workers, and administrators as they worked to recover and either get back to the 

line or get on with their lives. One soldier expressed this common sentiment bluntly; 

‘‘They treat us like . . . 5 year olds!’’ These frustrations are exacerbated by feelings 

of powerlessness and an overly complex MEB/PEB process especially among those 

suffering from TBI and/or PTSD. One soldier who was at WRAMC when I was injured in July of 2003 is still in MED HOLD 3 years and 8 months later. 

VA BENEFITS

When I went to my local VA to apply for benefits after I was medically retired 

in December of 2005 I discovered that, despite what I had been told, an earlier application for a vehicle adaptive grant had been submitted as my disability claim. 

The claim failed to include the amputation of my right leg! Try as I might, I, nor 

anyone at the VAMC could actually contact anyone in the regional claims office who 

could address my concerns. Fortunately, I knew a senior VA administrator in Washington, DC. He had one of the key leaders over VA benefits in VA Central Office 

call me. Through them I finally made contact with a manager in the regional claims 

office who was able to help correct the situation. Wounded servicemembers should 

not have to have to ‘‘work the system’’ to ensure their claims are properly handled. 

VA CARE

At VA facilities I have been asked at least a dozen times if I lost my leg to diabetes/vascular disease. VA practitioners have become specialists in geriatrics and have 

very little experience with blast injuries and young patients. Currently, the majority 

of their patients are over 50, however these doctors are facing a new wave of veterans with different needs. While reestablishing Activities of Daily Living (ADLs) 

may be an acceptable goal for an 80-year-old veteran, OEF/OIF veterans typically 

want to return to the active lives they led before being wounded.

• Seriously wounded veterans should be assigned to the best/ most experienced 

Primary Care Managers (PCMs) available. Too often it seems the veterans who have 

been in the system a long time know who the best physicians are. This means that 

the ‘‘best’’ PCMs are perpetually ‘‘booked up’’ by older veterans. Unfortunately, this 

leaves the newest veterans, who may have the most complex and challenging medical issues, under the care of the least experienced or desirable Nurse Practitioner. 

• The VA should offer drug rehabilitation to combat veterans who received an 

Other Than Honorable discharge from the service for substance abuse. 

CLEAR, ACCURATE, AND TIMELY EXCHANGE OF INFORMATION

The most significant challenges to a truly seamless transition for our wounded 

often result from poor communication. In September of 2002, a VA news release 

touted the development of ‘‘a single, reliable, data source and a single point of integration between VA and DOD.’’ Four and a half years later no such system exists 

for practitioners ‘‘on the ground.’’ Last summer GAO reported that the two VA 

Polytrauma centers they visited could still not access DOD electronic medical 

records. (GAO–06–794R Transition of Care for OEF and OIF Servicemembers GAO.) 

I have filled out the Post Deployment Health Assessment (PDHA) five separate 

times at Walter Reed Army Medical Center, Brooke Army Medical Center, EisenVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
21

hower Army Medical Center, Winn Army Community Hospital, and Portsmouth 

Naval Hospital. Never has a facility had a record of me filling out this form. The 

VA also has no record of me filling out a PDHA. 

I have requested, in writing, a record of my amputation at Portsmouth Naval Hospital from PNH, WRAMC, DOD, and the VA. The only evidence that I had an amputation is my lack of a leg a copy of my discharge paperwork from PNH. 

We can do better than this. 

CONCLUSION

Recently, my cousin was severely injured in a helicopter crash in Afghanistan. I 

have been impressed by the level of care and support he and his family have received both medically and administratively. A great deal has changed since 2003. 

Over the past 3.5 years I’ve witnessesed an evolution in the depth and nature of 

the health and social services provided by DOD and the VA for the wounded returning from combat. These changes will ensure that my cousin and others wounded 

today will not face many of the issues faced by those wounded in 2003. 

Fourteen servicemembers on my cousin’s helicopter came back to the United 

States on stretchers. Eight returned in flag draped caskets. These wounded, and the 

families of those who were killed, deserve the best this Nation has to offer. The 

work that you all are doing is, and will continue to be, critical to ensuring wounded 

servicemembers and Veterans of every generation receive the best care this Nation 

can offer. 

Thank you all for all that you are doing and thanks for having me here today. 

RESPONSE TO WRITTEN QUESTION SUBMITTED BY HON. JOHN D. ROCKEFELLER IV

TO JONATHAN D. PRUDEN, VETERAN, OPERATION IRAQI FREEDOM

Question 1. I am interested in your suggestion about providing rehabilitation services to veterans on request for substance abuse. Can you explain more about why 

you think it is such a priority, and how you think your colleagues would react to 

such an offer? Do you think that some type of substance abuse screening would be 

important for veterans with PTSD or TBI diagnoses? 

Response. The extensive substance abuse that devastated so many lives in the 

wake of Vietnam should make us consider how we will care for those with similar 

issues after combat in Iraq and Afghanistan. Time and again I have witnessed soldiers slide into substance abuse after combat. Some ask for help, go through rehabilitation, and return to duty. Too many however, wind up being discharged when 

they ‘‘come up hot’’ during drug screens or for behavioral issues secondary to substance abuse. A large number of those discharged for substance abuse likely turned 

to drugs or alcohol to medicate psychological problems stemming from combat. 

After recent policy changes, the VA is now screening all OIF/OEF veterans for 

TBIs, PTSD, alcohol abuse, depression, and infectious diseases. However, there is 

not a separate screen for drug/substance abuse. The VA has world class substance 

abuse rehabilitation programs but the door to these programs is closed if a veteran 

left the service with an ‘‘Other than Honorable’’ or ‘‘Dishonorable’’ discharge. 

Those who believe that veterans who are not honorably discharged do not deserve 

any VA care should consider how rehabilitation may reduce the long term costs of 

substance abuse for family, community, society, and the government. I’ve spoken to 

several soldiers, VA employees, and friends about this matter and every person has 

supported this idea. Several expressed shock that the VA did not currently offer rehabilitation to those discharged for substance abuse. 

I am not proposing free healthcare for these veterans. However, it seems that we 

have an obligation to help these men and women when they show up at the VA 

wanting to ‘‘get clean.’’ Although DOD and the VA are taking proactive steps to address post-combat PTSD, TBI, and substance abuse they cannot change human nature nor the horrors of war. The entanglement of TBI, PTSD, depression, and substance abuse can make it difficult to determine what the roots of substance abuse 

may be. Veterans who were other than honorably discharged due to substance abuse 

may have turned to drugs and alcohol to cope with devastating combat experiences. 

They deserve our compassion, not disdain.

Chairman AKAKA. Thank you very much, Mr. Pruden. 

Denise Mettie? 

22

STATEMENT OF DENISE METTIE, REPRESENTING THE 

WOUNDED WARRIOR PROJECT, AND MOTHER OF

ARMY SPC. EVAN METTIE 

Ms. METTIE. Mr. Chairman and Members of the Committee, my 

name is Denise Mettie, and I am representing my son, Retired 

Army Specialist Evan Mettie, who was injured in Iraq on January 

1, 2006, and the Wounded Warrior Project, a group that assists 

wounded servicemen from Iraq and Afghanistan. 

Let me start by giving you some details of Evan’s initial injury 

and his subsequent treatment. 

Chairman AKAKA. Would you please turn the microphone on? 

Ms. METTIE. But I want to whisper. 

[Laughter.] 

Ms. METTIE. Evan was injured while on a highway outside of 

Baji when his patrol stopped to investigate a car. When they challenged the driver, he blew himself up. We were told that Evan was 

initially reported as killed in action, but when a medic arrived 15 

to 20 minutes later, she discovered he was still breathing. He was 

quickly evacuated to the nearest medical facility. In Balad, doctors 

performed a left-side craniectomy and removed shrapnel from his 

brain. Evan stabilized very well and was transferred to Landstuhl, 

Germany, the next day. 

Since I could not be there with him, I had the staff put the phone 

to his ear, told him we loved him, hang in there, we would be with 

him very soon. The nurse said that as soon as I started talking to 

him, she saw his heart rate go up. From that moment on, I knew 

he was there and God was with our son and was bringing him back 

to us. 

Evan arrived at Bethesda on January 3, 2006, just 3 days after 

the blast, and we arrived a day later—my husband and two teenage daughters. Evan spent the next 86 days in ICU at Bethesda. 

He endured fevers as high as 106, and his weight dropped from 190 

to 99 pounds. We were told he would most likely remain in a vegetative state, not breathe or eat on his own, and be paralyzed on his 

right side. 

Before Evan came out of his coma, approximately 17 days after 

his injury, we were approached about his Medical Boards and the 

process that would initiate his retirement from the military. Not 

knowing or having the time at that time to figure out what was 

going on, I just said, ‘‘Do what you have to do.’’

During the months of January and February, Evan moved his 

head from side to side, opened his right eye, and squeezed my fingers. When Evan’s sister came back for a visit, his response was 

amazing. As soon as he heard her voice, he lifted his head and 

shoulders and raised his arms out like he was trying to sit up. 

On March 10th, it was like an awakening. Evan was really alert. 

He even watched a movie for 2 hours for the first time. 

By this time the doctors at Bethesda recommended that we return home so I could be closer to the family and return to a more 

normal life and Evan could go to the Seattle VA. We asked about 

rehab and were told he was not ready. At no point did anyone mention the possibility of going to one of the VA’s polytrauma centers 

let alone private rehab. 

23

On March 26th, he was medevaced to the Seattle VA. That night 

when I kissed him goodnight and turned to leave, he raised his 

right hand and hit my arm for the first time. I just cried for joy. 

Frustratingly, Evan’s records were sent with us in large packets, 

but somehow some had been misplaced. So for the next several 

days, I was filling the doctors in on his care that he had received 

for the previous 3 months. 

Four days after being there, the doctors told me that Evan was 

too healthy to be in ICU and that we needed to move him out as 

soon as possible. Since Evan was still on a ventilator, that meant 

he has one of four civilian skilled nursing facilities to choose from 

in the State of Washington. 

One of the VA doctors told me that Evan’s brain injury was the 

most devastating that she had seen and hope for recovery was unlikely. Like all of the other times, I told her, ‘‘We have seen Evan 

do amazing things. You have your prognosis and I have mine, and 

I am following mine.’’

Before being sent to the nursing facility, Evan was making significant progress. He ultimately went 24 hours breathing on his 

own. He was squeezing hands on command, smiling, tried to lift his 

left hand several times. He would give little modified ‘‘thumbs up’’ 

when we asked him questions or asked him to do it, raised his 

head and would try to lift both hands at the same time. 

Because there was no interim place in the hospital to place him 

for a week or even two, to continue his vent weaning, he was transferred directly to a civilian skilled nursing facility, a SNF. This was 

undoubtedly the most horrendous experience we have ever endured. The medevac nurses were initially afraid to leave him because they feared for his safety. After 3 weeks of enduring continuous disregard to his care, his pain, and the fact that he could not 

speak for himself, the VA investigated and moved him back to the 

Seattle VA. 

I could not even begin to tell you how relieved I was. At that 

point I could just take a breath again. 

In May, however, because Evan’s MEB had been stalled until we 

gained guardianship, he was still on active duty. His medical holding was changed to Fort Lewis. Due to this change, I was no longer 

able to get a per diem. I had quit my job with US Bank to be with 

him, and now all motel, food, and gas costs were at our expense. 

The people in Seattle treated Evan wonderfully, but he was the 

first OIF TBI to come through there, and there was no overall 

treatment plan. To this day, I am still unsure how Evan originally 

bypassed the entire polytrauma system that could have potentially 

provided such a plan. I even asked for referrals, but was told Palo 

Alto could not take him because he was not ready. 

At that point Evan’s rehab program consisted of a 30-minute 

range of motion each morning, Monday through Friday. One to 

three times a week a physical therapist would come in and sit him 

upright on the side of his bed for approximately 30 minutes. That 

was it. 

During this time I did my own research. I devised my own coma 

stimulation program, and I did his extra range-of-motion activities. 

Part of the problem lay with a test, an SSEP test that they took 

that measures the impulse activity throughout the nervous system. 

24

And when they did it, the testing resulted normal, up, through, behind his ears, the electrodes they had placed on top of his head did 

not pick up any electrical impulse activity in the cortex of his 

brain. In studying these tests, they can be inaccurate for a variety 

of reasons. When the rehab doctor met with me to tell me about 

this, I told her that it was wrong. I had seen him do too many 

things that he would not have been able to do if he did not have 

this impulse activity. 

On November 30th, almost a year after his initial injury, Evan 

finally made it to rehab at Palo Alto and soon started command responses again. Evan came in for a 30-day evaluation and was extended 2 more weeks. He occasionally could answer questions with 

raising his right hand, and he would move his head to the left and 

right, and they extended him for another 2 weeks. 

In January, I was advised to take Evan home and put him in a 

skilled nursing facility until he reached the next level and that he 

could come back for more therapy. My question was: How can he 

reach the next level if he is not receiving rehabilitation therapy? 

They said they would send videos and written instructions for the 

staff at the nursing home to follow and I would be there to train 

them. After our experience with the previous facility, this scared 

the living daylights out of me. Evan was to heal himself before he 

could get further rehab. 

Unfortunately, by mid-February Evan’s lack of responses was noticeable, and I could not figure out what was happening. On the 

16th, I was told the team doctors thought it would be a good idea 

to transfer Evan to a VA long-term facility until he could be transferred elsewhere. I was livid. First, any moves are extremely hard 

on Evan, especially if it is just for a week or two. Second, since 

mid-January I had not seen a particular neuropsychologist with 

Evan. He was an integral part of his program. He had been seeing 

him for 3 to 4 weeks prior to this, and he was making continual 

progress. I requested a meeting to address my concerns, and the 

doctors agreed to check the records. 

On March 14th, I received an apology from the hospital director 

as it appeared that Evan’s records were not accurate. They offered 

another evaluation and therapist for Evan, and in the meantime, 

I had requested second opinions from both Tampa VA and a private rehab facility called Casa Colina. Representatives from Tampa 

VA met with me and, without seeing Evan, told me since he is a 

year out in his injury they could not help us. I asked if further 

therapy would be beneficial and was told no. 

The ironic thing was earlier that day, I asked Evan if he was 

going to work with PT today. He raised his right hand for yes. 

Therapists came in and asked him questions about what hair color 

he liked on girls. Blondes? Right hand raised for yes. Brunettes? 

No response. Redheads? Right hand raised for yes. And this is from 

the kid who is not worth more therapy. 

A recent CT scan showed a buildup of fluid in Evan’s brain. If 

it is causing the pressure, this could explain his regression. To 

date, Casa Colina has not responded to my inquiries, but the Rehabilitation Institute of Chicago is sending an evaluator. Although I 

do not know who will pay for this care should they accept him, 

RIC’s answer will determine Evan’s future. He will either progress 

25

with more rehab or go home to a local skilled nursing facility until 

our house is adapted. Then he will come home where, with my own 

prognosis, we will continue his rehab. 

This is our story, and I wish it were unique. But, unfortunately, 

many of the challenges we face are faced by other families also. If 

you take but a few things from this story, please let it be this: 

Traumatic brain-injured patients and families need time to adjust 

to the reality of their situations, and it is unfair to quickly begin 

the retirement process for individuals with such an unknown and 

unpredictable injury, especially when retirement limits care options. Give us time to get our feet under us and understand what 

we are dealing with. 

Traumatic brain-injured patients and families need options. I 

know that the VA is building their program, and I understand it 

continues to make progress. Still, there are many private hospitals 

which have many years of experience treating and rehabilitating 

patients like my son. It is unfair to deny us access to the same 

level of care that you would choose for your own children. At the 

same time, the VA must use these private facilities as the resources they are so that one day, hopefully soon, the VA will be the 

facility of choice. 

Thank you, and I look forward to your questions. 

[The prepared statement of Ms. Mettie follows:]

PREPARED STATEMENT OF DENISE METTIE, REPRESENTING THE WOUNDED WARRIOR

PROJECT, AND MOTHER OF ARMY SPC. EVAN METTIE

Mr. Chairman, and Members of the Committee, my name is Denise Mettie, and 

I am representing my son, retired Army Spc. Evan Mettie who was injured in Iraq 

on January 1st, 2006 and the Wounded Warrior Project, a group that assists wounded servicemembers from Iraq and Afghanistan. 

Let me start by giving you some of the details of Evan’s initial injury and subsequent treatment. Evan was injured while on a highway outside of Baji when his patrol stopped to investigate a car. When they challenged the driver, he blew himself 

up. We were told that Evan was initially reported as ‘‘Killed in Action,’’ but when 

a Medic arrived 15–20 minutes later, she discovered he was still breathing. He was 

quickly evacuated to the nearest medical facility. 

In Balad, doctors performed a left side cranectomy and removed shrapnel from his 

brain. Evan stabilized very well and he was transferred to Landstuhl, Germany the 

next day. Since I could not be there with him, I had the staff put the phone up to 

his ear, I told him to hang on, we loved him and we would be with him soon. The 

nurse told me his heart rate went up as soon as I started speaking—I knew then 

the good Lord was watching my guy. 

Evan arrived at Bethesda on January 3, 2006, just 3 days after the blast that injured him, and we arrived a day later. Evan spent the next 86 days in ICU at Bethesda. He endured fevers as high as 106, and his weight dropped from 190 to 99lbs. 

We were told he would most likely remain in a vegetative state, not breathe or eat 

on his own, and be paralyzed on his right side. 

Before Evan came out of his coma, and just 17 days after his injury, we were approached about his Medical Boards, the process that would initiate his retirement 

from the military. Not knowing or having the time to figure out what that meant, 

I said ‘‘do what you have to do.’’

During the months of January and February, Evan moved his head from side to 

side, opened his right eye, and squeezed my fingers. When Evan’s sister Kira arrived, and as soon as she started talking to him there was a huge response. He 

opened both eye’s wide, lifted his head and shoulders up and outstretched his arms 

as if he were trying to sit up. On March 10th , it was like an ‘‘awakening’’—Evan 

was really alert, he even watched a 2-hour movie and smiled. 

By this time the doctor at Bethesda recommended that we return home so I could 

be closer to family, return to a more normal life and Evan could go to the Seattle 

VA. We asked about rehab and were told he wasn’t ready. At no point did anyone 

26

mention the possibility of going to one of the VA’s Polytrauma Centers let alone a 

private rehab facility. 

On March 26th, he was medivaced to the Seattle VA. That night when I kissed 

him goodnight and turned to leave, his right hand reached up and hit my arm. I 

cried for joy. Frustratingly, Evan’s records had not arrived at Seattle with him, so 

for the next few days I was filling them in on his condition. They then told me Evan 

was too healthy to be in the ICU and we needed to get him out ASAP. That meant 

Evan had to go to a civilian Skilled Nursing Facility. 

One of the VA Doctors told me Evan’s brain injury was one of the most devastating she had seen and hope for recovery was unlikely. Like all of the other 

times, I told her ‘‘we’ve seen Evan do things no one else has and we have a strong 

Faith, so you can have your prognosis and I will have mine.’’

Before being sent to the Nursing Facility, Evan seemed to be making significant 

progress. He ultimately went 24 hours breathing on his own, squeezed his hand on 

command, smiled, lifted his left hand several times, gave a thumbs up sign, raised 

his head, and tried to lift both arms. 

Because there was no interim place in the hospital to place him for a week or 

two to continue his vent weaning, he was transferred directly to a civilian Skilled 

Nursing Facility (SNF). This was a horrendous experience due mostly to their inattention to Evan’s needs, their disregard for his constant pain, and their blatant disrespect of a patient unable to speak for himself. 

After a month of this substandard care, the VA investigated, and Evan was transferred back to Seattle. Everyone there was wonderful, and he was treated with kindness and respect. I could finally breathe again. 

In May, however, because Evan’s MEB had been stalled until we gained guardianship and he was still on active duty, his Medical holding was changed to Ft. Lewis. 

Due to this change I was no longer able to get a per diem. I had quit my job with 

US Bank to be with him, and now all motel, food and gas costs were at our own 

expense. 

The people in Seattle treated Evan wonderfully, but he was the first OIF TBI to 

come through there, and there was no overall treatment plan. To this day, I am still 

unsure how Evan originally bypassed the entire polytrauma system that could have 

potentially provided such a plan. I even asked for referrals but was told Palo Alto 

wouldn’t take Evan because he was not ready. 

At that point, Evan’s rehab program consisted of 30 minutes of Range of Motion 

each morning Monday thru Friday, and 1–3 times a week a physical therapist sits 

him upright on his bed. That was it. I dedicated my time to research, devising my 

own Coma Stimulation program and doing extra ROM activities. 

On November 30th, almost a year after his initial injury, Evan finally made it 

to rehab at Palo Alto and soon started command responses again. Evan came in for 

a 30-day evaluation and was extended 2 more weeks. He occasionally could answer 

a few questions by raising his right hand for yes and was extended another 2 weeks. 

In January, I was advised to take Evan home and put him into a SNF until he 

reached ‘‘the next level’’ and then he could come back for more therapy. How could 

he reach the next level if he was receiving no rehabilitation therapy? They said they 

would send videos and written instructions for the staff at the nursing home to follow, and I would be there to train them. After our experience with the previous facility, this scared the living daylights out of me. Evan was to heal himself before 

he could get further rehab. 

Unfortunately, by mid-February Evan’s lack of responses was noticeable, and I 

couldn’t figure out what was happening. On the 16th, I was told the ‘‘team’’ doctors 

thought it would be a good idea to transfer Evan to a VA long term care facility 

until he could be transferred elsewhere. I was livid, first, because moves are very 

hard on Evan, especially for a week or two. Second, since mid January I had not 

seen a particular Neuro Psychologist with Evan, which was an integral part of his 

therapy. He had been seeing her 3–4 times a week prior to that and was making 

continual progress. I requested a meeting to address my concern and the doctors 

agreed to check the therapist’s records. 

On March 14th, I received an apology from the Hospital Director, as it appeared 

that Evan’s records were not accurate. They offered another evaluation and therapist for Evan, and in the meantime I had requested a second opinion from both the 

Tampa VA and a private rehab facility called Casa Colina. Representatives from the 

Tampa VA met with me, and without seeing Evan, told me since he’s a year out 

in his injury they could not help us. I asked if further therapy would be beneficial 

and was told no. The ironic thing was that earlier that day, I asked Evan if he was 

going to work with PT today, he raised his right hand for yes. Therapists asked him 

questions about what hair color he liked on girls, blonde? Right hand raise, yes. 

27

Brunettes, no response. Redheads? Right hand raise, yes. This, from the kid who 

isn’t worth more therapy. 

A recent CT scan shows a buildup of fluid in Evan’s brain. If it is causing pressure, this could explain his regression. To date, Casa Colina has not responded to 

my inquiries, but the Rehabilitation Institute of Chicago (RIC) is sending an evaluator. Although I don’t know who will pay for this care should they accept him, 

RIC’s answer will determine Evan’s future—he will either progress with more rehab 

or go home to a local Skilled Nursing Facility until our house is adapted. Then he 

will come home where with my own prognosis, we will continue his rehab. 

That is our story, and I wish it were unique. Unfortunately, many of the challenges we faced are being encountered by others in similar situations. If you take 

but a few things from this story, please let it be this:

• Traumatic Brain Injured patients and families need time to adjust to the reality 

of their situations, and it is unfair to quickly begin the retirement process for individuals with such an unknown and unpredictable injury, especially when retirement 

limits care options. Give us time to get our feet under us and understand what we 

are dealing with. 

• Traumatic Brain Injured patients and families need options. I know that the 

VA is building their program, and I understand that it continues to make progress. 

Still there are many private hospitals which have many years of experience in treating and rehabilitating patients like my son. It is unfair to deny us access to the 

same level of care that you would choose for your children. At the same time the 

VA must use these private facilities as the resources they are, so that one day, hopefully soon, the VA will be the facility of choice.

Thank you, and I look forward to your questions.

Chairman AKAKA. Thank you very much for your testimony. 

Dr. Gans? 

STATEMENT OF BRUCE M. GANS, M.D., EXECUTIVE VICE 

PRESIDENT AND CHIEF MEDICAL OFFICER, KESSLER

INSTITUTE FOR REHABILITATION, NEW JERSEY 

Dr. GANS. Thank you, Mr. Chairman, Members of the Committee. I am really moved by the testimony of the three panelists 

who have preceded me. It makes me remember that we are here 

about people and their families and the injuries and the concerns 

and the hope and the optimism and opportunity that they face. 

And I would like to share you the view from the private rehabilitation community, the things that we try to do, the things we would 

like to be able to do, and the capacity that we do represent that 

may be at least in part a way of helping with the current problem. 

We tried over 4 years ago as an institution to reach out to the 

DOD when we saw injured soldiers coming back without access to 

services. It was visible in the press at that time. We reached out 

to the VA. Many of our other organizations in the private rehabilitation community did so. Unfortunately, we could not find a way 

in. We could not find a way to offer our services. It was not about 

business. It was about care for people and the needs. We had the 

capacity. We wanted to provide the service. We continue to be frustrated in those regards as a field for a number of years. 

Let me tell you about the private rehabilitation community capacity in this country. Actually, World War II created much of 

what exists, and the VA itself was a leader in creating the rehabilitation capacity that became a very large part of what is available 

in the civilian community. Today there are more than 217 freestanding rehabilitation hospitals in this country, more than 1,000 

rehabilitation units in acute-care hospitals, and many thousands of 

outpatient rehabilitation therapy centers. Many of those have very 

specialized programs for exactly the kinds of injuries and disabling 

28

conditions that our injured warriors are coming back with—amputations, traumatic brain injuries, spinal cord injuries, and many 

other disabling conditions. And we even have organized networks 

of research and clinical service that are capable of dealing with 

them that are even funded by the Federal Government. The National Institute on Disability and Rehabilitation Research funds 

currently 16 model systems in spinal cord injury and is re-funding 

right now 14 systems in traumatic brain injury. These are model 

systems that provide research, that collaborate, provide education 

services, and advance the state of the knowledge and the art of rehabilitation. And there is a smaller network of burn injury rehabilitation programs as well. 

I merely mention these to say that the civilian community has 

capacity for exactly the kinds of injuries that are being seen and 

has ways of identifying those programs that have true expertise 

and are uniquely qualified, and that I think is part of the key to 

how the civilian sector could be helpful to augment what the DOD 

and the VA systems currently have available to them. 

At the same time, it is ironic to think that the VA rehab capacity 

has sadly shrunk over the years in response to the changing needs 

of its members and service providers while the civilian community 

has grown and its capacity has been enriched. We now serve injured individuals in urban violence, people in motor vehicle accidents, older people with the same kinds of problems that the VA 

is experiencing, but we do have experience with trauma and all the 

range of services that are needed. 

What is needed is accessible, excellent quality care that is organized and where people need to have it accessible to them, not just 

the quality but also the location. The civilian sector is capable of 

augmenting and complementing the military and the VA systems 

if you will find a way to let us help so that we can do that. 

Last week, I had the privilege of meeting with Secretary Nicholson at his offices with several of his key staff members to talk 

about just this issue. We made, on behalf of the rehabilitation hospital facilities, a proposal that we could establish a coordinating 

council that would let the private sector coordinate and cooperate 

and plan together with both the military and the VA systems to 

identify mechanisms of identifying service centers of excellence 

that could be qualified for participation in serving our 

servicemembers, that could be located geographically where they 

are needed to complement the existing excellence of the VA facilities and the military systems, and could arrange for information 

exchange and even could organize a research effort so that the information that is learned about how the private sector and the publicly sponsored programs can work together can be enhanced so 

that the quality of care that we all want to provide can be made 

more effective, more efficient, cost even less, but do even a better 

job. 

I would like to mention one other problem that may seem irrelevant but is very germane. The rehabilitation capacity in the civilian sector is starting to fall apart in this country because of pressure from CMS, the Medicare program, that is forcing beds to close 

because of changing views as to where rehabilitation is appropriate. Over the last year alone, more than 8 percent of the NaVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
29

tion’s rehabilitation beds have closed because of pressure from the 

75 percent rule, which is a Medicare regulation, and we have only 

seen the tip of the iceberg. This is going to be a huge problem that 

may close as many as a third to half of the rehab beds and facilities in this country if it is not addressed. 

We are very grateful that Senators Nelson, Bunning, Stabenow, 

and Snowe have introduced S. 543, the Preserving Patient Access 

to Inpatient Rehabilitation Act of 2007, which will help stop this 

problem from continuing. We do not need the civilian sector to be 

disassembled the way the VA system was just at the time that we 

need it most. The civilian community wants to help, can make 

itself available, has services and resources to complement the VA, 

and we want to make that possible so that the kinds of stories that 

I just heard do not have to be replicated. 

Thank you for your attention. 

[The prepared statement of Dr. Gans follows:]

PREPARED STATEMENT OF BRUCE M. GANS, M.D., EXECUTIVE VICE PRESIDENT AND

CHIEF MEDICAL OFFICER, KESSLER INSTITUTE FOR REHABILITATION, NEW JERSEY

Good morning, Senator Akaka and Members of the Committee. Thank you for inviting me today to share my experience and recommendations regarding cooperation 

among the DOD, the VA, and the civilian rehabilitation hospitals to provide for the 

medical rehabilitation needs of returning servicemembers. 

I am Dr. Bruce Gans, a physician who specializes in Physical Medicine and Rehabilitation (PM&R). I currently am the Executive Vice President and Chief Medical 

Officer of the Kessler Institute for Rehabilitation in New Jersey. I have been president of the Association for Academic Physiatrists (the society that serves medical 

school faculty members and departments), and the American Academy of PM&R, 

which represents approximately 8,000 physicians who specialize in PM&R. I currently serve as a Board member and officer of the American Medical Rehabilitation 

Providers Association (AMRPA), the national association that represents our Nation’s rehabilitation hospitals and units. In the past, I have chaired medical school 

departments at Tufts University School of Medicine in Boston, and Wayne State 

University School of Medicine, in Detroit. I also served as President and CEO of the 

Rehabilitation Institute of Michigan in Detroit for 10 years. 

Kessler Institute for Rehabilitation is the largest medical rehabilitation hospital 

in the Nation. We operate specialized Centers of Excellence to treat patients with 

amputations, traumatic brain injuries, spinal cord injuries, strokes, and many other 

neurological and musculoskeletal diseases and injuries. We also offer more than fifty 

sites for outpatient rehabilitation services in New Jersey that provide services such 

as medical care, physical therapy, prosthetic fabrication and fitting, cognitive rehabilitation treatment, high technology wheelchairs and electronic assistive device fittings, and many other services. 

We are also a major medical rehabilitation education and research facility. We 

train physicians, therapists, psychologists, and others as to how to provide rehabilitation programs and services. We also host many research programs and projects 

to advance the knowledge and science of medical rehabilitation. Much of this research is funded by Federal grants from the National Institutes of Health (NIH), 

the National Institute for Disability and Rehabilitation Research (NIDRR), other 

Federal and state organizations, and private foundations. 

The reason I am speaking with you today is to share my experience regarding 

how in the past we tried, without success, to offer our medical rehabilitation services to returning military personnel, both active military and veterans. I will also 

share my views as to how the civilian medical rehabilitation provider community 

can help the DOD and VA health systems to provide the highest quality immediate 

and long-term rehabilitation care to our wounded warriors at facilities that are close 

to their homes, while still being cost effective for our Nation. 

REHABILITATION CAPACITY IN THE CIVILIAN HEALTH CARE SYSTEM

Over the past 60 to 70 years, our Nation’s civilian health care system has developed a rich capacity to provide sophisticated medical rehabilitation care through an 

array of several hundred free-standing rehabilitation hospitals, more than a thousand rehabilitation units of acute care hospitals, and thousands of outpatient therVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
30

apy centers. Many of these facilities are capable of providing technically advanced 

care for patients with traumatic brain injuries, amputations, and all the other injuries being experienced by our servicemembers. This rehabilitation care is provided 

by multidisciplinary teams of physicians, nurses, therapists, neuropsychologists, and 

many other professionals in well organized and goal directed programs. 

Highly specialized expertise exists in some of these facilities to deal with the exact 

problems our servicemembers have. For example, there currently is a network of 14 

Spinal Cord Injury Model Systems in a grant supported program funded by NIDRR 

that provides state-of-the-art clinical care, as well as conducts cutting edge research 

to advance the effectiveness of medical rehabilitation. Similarly, there is a network 

of 16 Traumatic Brain Injury Model Systems, and a smaller network of Burn Rehabilitation Model Systems also funded by NIDRR. Each of these centers has been 

able to demonstrate objectively how they provide exceptional clinical care, as well 

as community outreach, education, and research. 

In addition to the centers that have received these grant designations, there are 

many other equally well-qualified rehabilitation programs in operation today that 

are serving patients with the same injuries. Consider that when the SCI Model System grant program was recently competed, more than 30 qualified organizations applied for the 14 awards that were eventually made. 

My point is that there is a rich care-giving capacity that already exists in our 

country that could be tapped to assist our servicemembers and their families. There 

is also an established basis for judging program quality, to determine which ones 

can meet rigorous standards of excellence. 

THE PRIVATE, DOD AND VA SECTORS HAVE NOT WORKED

OR PLANNED TOGETHER WELL

About 4 years ago, when it became apparent that serious injuries were being incurred by growing numbers of our troops, we at Kessler tried to reach out to offer 

our services to the DOD and VA. We called, wrote, e-mailed, and in other ways tried 

to engage medical and administrative leaders in the Departments and individual facilities to offer our assistance. Unfortunately, at that time we were unable to find 

a receptive ear. 

One of the reasons we reached out to the VA in particular, is because we knew 

that over the last few years, much of the VA’s clinical ability to deliver rehabilitation care in organized units had been taken out of service, presumably as a response 

to budget pressures and a belief that the demand for services was in decline as our 

veterans were aging and expiring. 

Sadly, in retrospect we can see that dismantling the VA rehabilitation capacity 

was an unfortunate choice. The need for physical medicine and rehabilitation has 

now grown dramatically. While I applaud the efforts of the DOD and the VA to create high quality treatment facilities such as the VA Polytrauma Centers, the current efforts fall far short of the immediate need for technically excellent, compassionate rehabilitation care that can be provided to all in need, in a timely manner, 

and close to home in the patient’s local community. 

Having a limited number of centers that can only be accessed by people if they 

uproot themselves and their families to live in temporary housing of variable conditions, only adds insult to injury. Further, it still leaves patients and families at risk 

to eventually return to a home community with no accessible lifelong care capacity 

that they can utilize. It seems to me that this is unwise, unnecessary, and a breach 

of our moral responsibility to our servicemembers as a grateful Nation. 

In the era following World War II, when there were very few local rehabilitation 

care delivery options, it made sense to create a national network of veteran specific 

settings to provide care not otherwise available for our returning GIs. In fact, that 

early work of the VA is largely responsible for having trained physicians, supported 

important research, and allowed the civilian sector to build upon their experience 

to create our rehabilitation capacity today. 

Now, however, the situation is reversed. A large and qualified network of services 

does exist in the civilian sector, and a limited distribution of VA and DOD facilities 

exists. There is no need to recreate a ‘‘separate but equal’’ VA-housed network that 

will have to be available for the next 80 years to provide solely for the lifelong specialized needs of our injured servicemembers. 

A RECOMMENDED COURSE OF ACTION

The solution is obvious: establish a mechanism for qualified civilian rehabilitation 

hospitals to contract with the VA and DOD to provide high quality services to our 

injured, both now and for the long term. Services should include medical, pharmaceutical, therapy, psychological, social, Durable Medical Equipment, and especially 

31

case management support. Certainly, we should continue to utilize the capacity of 

the VA and DOD where it now exists. But we should not force people to leave their 

homes and support systems for many months. And we should not just drop them 

back into distant home communities without access to appropriate ongoing services 

that they will need indefinitely (for repairs and replacements for prostheses, ongoing 

cognitive rehabilitation therapies, continuing counseling for Post Traumatic Stress 

Disorder, or the treatment of other related conditions). 

Last week, I had the privilege to meet with Secretary Nicholson and several members of his senior staff, to discuss these matters. At that meeting, I recommended 

to them that a standing Coordinating Council between the DOD, the VA, and the 

private medical rehabilitation hospital community be established. This Council could 

work together to Develop standards to qualify appropriate provider organizations to 

serve servicemembers: 

(1) Target case management resources to oversee these servicemembers’ unique 

needs; 

(2) Establish appropriate contracting and payment mechanisms; and 

(3) Provide ongoing monitoring of the programs it would create. 

In addition, there should be funds targeted to create a focused research program 

to understand how effective this collaboration will be, and how to improve upon it, 

based on outcomes of care and satisfaction of patients and their families. 

ANOTHER PROBLEM EXISTS

There is another current problem of enormous importance in the civilian rehabilitation community that is threatening the ongoing existence of the care delivery capacity I have just described. It centers on drastic cutbacks being imposed on the 

field by the Centers for Medicare and Medicaid Services (CMS) that are trying to 

balance budgets and constrain expenditures by denying access to needed rehabilitation services. Due to the regulation we know as the ‘‘75 percent Rule,’’ more than 

8 percent of the Nation’s rehabilitation beds have been closed in just the last year. 

Those beds closed because of these pressures, and thousands more are expected to 

be forced to close as the regulatory pressures continue. 

We desperately need a rational plan for maintaining and nurturing an appropriate care giving capacity for medical rehabilitation. By stopping the further escalation of the pressures forcing bed and facility closures now, we will preserve the 

availability of services that can be of enormous help to our soldiers today, and sustain the availability of those services for their lifetimes. Senators Ben Nelson, Jim 

Bunning, Debbie Stabenow, Olympia Snowe, and colleagues have recently introduced S. 543, the ‘‘Preserving Patient Access to Inpatient Rehabilitation Hospitals 

Act of 2007’’ to address this critical problem. 

I urge that in addition to creating effective mechanisms to allow the cooperation 

of the DOD, the VA, and the private rehabilitation hospital community, you also 

support S. 543 to preserve the private-public rehabilitation hospital resource so that 

our servicemembers may readily access it now and in the future. 

Thank you very much for giving me the opportunity to address the Committee. 

I would be happy to respond to any questions you might have. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN D. ROCKEFELLER IV 

TO BRUCE M. GANS, M.D., EXECUTIVE VICE PRESIDENT AND CHIEF MEDICAL

OFFICER, KESSLER INSTITUTE FOR REHABILITATION, NEW JERSEY

Question 1. Can you provide a list and locations of the rehabilitation centers funded by NIH, and the National Institute for Disability and Rehabilitation Research 

(NIDRR), and if possible provide information on how such centers overlap with existing VA facilities to help highlight the potential to expand access and coverage? 

Response. Attached are listings from the Web site for the National Institute for 

Disability and Rehabilitation Research (http://www.ed.gov/about/offices/list/

osers/nidrr/index.html) that describe their current funded portfolio of Model Systems for Burn Rehabilitation, TBI Rehabilitation and SCI Rehabilitation. In addition, I am providing you with a list of its Rehabilitation Research and Training Centers and Rehabilitation Engineering Research Centers, which cover many highly relevant clinical areas. 

I have also included a project listing from the National Center for Medical Rehabilitation Research (NCMRR), which is a division of the National Institute for Child 

Health and Human Development (NICHD) at the National Institutes of Health 

(NIH). These projects are directly relevant to the TBI problem as well. 

Please note that this is only a representative sample of the locations in the civilian care delivery system where expertise exists that could be tapped to complement, 

32

supplement and enhance the current VA and DOD capabilities. Many of these civilian programs are located in larger urban areas, and are associated with universities 

and academic medical centers. As such, it is likely that a number will be proximate 

to existing VA or military facilities. 

In the case of the Kessler Institute for Rehabilitation, we are very near the East 

Orange VA (which has recently reached out to us to explore the potential for clinical 

collaboration), and also have active clinical research projects in cooperation with the 

Bronx VA in New York. 

Many of the civilian clinical programs operate extended networks of outreach 

themselves. For example, while Kessler Institute for Rehabilitation’s primary TBI 

Center of Excellence is located on our West Orange, New Jersey campus (12 miles 

from Manhattan); we operate additional programs in northern New Jersey at our 

Saddle Brook campus, and also in western New Jersey at our Chester campus. 

It is also common for rehabilitation hospitals to operate outpatient therapy facilities and clinics. Kessler, for example, operates more than 50 rehabilitation centers 

throughout New Jersey. Many of our sites are capable of delivering specialized programs for patients who have completed inpatient programs in our Centers of Excellence. Thus, the private sector is very likely to represent an extensive distribution 

channel to reach smaller communities where no VA or military facilities exist. 

I am not familiar with all of the existing 1,266 VA facilities, nor their specific capabilities, but I suggest that taking stock of them would best be pursued by a Coordinating Council that included VA, DOD and civilian representation.

[National Institute for Disability and Rehabilitation Research (NIDRR) rehabilitation model systems for Burn, TBI and SCI; list of NIDRR Rehabilitation Research 

and Training Centers; list of NIDRR Rehabilitation, Engineering Research Centers; 

and list of projects for the National Center for Medical Rehabilitation Research 

(NCMRR) follow:]

MODEL SYSTEMS FOR BURN REHABILITATION FUNDED BY THE NATIONAL

INSTITUTE FOR DISABILITY AND REHABILITATION RESEARCH

UCHSC Burn Model System Data Coordination Center (BMS/DCC) 

Dennis C. Lezotte, Ph.D., University of Colorado Health Sciences Center, Denver, 

CO; Project Number: 144; Start Date: October 1, 2002; Length: 60 months.

Abstract: The BMS/DCC establishes a data management and analytical support 

facility for Burn Model Systems clinical and outcomes research projects. 

Objectives include: (1) to serve the clinical, research, and public communities to 

which it is responsible; (2) to serve the needs of good scientific procedure in multiinstitutional outcomes research; and (3) to support the needs for patient safety and 

data confidentiality as required by Federal regulations when conducting collaborative clinical studies. The BMS Project is structured as a set of interacting, observational, randomized, and quasi-experimental clinical studies run at different centers that share the common purpose of acquiring and disseminating knowledge 

about burn injury care and rehabilitation. The project offers support in four important areas: project management, data management, analytical support, and dissemination. Support is provided in developing appropriate integrated systems to affect 

national data collection, project management, data coordination, technical support, 

collaborative clinical projects, scientific conduct, scientific publication, and effective 

dissemination. The UCHSC BMS/DCC continues to accumulate and integrate a central repository of data from the Model Systems to enhance their abilities to make 

sentinel statements and change the way burn injury rehabilitation is done. While 

the main function of the DCC is to integrate and manage these data, it also needs 

to be responsive to the technical and analytical needs of these individual clinical 

centers. In addition, the DCC provides and coordinates statistical support among 

the clinical and statistical groups from each Burn Center and is prepared to expand 

this support, adding several new protocols and/or clinical studies where appropriate.

Johns Hopkins University Burn Injury Rehabilitation Model System (JHU–BIRMS) 

James A. Fauerbach, Ph.D., Johns Hopkins School of Medicine, Baltimore, MD; 

Project Number: 101; Start Date: October 1, 2002; Length: 60 months.

Abstract: This project tests interventions targeting three common postburn secondary complications affecting health and function: generalized deconditioning, muscle atrophy, and acute stress disorder. Testing the effectiveness of these interventions holds promise for improving the health and function of burn survivors as well 

as enhancing their options for workplace and community reintegration. The JHU–

BIRMS includes several projects: (1) testing the efficacy of its augmented exercise 

program in rehabilitating people with generalized deconditioning, (2) testing the efVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
33

ficacy of enhanced cognitive-behavioral therapy in treating individuals with acute 

stress disorder and preventing the development of chronic posttraumatic stress disorder, (3) developing a new measure that quantifies the degree of social stigmatization experienced by burn survivors and its impact on emotional adjustment and integration into the workplace and the community (this project involves the Phoenix 

Society, the largest foundation supporting burn survivors and their significant others), (4) a collaborative effort with the University of Washington on a workplace integration study identifying and quantifying those factors interfering with early and 

complete return to work, and (5) a collaborative study on health and function with 

the University of Texas.

North Texas Burn Rehabilitation Model System (NTBRMS) 

Karen Kowalske, M.D., The University of Texas Southwestern Medical Center, Dallas, TX; Project Number: 143; Start Date: October 1, 2002; Length: 60 months.

Abstract: This project conducts five research projects, two collaborative and three 

site-specific: (1) barriers to return-to-work following major burn injury; (2) long-term 

outcome following major burn injury; (3) outcome following deep, full-thickness hand 

burns; (4) the evolution over time of burn-associated neuropathy; and (5) the socioeconomic determinants of disability in individuals with burn injury. The North 

Texas Burn Rehabilitation Model System (NTBRMS) is a collaboration of Parkland 

Health and Hospital System (PHHS) and the University of Texas, Southwestern 

Medical Center (UTSW). Collaboration occurs on many levels at the NTBRMS. Clinical collaboration is the hallmark of the burn team, which includes individuals from 

several institutions who work together seamlessly, as well as collaboration with 

rural care providers through rural clinics and a biannual seminar. Research collaboration occurs locally with the surgeons and academic computing staff, and nationally 

with the other model systems.

Pediatric Burn Injury Rehabilitation Model System 

David Herndon, M.D., University of Texas Medical Branch, Galveston, TX; Project 

Number: 102; Start Date: October 1, 2002; Length: 60 months.

Abstract: This program conducts independent and multi-center projects focusing 

on evaluating and improving the rehabilitation provided to the burned child, striving to decrease disability and improve reintegration into society. The project continues longitudinal assessments of patients, expanding the database that includes 

measures of cardiopulmonary function, physical growth and maturation, bone density, range of motion, activities of daily living, scar formation, reconstructive needs, 

and measures of psychosocial adjustment. This data is used to identify areas that 

require improvement and provide functional outcome measures that can be used in 

the evaluation of treatment methods. 

Research activities include: (1) a multi-center project assessing the efficacy of the 

long-term administration of oxandrolone in the treatment of burn injury with 

endpoints of improved strength, lean body mass, bone density, and growth; (2) improving rehabilitative outcomes for children by instituting and evaluating major 

modifications to current treatment for children with large burns; (3) evaluating the 

use of pressure garments in controlling scar following burn injury; (4) a multi-center 

study evaluating the relationship between treatment, injury, patient characteristics, 

and patient outcome in those patients sustaining full thickness hand burns; and (5) 

evaluating acute stress disorder and posttraumatic stress disorder, including its occurrence, predictive elements, and efficacy of treatment.

University of Washington Burn Injury Rehabilitation Model System 

Loren H. Engrav, M.D., University of Washington, Seattle, WA; Project Number: 

103; Start Date: October 1, 2002; Length: 60 months.

Abstract: This model system conducts five research projects: (1) A New Approach 

to the Etiology of Hypertrophic Scarring: develops an increased understanding of hypertrophic scarring. (2) Effect of Virtual Reality on Active Range-of-Motion During 

Physical Therapy: uses distraction via immersive virtual reality as an adjunctive 

non-pharmacologic analgesic. This study tests the hypothesis that virtual reality allows patients to tolerate greater stretching during physical therapy compared to no 

distraction, and that in spite of achieving greater range-of-motion, patients still experience lower pain levels while in virtual reality. (3) Determination of Reasons for 

Distress in Burn-Injured Adults: identifies reasons behind a burn survivor’s distress 

at various time-points after hospital discharge. (4) Barriers for Return to Work: 

identifies specific barriers to return to work for burn survivors. (5) Acute Stress Disorder Among Burn Survivors: evaluates the effectiveness of cognitive-behavioral 

therapy, relative to a non-directive, supportive therapy control group, and a national 

34

comparison sample in reducing the prevalence of posttraumatic stress disorder diagnosis and symptom severity. Projects 4 and 5 are collaborative. In addition, this 

project participates in the national database.

MODEL SYSTEMS FOR TRAUMATIC BRAIN INJURY REHABILITATION FUNDED BY THE

NATIONAL INSTITUTE FOR DISABILITY AND REHABILITATION RESEARCH

UAB TBI Model System 

Thomas A. Novack, Ph.D., University of Alabama/Birmingham, Birmingham, AL; 

Project Number: 151; Start Date: October 1, 2002; Length: 60 months.

Abstract: The University of Alabama at Birmingham (UAB) is maintaining and 

further developing a Traumatic Brain Injury Model System (TBIMS) that improves 

rehabilitation services and outcomes for persons with TBI. This project provides a 

multidisciplinary system of rehabilitation care specifically designed to meet the 

needs of individuals with TBI, and, as demonstrated over the past 4 years as a 

TBIMS, adequately enrolls subjects to complete research projects successfully. In addition to contributing data to the TBI National Database, the UAB TBIMS conducts 

two research projects: (1) an examination of the use of a serotonin agonist medication (sertraline) to lessen the incidence and severity of depression during the first 

year of recovery following TBI; (2) a study of the impact of a training program in 

problems solving for caregivers.

Northern California Traumatic Brain Injury Model System of Care 

Tamara Bushnik, Ph.D., Santa Clara Valley Medical Center (SCVMC), San Jose, 

CA; Project Number: 159; Start Date: October 1, 2002; Length: 60 months.

Abstract: This project conducts two studies to better characterize the type and impact of fatigue on the TBI population: (1) a cross-sectional study of people up to 10 

years post-TBI and (2) a longitudinal study that focuses on the evolution of fatigue 

over the first 2 years post-injury. Both studies utilize standardized measurements 

of fatigue, as well as those for depression/affective disorders, sleep disturbance, activity scales, and measurements of hormone levels reflective of the health of the 

neuroendocrine system. Two additional studies characterize the impact of late 

posttraumatic seizures on recovery: (1) a study utilizing data already in the TBIMS 

National Database that compares the functional, vocational, and medical complication outcomes of those with and without late posttraumatic seizures; (2) a study in 

collaboration with Denver Hospital Medical Center that interviews individuals at 

both sites who participated in a previously funded NIDRR grant on seizure risk 

identification. This study further evaluates barriers to the environment, transportation, and challenges in control of their seizures.

The National Data and Statistical Center for the Traumatic Brain Injury Model

Systems 

Cynthia Harrison-Felix, Ph.D., Craig Hospital, Englewood, CO; Project Number: 

1713; Start Date: October 1, 2006; Length: 60 months.

Abstract: By implementing a comprehensive and innovative program of new data 

management technologies and operating procedures that emulate the best practices 

of clinical research organizations and data coordinating centers, the National Data 

and Statistical Center (NDSC) increases the rigor and efficiency of scientific efforts 

to longitudinally assess the experience of individuals with traumatic brain injury 

(TBI) and advances TBI rehabilitation. The TBIMS database and the NDSC introduce the following innovations: a state-of-the-art Web-based data management system; a computer-assisted interview system; a Standard Operating Procedures Manual; training through quarterly Web-based conferences, as well as more frequent inperson conferences; comprehensive Data Collector certification; annual data monitoring visits to each center; analysis of ethnic/racial bias in participant recruitment 

and retention and collaboration with the NIDRR-funded Center for Capacity Building on Minorities with Disabilities Research; providing more comprehensive methodological as well as statistical consultation; continuation of the TBIMS survival 

study; a system for following participants from defunded centers; and the use of 

common procedures, technologies, and training among all Model System Data Centers.

The Rocky Mountain Regional Brain Injury System (RMRBIS) 

Gale G. Whiteneck, Ph.D., Craig Hospital; Englewood, CO; Project Number: 152; 

Start Date: October 1, 2002; Length: 60 months.

Abstract: The Rocky Mountain Regional Brain Injury System (RMRBIS) conducts 

three research projects: Study 1 examines the effects of Modafinil on fatigue and exVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00038 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
35

cessive sleepiness after TBI. Study 2 assesses the effectiveness of a group therapy 

intervention for social pragmatic communication. Study 3 uses the unique database 

assets of Craig Hospital and investigates the environmental and clinical factors that 

influence outcome over a 40-year time frame to understand the process of living and 

aging with a TBI. In addition to clinical research and service, Craig Hospital, as 

the RMRBIS, documents an outstanding record of dissemination, for all customers 

including clinical consumers, community agencies and advocacy groups, other clinical service centers and systems, and professionals engaged in the treatment of persons with TBI.

The Spaulding/Partners TBI Model System at Harvard Medical School 

Mel B. Glenn, M.D., Spaulding Rehabilitation Hospital, Boston, MA; Project Number: 153; Start Date: October 1, 2002; Length: 60 months.

Abstract: The Spaulding TBI Model System (TBIMS) provides a comprehensive 

spectrum of care for people with TBI through the collaborative efforts of three hospitals that are part of Partners Health Care System, Inc., and four organizations 

that operate a variety of postacute rehabilitation programs. Research at the center 

includes development of functional neuroimaging as a tool to guide cognitive rehabilitation treatment for people with TBI, and use of functional magnetic resonance 

imaging (fMRI), with both a cross-sectional and longitudinal component. The crosssectional component assesses regional brain activation during the memorization of 

word lists, both under undirected (spontaneous) conditions and following training 

and cueing to use a categorization strategy. The longitudinal component studies the 

ability of the fMRI findings to predict outcome among people with TBI who participate in community integration program with a cognitive rehabilitation focus.

Southeastern Michigan Traumatic Brain Injury System (SEMTBIS) 

Robin A. Hanks, Ph.D., Wayne State University and Rehabilitation Institute of 

Michigan, Detroit, MI; Project Number: 155; Start Date: October 1, 2002; Length: 

60 months.

Abstract: The Southeastern Michigan Traumatic Brain Injury System (SEMTBIS) 

program conducts projects developed with the help of SEMTBIS consumers, as well 

as other members of the Detroit community. There are three principal studies during this grant cycle: (1) a peer-mentoring intervention: This study is a randomized 

controlled trial of a peer-mentoring program for both survivors and their caregivers; 

(2) a dynamic system of survivor and significant-other well-being: This investigation 

studies 250 community-dwelling adults with TBI and their caregivers/significant 

others, exploring the relationship of survivor-caregiver situations with survivor distress and family dysfunction. It also studies whether or not social support acts as 

a moderating influence upon the well-being of persons with TBI; (3) resumption of 

driving after brain injury: This study examines correlates of driving after brain injury: barriers, fitness to drive, and community rapport. Participatory action is a central component of project implementation, evaluation, and dissemination. SEMTBIS 

participates in clinical and systems analysis studies of the TBI Model Systems by 

collecting and contributing data to the uniform, standardized national database. 

Project findings for the studies described above are available at: TBINDC.org or 

http://tbindc.org/registry/searchresults.php?searchparam=project/center/4.

Mayo Clinic Traumatic Brain Injury Model System 

James F. Malec, Ph.D., Mayo Medical Center, Rochester, MN; Project Number: 149; 

Start Date: October 1, 2002; Length: 60 months.

Abstract: This Traumatic Brain Injury Model System (TBIMS) focuses on three 

local research projects: (1) decisionmaking and outcomes of inpatient and outpatient 

rehabilitation pathways, (2) very-long-term (5–15+ years postinjury) process and 

outcome for people with TBI, identified through the Rochester Epidemiology Project, 

and (3) telehealth-based (Internet) cognitive rehabilitation. Telehealth is a potentially important innovation in this system’s region, where distance limits access to 

medical and rehabilitation services and many consumers have limited access to 

health care, insurance, employment, and viable political representation. In addition 

to professional publications and presentations, continuing dissemination efforts include the Mayo Clinic TBIMS Web site, the TBI Hotline, the Messenger newsletter, 

contributions to the COMBI Web site and COMBI and TBIMS newsletters, and regular participation by Mayo Clinic TBIMS staff at all annual state brain injury association meetings in the extended five-state geographical region. During the next 5 

years, the project plans to develop an advocacy training program to help people with 

TBI and their families and significant others in the region learn self-advocacy skills. 

36

Members of the Mayo TBI Regional Advisory Council were proactively involved in 

developing this project.

Traumatic Brain Injury Model System of Mississippi (TBIMSM) 

Mark Sherer, Ph.D., ABPP–Cn, Methodist Rehabilitation Center, Jackson, MS; 

Project Number: 154; Start Date: October 1, 2002; Length: 60 months.

Abstract: The TBI Model System of Mississippi (TBIMSM) is a collaborative 

project of Methodist Rehabilitation Center and the University of Mississippi Medical 

Center. This project involves three studies. The first study investigates two medications in a parallel group, double blind, placebo controlled, randomized assignment 

design. The drugs under investigation have differing neurotransmitter effects, although each drug has been reported to have therapeutic benefit. The target population for this study is persons with TBI who are in a state of posttraumatic confusional state (PCS). This is considered a state-of-the-art approach to PCS given the 

severe lack of controlled research to measure medication usage in PCS. The second 

study develops and conducts a trial of an intervention to improve the therapeutic 

alliances between persons with TBI and family members and professional staff serving persons with TBI in a post-acute brain injury neurorehabilitation program 

(PABIR). The third research project investigates the use of transcranial magnetic 

stimulation (TMS) to improve the characterization of motor disorders after TBI. 

Current research suggests that improved use and better understanding of TMS 

technology will lead to new intervention trials to improve motor function after TBI.

JFK-Johnson Rehabilitation Institute TBI Model System 

Keith D. Cicerone, Ph.D., JFK Johnson Rehabilitation Institute, Edison, NJ; Project 

Number: 157; Start Date: October 1, 2002; Length: 60 months.

Abstract: This project implements and evaluates innovative rehabilitation interventions that address the spectrum of severity and needs of persons with TBI. The 

first research study investigates the relationship between neurobehavioral (i.e., 

standardized rating scale) and neurophysiologic (i.e., functional MRI data) indices 

of brain function in persons with traumatic minimally conscious state (MCS). The 

second study addresses current clinical and methodological concerns over the effectiveness of cognitive rehabilitation on cognitive functioning, community integration 

and social participation, return to school and work, and quality of life after traumatic brain injury. The third study uses qualitative inquiry to describe the quality 

of life after TBI from the perspective of persons at various stages after their injuries. These findings are triangulated with quantitative indices of community integration and satisfaction with functioning, which should provide a richer and more 

authentic understanding of what it takes to live a fulfilling life after traumatic brain 

injury.

New York Traumatic Brain Injury Model System (NYTBIMS) 

Wayne A. Gordon, Ph.D., Mount Sinai School of Medicine, New York, NY; Project 

Number: 145; Start Date: October 1, 2002; Length: 60 months.

Abstract: This project advances the understanding of TBI and its consequences 

and improves rehabilitation outcomes. The research projects focus on depression and 

fatigue, impairments that limit participation in community and vocational activities: 

Treatment of Post-TBI Depression is a randomized clinical trial to examine the efficacy of sertraline (Zoloft) in the treatment of depression and anxiety after traumatic 

brain injury. Study of Post-TBI Fatigue and its Treatment investigates the components, consequences, and correlates of post-TBI fatigue, and in a randomized clinical 

trial, evaluates the benefits of modafinil (Provigil) to treat fatigue in individuals 

with TBI.

Carolinas Traumatic Brain Injury Rehabilitation and Research System (CTBIRRS) 

Flora M. Hammond, M.D., Charlotte Mecklenburg Hospital Authority, Charlotte, 

NC; Project Number: 158; Start Date: October 1, 2002; Length: 60 months.

Abstract: This project investigates posttraumatic irritability, its relationship to 

the caregiver as a component of the environment, the reaction to amantadine hydrochloride, and the nature of the problem as experienced by those in the community. 

The mission of CTBIRRS is to improve care and outcomes for survivors of TBI 

through medical treatments, services, research, and dissemination to expand and 

enhance services throughout their lifetime. The system begins with prevention and 

emergency medical services and extends through intensive care, acute care, and 

comprehensive medical rehabilitation to long-term follow-up, community reintegration, and vocational rehabilitation.

37

Ohio Regional TBI Model System 

John D. Corrigan, Ph.D., Ohio Valley Center for Brain Injury Prevention and Rehabilitation, Columbus, OH; Project Number: 147; Start Date: October 1, 2002; Length: 

60 months.

Abstract: This model system includes two local research projects on substance 

abuse and persons with TBI. Study 1 is a randomized clinical trial testing interventions to promote retention in substance abuse treatment. This study employs intervention strategies found effective for clients with TBI when first engaging with a 

treatment program. Study 2 tests the concurrent validity of an instrument that documents the extent of a person’s prior history of TBI objectively. This instrument is 

intended for research on TBI as a mediating factor in substance abuse treatment. 

This model system utilizes innovative community integration programs: Team Brain 

Injury (follow-up case management), the TBI Network (substance abuse treatment), 

and Community Capacity Building (education and advocacy operated in conjunction 

with the Brain Injury Association of Ohio).

The Moss Traumatic Brain Injury Model System 

Tessa Hart, Ph.D., Albert Einstein Healthcare Network, Philadelphia, PA; Project 

Number: 148; Start Date: October 1, 2002; Length: 60 months.

Abstract: This project provides cutting-edge care for persons with TBI, conducts 

research on treatment of TBI in three key areas, and disseminates new knowledge 

to consumer and professional audiences, using an extensive collaborative network. 

Seven Trauma Centers and two nationally renowned rehabilitation facilities, 

MossRehab and Magee Rehabilitation, collaborate in the clinical component of the 

Moss Traumatic Brain Injury Model System. The Moss Rehabilitation Research Institute administers the research component, which includes collaborative longitudinal data collection, as well as three local research projects on: (1) the use of assistive technology for cognitive and behavioral disabilities, (2) validation of an observational rating scale of attention dysfunction in a psychostimulant treatment trial, 

and (3) use of botulinum toxin for treating severe spasticity caused by TBI. The 

Moss TBIMS emphasizes consumer involvement in clinical program improvement, 

research design, and dissemination via collaboration with the Brain Injury Association of Pennsylvania and other consumers.

University of Pittsburgh Brain Injury Model System (UPBI) 

Ross D. Zafonte, D.O., University of Pittsburgh, Pittsburgh, PA; Project Number: 

146; Start Date: October 1, 2002; Length: 60 months.

Abstract: The research focus of the University of Pittsburgh Brain Injury Model 

System is on innovation in rehabilitation technology for persons with TBI. The 

project evaluates the impact of selected innovations in technology on service delivery, functional outcome, and as a therapeutic intervention. It addresses the shortcoming in wheelchair design for persons with brain injury by evaluating a unique, 

personalized powered mobility system. Collaboration with the Robotics Institute at 

Carnegie Mellon University allows researchers to perform a randomized trial evaluating the efficacy of virtual reality and robotics for persons with TBI. Finally, the 

project uses intelligent navigation technology to implement and evaluate a Webbased virtual case manager support structure for persons with TBI and their families.

North Texas Traumatic Brain Injury Model System (NT-TBIMS) 

Ramon R. Diaz-Arrastia, M.D., Ph.D., The University of Texas Southwestern Medical Center, Dallas, TX; Project Number: 160; Start Date: October 1, 2002; Length: 

60 months.

Abstract: The North Texas Traumatic Brain Injury Model System (NT–TBIMS) 

provides a comprehensive continuum of care for TBI patients from the time of arrival at the emergency department through the intensive care unit, inpatient and 

outpatient rehabilitation, and long-term follow-up after community integration. Additionally, the NT–TBIMS conducts two research projects aimed at obtaining predictive information regarding outcome after TBI, which is important to the goal of 

developing novel therapies and tailoring these therapies to individual patients: (1) 

to determine whether the inheritance of particular alleles in certain candidate genes 

is associated with a greater risk of poor outcome after TBI; and (2) to determine 

whether Diffusion Tensor Magnetic Resonance Imaging, a novel imaging technique, 

is a more reliable indicator of Diffuse Axonal Injury than standard structural MRI.

38

Virginia Commonwealth Traumatic Brain Injury Model System 

Jeffrey S. Kreutzer, Ph.D., Virginia Commonwealth University, Richmond, VA; 

Project Number: 156; Start Date: October 1, 2002; Length: 60 months.

Abstract: This project, utilizing rigorous scientific methods, examines the benefits 

of intervention during the acute and post-acute periods after brain injury. TBIMS 

and other researchers have primarily focused on delineating outcomes. Until recently, concerns about survivors’ emotional well-being and adjustment to injury received scant attention. Yet, recent studies have identified a high prevalence of depression, with many survivors reporting feelings of hopelessness, diminished self-esteem, and social isolation. Brain injury also affects the family system; family members commonly describe emotional distress, lack of respite, financial stress, and lack 

of community support. Projects in three major research areas focus predominantly 

on survivors. One study examines pharmacological approaches to the treatment of 

depression, while another examines a structured approach to the treatment of acute 

cognitive and neurobehavioral problems. Examining the benefits of intervention programs for family members is the third major research area.

University of Washington Traumatic Brain Injury Model System 

Kathleen R. Bell, M.D., University of Washington, Seattle, WA; Project Number: 

150; Start Date: October 1, 2002; Length: 60 months.

Abstract: This program conducts research relevant to TBI, enhances services to 

consumers, and furthers the National Database and intersystem collaboration. The 

program’s three research projects are: (1) a randomized controlled intervention 

study examining the effect of exercise on depression after TBI. This low-cost, community intervention seeks to combat depression and emotional distress in persons 

with stable TBI by employing exercise as a positive approach to improved emotional 

and physical functioning and socialization. (2) An examination of the characteristics 

of TBI survivors who are able to return to employment and hold jobs that are stable 

and complex in nature, utilizing both the UW TBI longitudinal database and the 

Model System database. (3) An examination of the impact of the Medicare prospective payment system for inpatient rehabilitation on TBI survivors receiving access 

to acute rehabilitation efforts. The program also contributes to the National

Database.

MODEL SYSTEMS FOR SPINAL CORD INJURY REHABILITATION FUNDED

BY THE NATIONAL INSTITUTE FOR DISABILITY AND REHABILITATION RESEARCH

UAB Model Spinal Cord Injury Care System 

Amie B. Jackson, M.D., University of Alabama/Birmingham, Birmingham, AL; 

Project Number: 1649; Start Date: October 1, 2006; Length: 60 months.

Abstract: The University of Alabama at Birmingham provides rehabilitation services specifically designed to meet the special needs of individuals with spinal cord 

injury (SCI) through its multidisciplinary, comprehensive Spinal Cord Injury Care 

System (UAB–SCICS). The UAB–SCICS spans the clinical continuum from emergency services through rehabilitation and community re-entry. The System’s research includes one collaborative research module and two in-house research 

projects, all of which ultimately aim at improving the health and function of its constituents. The collaborative research module involves the validation of an outcome 

measure for functional recovery. One in-house research project involves the assessment of the predictive value of key parts of the neurological exam for return of bladder function; the second is an investigation of the effect of nicotine on different types 

of SCI pain. The project continues to benefit from the active involvement of persons 

with SCI in the design and execution of the proposed activities. Project results are 

disseminated via a variety of accessible formats and venues for both professionals 

and persons with SCI and their families. A detailed plan of operation ensures timely 

completion of project goals and tasks. Finally, an evaluation plan has been designed 

to assess the quality and timeliness of project outcomes and dissemination, as well 

as short and long term impacts of project activities. Activities of the UAB–SCICS 

reflect an active partnership both within the components of UAB’s health system 

and between UAB, the Lakeshore Foundation, and the Birmingham VA Medical 

Center. The project continues as a participant in data collection activities for the 

National Spinal Cord Injury Statistical Center.

Regional Spinal Cord Injury Care System of Southern California 

Robert L. Waters, M.D.; Rod Adkins, Ph.D., Los Amigos Research and Education Institute, Inc. (LAREI), Downey, CA; Project Number: 1029; Start Date: September 1, 

2000; Length: 72 months.

39

Abstract: The Regional Spinal Cord Injury Care System of Southern California’s 

primary mission is to collect initial and follow-up data on persons who have sustained spinal cord injuries and submit it to the national statistics database at the 

University of Alabama at Birmingham. Another component of the project focuses on 

literacy in individuals with SCI. Also, the project identifies, evaluates, and eliminates environmental barriers, particularly cultural and social barriers, to enable 

people with SCI to reintegrate fully into their community, and thus improve their 

lives. The project has been designed to meet the needs of the approximately 75 percent minority and underserved populations that comprise its clientele, and has samples sufficient for achieving adequate statistical power in the relevant designs and 

producing meaningful research. Finally, the System contributes new and useful information to the current collection of SCI literature. This project contributes to the 

national statistics database at the University of Alabama at Birmingham.

The Rocky Mountain Regional Spinal Injury System 

Daniel P. Lammertse, M.D.; Susan Charlifue, Ph.D., Craig Hospital, Englewood, 

CO; Project Number: 1652; Start Date: October 1, 2006; Length: 60 months.

Abstract: The Rocky Mountain Regional Spinal Injury System (RMRSIS) goals are 

to: (1) implement a program of research focusing on the immediate and long-term 

health, function, and community integration and participation of people with SCI; 

(2) improve its existing lifetime system of care for people with SCI; and (3) continue 

exemplary participation in the National SCI Database. A site-specific study determines if high vs. low tidal volumes are more effective in achieving ventilator 

weaning for individuals with high level tetraplegia, using a randomized clinical trial 

design. A collaborative research module study involves the development of a reliable, valid measurement tool to assess community participation. RMRSIS was first 

designated as a Regional Model System in 1974. The system includes two Level I 

trauma centers with specialized acute neurotrauma care facilities (St. Anthony Hospital and Swedish Medical Center) and the rehabilitation and lifetime follow-up 

services of Craig Hospital.

National Capital Spinal Cord Injury Model System 

Suzanne L. Groah, M.D., National Rehabilitation Hospital/MedStar Research Institute, Washington, DC; Project Number: 1657; Start Date: October 1, 2006; Length: 

60 months.

Abstract: The National Capital Spinal Cord Injury Model System (NCSCIMS) 

serves Washington, DC and the Nation. By focusing on the frequent and costly complication of pressure ulcers (PU), the NCSCIMS leverages two unique strengths: an 

existing Rehabilitation Research and Training Center on SCI that focuses on reduction of secondary conditions, and the population of Washington, DC, which is predominantly composed of underserved individuals. The Center includes two site-specific and one modular project and describes a system of care that meets SCIMS priorities: Site Specific Project 1 is a Practice-Based Evidence (PBE) project specifically 

focused on PU prevention for all individuals with SCI and/or disease (SCUD) during 

the acute and rehabilitative phases of care (to evolve to the community in later 

phases). The PBE approach allows a detailed examination of the effects of methods, 

modalities, and therapies utilized in rehabilitation to prevent PUs, which are often 

based on evidence-based medicine, but in reality may not be extrapolated to the 

broader population with SCUD. In this project, researchers aim to utilize a PBE approach to augment evidence based practice while addressing a critical secondary 

complication for individuals with SCI. Site Specific Project 2 is an SCI Navigator 

pilot project that combines elements of Peer Mentoring and Patient Navigation to 

decrease the occurrence of PUs once the individual has returned to the community. 

In this project, an SCI Navigator assists people with newly acquired SCI in the 

transition from inpatient rehabilitation to the community, within the framework of 

an, at times, dysfunctional healthcare system. The NCSCIMS works with the Model 

System at the University of Pittsburgh to explore Assistive Technology for Mobility 

(ATM). In this project, researchers investigate the degree to which inadequate 

wheelchair technology is the factor preventing people with SCI from doing more, 

work to understand the impact of changes in wheelchair reimbursement, and fully 

explore the issue of disparity in ATM prescription.

Georgia Regional Spinal Cord Injury Care System 

David F. Apple, Jr., M.D., Shepherd Center, Inc., Atlanta, GA; Project Number: 

1659; Start Date: October 1, 2006; Length: 60 months.

Abstract: The Georgia Regional Spinal Cord Injury Care System admits approximately 200 individuals annually with acute onset paralysis secondary to spinal cord 

40

injury, and collects post-discharge data on 600 individuals each year. Its patient 

population comes primarily from Georgia, the rest of the Southeast, and the Eastern 

Seaboard. The continuum of care begins at injury and continues through transport, 

assessment, acute care, rehabilitation, emotional adjustment, community reintegration, and lifetime follow-up. The project continues a long record of comprehensive 

and timely collection of data on subjects who meet the inclusion criteria in three 

categories: inpatient hospitalization; longitudinal collection at 1, 5, 10, 15, 20, and 

25 years post-injury; and registry. In addition to continued model system research, 

the project conducts two site specific research projects: (1) Psychological Status During Inpatient Rehabilitation and One Year After Onset: Stress, Coping, and Expectation Hope for Recovery; (2) Development and Validation of a Clinical Measure of 

Wheelchair Seat Cushion Degradation. The project also manages a collaborative 

data collection research module entitled Impact of SCI on Labor Market Participation.

Midwest Regional Spinal Cord Injury Care System (MRSCIS) 

David Chen, M.D., Rehabilitation Institute of Chicago, Chicago, IL; Project Number: 

1658; Start Date: October 1, 2006; Length: 60 months.

Abstract: The Spinal Cord Injury Rehabilitation Program at the Rehabilitation Institute of Chicago and the Acute Spinal Cord Injury Program at Northwestern Memorial Hospital demonstrate the ongoing comprehensive, multidisciplinary services 

that are provided to individuals with SCI which allow them to optimize their rehabilitation outcomes and enhance their ability to return to productive, independent 

living in the community. In order to contribute to the improvement of outcomes for 

persons with SCI, the System conducts two site-specific research projects: (1) Development of Low-Cost Devices to Increase Delivery of Intensive Treadmill Training, 

and (2) Disparities in Access to and Outcomes of Rehabilitation Care for Medicare 

and Medicaid Beneficiaries with Spinal Cord Injury. In addition, the project includes 

collaboration on one research project, Assistive Technology for Mobility (ATM) Module. MRSCICS has the capacity to enroll 140 individuals from culturally diverse 

backgrounds with new spinal cord injuries annually into the Spinal Cord Injury 

Model Systems database, and collect follow-up data on individuals enrolled between 

1973 and 2000.

The New England Regional Spinal Cord Injury Center 

Steve Williams, M.D., Boston University Medical Center Hospital, Boston, MA; 

Project Number: 1656; Start Date: October 1, 2006; Length: 60 months.

Abstract: The New England Regional Spinal Cord Injury Center (NERSCIC), 

based at Boston Medical Center (BMC), continues to forge new pathways in the care 

and quality of life of people with traumatic spinal cord injury (SCI). Additionally, 

NERSCIC maintains a research partnership with Boston’s Spaulding Rehabilitation 

Hospital, Northeast Rehabilitation Hospital in Salem, NH, and Gaylord Hospital in 

Wallingford, CT. NERSCIC conducts innovative research projects to improve health 

and long-term functioning of patients with SCI through a site-specific project, Computer Adaptive Testing (CAT) for SCI, and a collaborative module, Telehealth for 

Health. NERSCIC’s site-specific research project involves designing an improved 

outcome instrument in SCI research using traditional outcome assessment technology that presents difficult choices between comprehensive breadth and precision 

versus acceptable administration time and respondent burden. To solve this dilemma, this project applies contemporary measurement methods (CATS) to initiate 

a major transformation in the outcome assessment technology used to assess activity limitation frequently monitored in SCI research. Once the SCI–CAT has been 

developed using data collected from a major field study, the project conducts a demonstration of the SCI–CAT to evaluate its respondent burden, acceptability to patients and clinicians, as well as its breadth, precision, sensitivity to change, and validity with inpatients and outpatients with SCI who are receiving care from 

NERSCIC. Comparisons are made between the FIM and SCI–CAT over a 6-month 

follow-up period. The goal of the collaborative research project, Telehealth for 

Health, is the development and evaluation of an automated, telephone-based screening, referral, and behavioral intervention system with the long-term objective of promoting health and function by preventing and decreasing the severity of important 

secondary conditions among individuals with acute SCI, namely pressure ulcers, depression, and substance abuse.

University of Michigan Model Spinal Cord Injury Care System 

Denise G. Tate, Ph.D., University of Michigan, Ann Arbor, MI; Project Number: 

1653; Start Date: October 1, 2006; Length: 60 months.

41

Abstract: The overall purpose of this project is to provide comprehensive rehabilitation and community participation services and to generate new knowledge 

through research, development, and demonstration designed to improve outcomes 

for persons with spinal cord injury (SCI). A site-specific research study is conducted 

in partnership with faculty from the University of Michigan Depression Center, Department of Psychiatry, and the Molecular and Behavioral Neurosciences Institute. 

This study is a randomized clinical trial study designed to evaluate the efficacy of 

a pharmacological agent, Duloxetine (Cymbalta), as a preventive agent for reducing depression among persons with SCI. This clinical trial addresses a major need 

in the field as there are no randomized clinical trials currently available on the effectiveness of antidepressants in persons with SCI. In this study, the drug’s effects 

on pain are also assessed. An outcome of this study is the formulation of recommendations for antidepressant medication use in SCI and implications for clinical 

practice guidelines. The project continues to operate an efficient data collection system, facilitating research and contributions to the National SCI Database.

Missouri Model Spinal Cord Injury System 

Laura H. Schopp, Ph.D., ABPP, University of Missouri/Columbia, Columbia, MO; 

Project Number: 1019; Start Date: October 1, 2000; Length: 72 months.

Abstract: The Missouri Model Spinal Cord Injury System (MOMSCIS) is committed to developing, implementing, and evaluating innovative research promoting 

independent living and community integration among persons with spinal cord impairment. The study focuses on the effect of a consumer-directed personal assistance 

services training intervention on consumer satisfaction, independent living, and 

community integration. The study develops, implements and evaluates the in-person 

Individualized Management of Personal Assistant/Consumer Teams (IMPACT) 

workshop. Workshop participants receive information on preventing and treating 

secondary medical conditions, including pressure sores, urinary tract infections, 

bowel and bladder management, autonomic dysreflexia, pain management, chronic 

fatigue, and thermoregulation, and information on relationship issues, such as hiring and firing, communication styles and strategies, assertiveness, and team building. Study objectives are: (1) to determine the effect of the IMPACT workshop on 

consumer satisfaction, the incidence of secondary conditions, activity, and participation (as defined by the ICF); (2) to determine the effect of the IMPACT workshop 

on personal assistants’ job satisfaction, job stress and attrition; and (3) to provide 

online resources to the disability community, including an online personal assistant 

training manual for consumers and assistants, and an online resources database. 

Activity and participation are measured by the PARTicipation Survey for persons 

with Mobility Limitations (PARTS/M).

Northern New Jersey Spinal Cord Injury System 

David S. Tulsky, Ph.D., Kessler Medical Rehabilitation Research and Education 

Corporation (KMRREC), West Orange, NJ; Project Number: 1651; Start Date: October 1, 2006; Length: 60 months.

Abstract: The Northern New Jersey Spinal Cord Injury System (NNJSCIS) provides a comprehensive continuum of state-of-the-art care for persons with spinal 

cord injury (SCI) and their significant others from time of injury through long-term 

follow-up in the community and conducts spinal cord research, including clinical research and the analysis of standardized data. NNJSCIS conducts both a site-specific 

research study and a collaborative module. These studies contribute to evidencebased rehabilitation interventions and clinical and practice guidelines that improve 

the lives of individuals with SCI and consist of the following: An innovative rehabilitation intervention utilizing technology to prevent respiratory disease in persons 

with SCI, now the leading cause of death and the third leading cause of hospitalizations in this population; a collaborative module that adapts, develops, and validates 

an innovative and promising outcome system for use in SCI intervention research; 

and the NNJSCIS coordinates with the NIDRR-funded Model Systems Knowledge 

Translation Center to provide scientific results and information for dissemination to 

clinical and consumer audiences. This project is a cooperative effort of the Kessler 

Medical Rehabilitation Research and Education Corporation (KMRREC), the Kessler 

Institute for Rehabilitation (KIR), the University of Medicine and Dentistry of New 

Jersey-The New Jersey Medical School (UMDNJ–NJMS), and UMDNJ-University 

Hospital.

Mount Sinai Spinal Cord Injury Model System 

Kristian T. Ragnarsson, M.D., Mount Sinai School of Medicine, New York, NY; 

Project Number: 1655; Start Date: October 1, 2006; Length: 60 months.

42

Abstract: The research program of Mount Sinai Spinal Cord Injury Model System 

(MS–SCI–MS) is designed to advance the understanding of spinal cord injury (SCI) 

and its consequences, and to develop better methods of treatment of secondary conditions of SCI, especially pain. The purpose of this project is to: (1) demonstrate and 

evaluate a multidisciplinary system of rehabilitation care for persons with SCI in 

the New York City metropolitan area, including innovative programs for community 

integration; (2) contribute longitudinal data to the SCI National Database of the 

Model Systems program; (3) systematically collect and analyze extensive information on chronic pain after SCI. The site-specific project studies modified-release formulation of morphine sulfate for neuropathic pain after spinal cord injury through 

a randomized, double-blind crossover trial of modified-release morphine and placebo 

for patients with uncontrolled neuropathic pain of three types.

Northeast Ohio Regional Spinal Cord Injury System 

Gregory A. Nemunaitis, M.D., MetroHealth System, Cleveland, OH; Project Number: 1662; Start Date: October 1, 2006; Length: 60 months.

Abstract: The Northeast Ohio Regional Spinal Cord Injury System (NORSCIS) at 

MetroHealth Rehabilitation Institute of Ohio in collaboration with Case Western Reserve University and the Cleveland FES Center conducts research to further develop the effectiveness of an innovative Model Spinal Cord Injury Care System and 

to demonstrate how the application of advanced assistive technology can benefit persons with disabilities. NORSCIS offers a world-class multi-disciplinary system of 

spinal cord injury care and a 40-year tradition of excellence. Efficiency and effectiveness of care (and research potential) are enhanced as all components of the continuum of care (from trauma/emergency care to acute medical/surgical treatment to 

inpatient rehabilitation to outpatient rehabilitation and community support services) are on one campus. A site-specific project studies advances in functional electrical stimulation (FES) technology to document improvements in function, health, 

and wellness. An innovative focus on trunk muscle stimulation targets specific clinical problems, including seated stability and mobility, reachable workspace, and pulmonary function. A collaborative research project with UPMC–SCI, is directed at 

testing and collecting the data needed to understand the impact of coverage changes 

and to fully explore the issue of disparity in assistive technology for mobility prescription. A collaborative project with Craig Hospital involves the development of a 

reliable, valid measurement tool to assess community participation. The goal of 

these hypothesis-driven research and demonstration projects is to develop and measure the effectiveness of new intervention strategies at both the individual patient 

level and overall systems of care for persons with spinal cord injury.

Regional Spinal Cord Injury Center of the Delaware Valley 

Ralph Marino, M.D., Thomas Jefferson University, Philadelphia, PA; Project Number: 1660; Start Date: October 1, 2006; Length: 60 months.

Abstract: The Regional Spinal Cord Injury Center of the Delaware Valley 

(RSCICDV) provides and evaluates a comprehensive program of coordinated patient 

care, education, and research activities for individuals who have sustained a traumatic spinal cord injury (SCI). Clinical activities are directed at promoting evidence 

based practice to improve outcomes and reduce medical complications in persons 

with SCI. Research activities are designed to develop and validate upper and lower 

extremity outcome measures for use in clinical trials. Specifically, RSCICDV: (1) 

contributes to the National Database by enrolling an estimated 50 new subjects per 

year into the database and by collecting follow-up data on previously enrolled subjects; (2) conducts an onsite research project whose focus is to develop and validate 

the Capabilities of Arm and Hand in Tetraplegia (CAHT), an objective test of arm 

and hand functional capabilities needed to conduct clinical trials for neurological recovery in SCI; (3) participates in a collaborative module on evaluating an automated 

phone follow-up system for people with SCI; (4) participates in a collaborative module on validation of an outcome measure for motor recovery in incomplete SCI; and 

(5) develops educational resources for patients, healthcare providers

and researchers.

University of Pittsburgh Model Center on Spinal Cord Injury 

Michael L. Boninger, M.D., University of Pittsburgh, Pittsburgh, PA; Project Number: 1650; Start Date: October 1, 2006; Length: 60 months.

Abstract: The UPMC–SCI continues its research focus on assistive technology 

(AT) for mobility. Pilot data collected during the previous funding cycle highlighted 

disparity in wheelchair prescription. Individuals from minority groups and people 

with low socioeconomic status received less and lower quality equipment. So that 

43

interventions can be developed, the project continues and expands this research to 

delve into the reasons for disparity. In addition, it investigates the impact of recent 

Centers for Medicare and Medicaid Services (CMS) changes for AT reimbursement. 

These changes will likely have a critical impact on the AT provided to individuals 

with spinal cord injury (SCI). Finally, the project develops a tool to determine how 

far, how fast, and when people travel in their wheelchairs. This data is related to 

the types of wheelchairs used, to the number of wheelchair failures, and to measures of participation. From these findings, researchers determine how the wheelchair prescribed impacts participation, and if greater use leads to greater failures. 

This data can be used to push for improvements in manufacturing and changes in 

coverage. UPMC–SCI also conducts a randomized, controlled trial to determine if 

following the Consortium of Spinal Cord Injury Medicine Guidelines on Upper Limb 

Preservation leads to decreased pain. These guidelines are applied to acutely injured 

patients who are followed for the first 6 months after injury. Validation of the guidelines’ effectiveness helps assure that they become the standard of care across the 

country. SCI care at the University of Pittsburgh is provided in a multidisciplinary 

manner with a high level of communication among the constituent services. The 

project has fully implemented a system of continuity of treatment that begins with 

the emergency response at the scene of injury and continues with comprehensive 

treatment and rehabilitation from medical/surgical to acute stage rehabilitation 

through utilization of assistive technology services and vocational rehabilitation. 

The research and Model of Care set forth in this proposal will have a significant 

impact on the lives of individuals with SCI, leading to greater participation and employment. UPMC-SCI continues to enroll and collect long term follow up data on 

SCI subjects for the National Spinal Cord Injury Statistical Center.

Texas Model Spinal Cord Injury System 

Daniel Graves, Ph.D.; William Donovan, M.D., The Institute for Rehabilitation and 

Research (TIRR), Houston, TX; Project Number: 1661; Start Date: October 1, 2006; 

Length: 60 months.

Abstract: The Texas Model Spinal Cord Injury System (TMSCIS) provides services 

along the entire continuum of care from emergency medical service to long-term follow-up and management of secondary conditions. The TMSCIS includes a site-specific research project that is designed to provide high level evidence of the efficacy 

of a novel treatment to prevent bladder complications. The project is a randomized, 

double blind placebo, controlled parallel groups investigation of the effects of Botulinum toxin A treatment of detrusor external sphincter dyssynergia (DESD) during 

early spinal cord injury. Many patients with SCI develop neurogenic bladder dysfunction associated with detrusor hyperreflexia and DESD that can lead to longterm complications in up to 50 percent of patients. These complications include hydronephrosis, vesicoureteral reflux, nephrolithiasis, sepsis, renal insufficiency or 

failure, and even death. This investigation is intended to determine if the prevention of DESD in the early phase of recovery can prevent some of these complications. In addition, the TMSCIS includes a module designed to develop an outcome 

measure of trunk and postural control to be utilized in activity-based therapy programs like locomotor training. The outcomes of large scale clinical trials of locomotor 

training highlight the need for outcome measures that are designed to capture 

changes brought about by translational research that may not have been necessary 

for more traditional therapy programs. This scale development project incorporates 

item response theory methods as well as reliability and validity investigations in a 

minimum of four model systems.

VCU Model Spinal Cord Injury Center 

William O. McKinley, M.D.; David X. Cifu, M.D., Virginia Commonwealth University, Richmond, VA; Project Number: 1020; Start Date: October 1, 2000; Length: 72 

months.

Abstract: This project develops and implements a Model Spinal Cord Injury System at Virginia Commonwealth University/Medical College of Virginia (VCU/MCV), 

that has a concentrated emphasis on employment. Researchers within this Model 

Systems systematically monitor and assess the impact of interventions, advancing 

technology, and policy changes on employment following SCI. In addition to contributing to the National Statistical Database at the University of Alabama at Birmingham, the VCU SCI Model System has three research studies. These studies involve the direct utilization of the SCI National Database, a major employment policy 

study across 18 states, and also an evaluation of technology training on employment 

of outcome. Involvement of SCI mentors in training new vocational mentors with 

SCI is also an important aspect of the project. By looking at the issues associated 

44

with employment for persons with SCI, this project complements other resources in 

place within VCU/MCV, including the RRTC on Workplace Supports, long-term relationships with the Virginia Department of Rehabilitation Services, and existing SCI 

Model Systems delivery of care. A significant number of persons with disabilities are 

involved as project staff as well as on an Advisory Board. A close relationship with 

the Mid-Atlantic Paralyzed Veterans Association (PVA) enhances training, dissemination, and other outreach activities.

Northwest Regional Spinal Cord Injury System 

Charles H. Bombardier, Ph.D., University of Washington, Seattle, WA; Project Number: 1654; Start Date: October 1, 2006; Length: 60 months.

Abstract: The University of Washington’s Northwest Regional Spinal Cord Injury 

System (NWRSCIS) serves a critical mass of patients with SCI and has all the necessary disciplines to provide state-of-the-art medical, surgical, and rehabilitation 

care. One site-specific project is a randomized controlled intervention study evaluating the effect of proactive, structured, telephone-based counseling and care management on rehospitalization rate and quality of life during the first year after discharge from acute rehabilitation. This study builds upon successful experiences with 

telephone counseling for both people with traumatic brain injury and multiple sclerosis. This research is particularly important because the lifestyle changes and 

health care behaviors required for successful living after SCI are tremendously challenging, rates of rehospitalization are high, and many people (especially in rural regions) lack ready access to knowledgeable advice, behavior change support, and specialty care sufficient to maintain their health. A modular project studies the natural 

history of major depression under conditions of usual care during the first year after 

SCI. This project establishes reliable and valid means of screening and diagnosing 

major depression soon after SCI. It examines the impact of depression on rehabilitation efficiency and compares the effect of standard treatment to clinical practice 

guideline level care of depression. This study describes depression treatment preferences among people with SCI and lays the foundation for a multi-site clinical trial. 

This project contributes to the national statistics database at the University of

Alabama at Birmingham.

REHABILITATION RESEARCH AND TRAINING CENTERS OF THE NATIONAL INSTITUTE

FOR DISABILITY AND REHABILITATION RESEARCH

Rehabilitation Research and Training Center on Measuring Rehabilitation Outcomes 

and Effectiveness 

Allen W. Heinemann, Ph.D., Feinberg School of Medicine, Chicago, IL; Project Number: 1463; Start Date: December 1, 2004; Length: 60 months.

Abstract: The purpose of this RRTC is to provide national leadership on the functional assessment, outcomes, and health policy issues facing the medical rehabilitation community and the diverse consumers it seeks to serve. The Center conducts 

research; hosts forums for discussion; publishes in rehabilitation, health policy, and 

consumer literature; trains researchers in rehabilitation-focused health services research; and disseminates information to diverse consumer, provider, and academic 

audiences. The RRTC’s research seeks to (1) enable comparison of functional status 

measures across post-acute settings so information can be provided to consumers 

and other rehabilitation stakeholders about the outcomes and effectiveness of various post-acute care settings; (2) develop an innovative measure of community participation in a meaningful, reliable, and valid manner in order to better describe the 

long-term outcomes of rehabilitation services; (3) increase the efficiency of outcome 

data collection so more resources can be directed to patient care; (4) examine how 

format and presentation style influences patient understanding of rehabilitation 

quality outcome indicators in order to provide information in ways that are helpful 

for consumers when selecting rehabilitation services. The project uses recent developments in item response theory and computer adaptive testing and stakeholder 

input in test development, outcomes reporting, and quality indicator reporting. The 

expected outcomes are a rational basis for provision of rehabilitation services postacute care settings, increased efficiency of data collection, a better measure of community participation, and outcome reporting that is responsive to stakeholder needs. 

Dissemination activities include post-graduate and post-doctoral training opportunities, conferences, and a Web site that provides information on measurement of rehabilitation outcomes across the continuum of post-acute settings.

45

Rehabilitation Research and Training Center on Policies Affecting Families of

Children with Disabilities 

H.R. Turnbull, L.L.M.; Ann Turnbull, Ed.D., University of Kansas; Lawrence, KS; 

Project Number: 110; Start Date: November 1, 2003; Length: 60 months.

Abstract: This center conducts eight research projects on the effects of the policies 

of governments, systems, networks, and agencies on the family quality of life and 

community integration (FQOL/FCI) of families who have children with developmental disabilities and emotional-behavioral disabilities or both. Researchers identify four target populations: families, providers, policy-leaders, and networks (all at 

the Federal, state, and local levels). Three policy challenges are prisms through 

which the effects of policy on families can be understood: early intervention, alternative schools, and consumer control of funding. For each policy challenge, researchers inquire into whether the applicable Federal and state policies and practices, and 

the applicable network policies, advance FQOL/FCI; whether the policies across education, social services, and health care are mutually consistent with each other and 

advance FQOL/FCI; and whether the practices of agencies in those systems advance 

FQOL/FCI. The center’s analytical framework holds that the core concepts shape 

policies, policies shape services, policies and services should be coordinated and delivered through partnerships. Enhanced FQOL/FCI occurs when there is coherence 

among core concepts, coordinated policies delivered through partnerships, and coordinated services delivered through partnerships; and influencing factors must invariably be taken into account.

Rehabilitation Research and Training Center on Demographics and Statistics 

Andrew J. Houtenville, Ph.D., Cornell University, Ithaca, NY; Project Number: 269; 

Start Date: December 1, 2003; Length: 60 months.

Abstract: The RRTC on Demographics and Statistics (Cornell StatsRRTC) bridges 

the divide between the sources of disability data and the users of disability statistics. The project conducts research exploring the reliability of existing data sources 

and collection methods, and studies the potential to improve current and future data 

collection efforts. In addition, the project utilizes existing data sources to provide a 

comprehensive and reliable set of statistics, and increase access to and understanding of how statistics can be used effectively to support decision making. Cornell StatsRRTC works with key organizations to determine their needs and helps 

them maximize the use of disability statistics in their ongoing efforts to improve the 

lives of people with disabilities and their families. As members of the Cornell 

StatsRRTC, the American Association of People with Disabilities, the Center for an 

Accessible Society, and InfoUse provide vital expertise and resources needed to 

reach the users of disability data and statistics. The Cornell StatsRRTC includes researchers from Cornell University, Mathematica Policy Research, the Urban Institute, and the Institute for Matching People and Technology, all of which bring extensive expertise in working with and creating sources of disability data.

University of Illinois at Chicago National Research and Training Center on

Psychiatric Disability 

Judith A. Cook, Ph.D., University of Illinois at Chicago, Chicago, IL; Project Number: 1559; Start Date: October 1, 2005; Length: 60 months.

Abstract: The University of Illinois at Chicago National Research and Training 

Center on Psychiatric Disability (UIC–NRTC) promotes access to effective consumercentered and community-based practices for adults with serious mental illness. The 

Center is conducting five rigorous research projects to enhance the state of evidencebased practice (EBP) in this field: A randomized controlled trial (RCT) study of 

Wellness Recovery Action Planning (WRAP) to gather evidence regarding its effectiveness; an RCT to evaluate the effectiveness of BRIDGES, a 10-week peer-led education course designed to provide mental health consumers with basic education 

about the etiology and treatment of mental illness, self-help skills, and recovery 

principles; an RCT of peer support services delivered by Georgia’s Certified Peer 

Specialists (CPS) at consumer-run Peer Support Centers in order to determine the 

outcomes of service recipients; a self-directed care program in which adults with serious mental illnesses are given control of financial resources to self-direct their own 

recovery; and a project using data from 12 clinical trials studies of consumer-operated service programs to create a national data repository to promote research and 

develop scholarship in this area. The Center also conducts state-of-the-art training, 

dissemination, and technical assistance projects designed to enhance the leadership 

skills of people with psychiatric disabilities, and evaluate a self-advocacy skills 

training program delivered to clients of a large psychosocial rehabilitation agency. 

Additional projects evaluate self-advocacy skills training programs and implement 

46

training programs to prepare consumer leaders in the State of California to take 

part in systems change in their local communities. UIC–NRTC is embarking on an 

academic curriculum transformation project starting at UIC in the medical, social, 

and behavioral sciences to incorporate principles of recovery and EBP for people 

with psychiatric disabilities. The UIC–NRTC is designing and administering a nocost online certification program, providing comprehensive introduction of knowledge required by peer providers. Additionally, the UIC–NRTC is providing training 

and developing projects and tools to assist individuals in recovery to gain the skills 

necessary for community integration through enhancing the research capacity of 

three federally funded consumer-run Technical Assistance Centers. Finally, the 

UIC–NRTC is offering an annual series of online workshops; Web-based continuing 

education courses; and a state of science national conference (2008) focusing on 

EBP, research implementation, consumer-centered systems, workforce development, 

and other emerging trends.

Rehabilitation Research and Training Center on Improving Vocational Rehabilitation Services for Individuals Who Are Deaf or Hard of Hearing 

Douglas Watson, Ph.D., University of Arkansas, Little Rock, AR; Project Number: 

263; Start Date: October 1, 2001; Length: 60 months.

Abstract: This program conducts coordinated research and training to enhance the 

rehabilitation outcomes of persons who are deaf or hard of hearing who are served 

by VR and related employment programs. When appropriate, the unique needs of 

specific subgroups within this diverse and heterogeneous population are investigated. The ultimate goal of these efforts is to improve the capacity of the VR system and related programs to address the career preparation, entry, maintenance, 

and advancement, as well as the community living needs, of the target population. 

Research activities include: investigating the impact of changes in Federal employment and rehabilitation legislation and policy on the delivery of services to the target population; investigating the impact of business practices that contribute to accessible work and workplace supports to enhance the employment of the target population; and identifying, developing, and assessing rehabilitation-related innovations 

that enhance employment and community living outcomes of the target population.

Rehabilitation Research and Training Center on Disability in Rural Communities 

Tom Seekins, Ph.D., University of Montana, Missoula, MT; Project Number: 265; 

Start Date: December 1, 2002; Length: 60 months.

Abstract: The research conducted by this project improves the employment status 

of people with disabilities in the rural U.S., enhances their ability to live independently, and advances the science of rural disability studies. Four core areas comprise 

eleven research projects in rural employment and economic development; rural 

health and disability; rural community transportation and independent living; and 

rural policy foundations. Projects include: (1) develop scientific methods to measure 

how rural environments influence an individual’s community participation; (2) collaborate with very small rural businesses to employ people with disabilities; (3) improve rural transportation options; and (4) create programs to prevent or improve 

secondary conditions. Other projects explore ways for new partners, including faithbased organizations, to be involved in improving rural services. A training program 

disseminates research findings, trains students, and sparks the creative engagement 

of policymakers and social advocates. The innovative STATE (Same-Time Availability to Everyone) policy requires that the project provide standard print publications to the general public only when at least two alternative formats are also available to individuals with disabilities.

Rehabilitation Research and Training Center on Employment Policy and Individuals 

with Disabilities 

Susanne Bruyere, Ph.D.; Richard Burkhauser, Ph.D.; David Stapleton, Ph.D., Cornell University, Ithaca, NY; Project Number: 1466; Start Date: December 1, 2004; 

Length: 60 months.

Abstract: The ultimate goal of the Employment Policy Rehabilitation Research 

and Training Center (EP–RRTC) is to increase the employment and economic selfsufficiency of people with disabilities and improve the quality of their lives. The immediate purpose is to contribute to the success of the transition from caretaker policies to economic self-sufficiency policies. Specific goals and objectives are: completion 

of new research activities that will generate knowledge about the effects of past disability policy and other factors on economic self-sufficiency, the impact of current 

and future initiatives designed to promote economic self-sufficiency, and/or the likely 

success of new policy options; completion of 20 publishable papers and companion 

47

policy briefs; training of consumers via 12 or more Washington-based Disability Policy Forums; training of 5 graduate students; a third-year conference; a conference 

volume; and technical assistance to consumers on policy research and evaluation 

methods and data. Short-term project outcomes include: annual interpretation of updated employment rate trends; a synthesis and critique of many relevant evaluation 

efforts; three or more significant policy options and ideas for next steps; reviews of 

three or more significant policy or program successes; detailed information on interactions between numerous programs and policies, and how they discourage employment; estimates of impacts of two public policies on employment and earnings for 

state VR clients; estimates of the impact of the ADA on both employer provision of 

accommodations and job retention after disability onset; estimates of the return to 

higher education for those with profound hearing loss; and two additional analyses 

of the role that human capital plays in determining economic self-sufficiency for 

adults with disabilities. Intermediate outcomes include use of this information in 

the policy improvement effort, and long-term outcomes include policy changes that 

increase the economic self-sufficiency of people with disabilities.

Rehabilitation Research and Training Center on Improving Employment Outcomes 

John O’Neill, Ph.D., Hunter College of CUNY, New York, NY; Project Number: 

1469; Start Date: October 1, 2004; Length: 60 months.

Abstract: This Employment Service Systems Research and Training Center develops, enhances, and utilizes partnerships to improve the quality of employment services, opportunities, and outcomes for people with disabilities. Five research projects 

have been designed to meet this goal and examine partnerships across public agencies, between not for-profit and public agencies, and between rehabilitation agencies 

and businesses. The Consortia for Employment Success (CES) creates and evaluates 

fully integrated disability service provider networks in three local communities. The 

CES increases access for people with disabilities to both effective, comprehensive 

placement services, and a well-managed and centralized employer network that will 

increase employment and career advancement opportunities for persons with disabilities. The Workplace Socialization Model (WPS) supplements the CES Model by 

focusing on job enhancement and retention. The WPS aims to extend the job tenure 

of employees with a disability and other positive work outcomes including the employee’s job satisfaction, organizational commitment, and level of work culture competency, as well as the employer’s satisfaction with the employee’s job performance. 

Identification of ‘‘Good Practices’’ Within Vocational Rehabilitation is designed to 

identify a variety of good practices currently being used in the State-Federal VR system across the U.S. that facilitate consumer access to services and enhance employment outcomes. Designing and Testing Comprehensive Employment Practice and 

Policy Initiatives within a Vocational Rehabilitation State Agency develops and tests 

a model that leads to enhanced employment outcomes. The model includes the 

‘‘human capital’’ characteristics of persons with disabilities as well as what vocational rehabilitation delivery systems add to these human capital factors to improve 

outcomes. A Study of Disability Navigators in One-Stops collects data on Workforce 

Investment Act regions in which Navigators operate and compares levels of customer satisfaction and employment outcomes between regions that use Navigators 

and regions that have no such positions.

Rehabilitation Research and Training Center on Substance Abuse, Disability, and 

Employment 

Dennis C. Moore, Ed.D., Wright State University, Kettering, OH; Project Number: 

1465; Start Date: December 1, 2004; Length: 60 months.

Abstract: This RRTC builds on previous findings to positively impact persons with 

disabilities who also experience substance use disorders, as well as the service providers upon whom they depend. The highly integrated program of research addresses the following goals and objectives: (1) Promote widespread use of substance use 

disorder screening among persons with disabilities who utilize disability-related employment services. This is accomplished by developing and validating a new substance abuse screener called the ‘‘SASSI–VR’’. Following two stages of development 

and validation, the SASSI–VR is evaluated in three vocational rehabilitation (VR) 

programs on a statewide basis. (2) Conduct a randomized clinical trial of a model 

of supported employment, Individualized Placement and Support (IPS), to test its 

efficacy among persons with traumatic brain injury or other severe disabilities that 

also have a substance use disorder. The two trial sites are affiliated with rehabilitation programs in the Wright State and Ohio State medical schools. Utilization of the 

IPS model with the study populations holds tremendous potential or impacting services delivery for consumers who experience very low rates of employment. (3) ReVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00051 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
48

search policy and practices relative to their impact on VR services for persons with 

a disability and coexisting substance abuse. Serving as a critical complement to Rl, 

the roles of policies, statutes, guidelines, and VR service delivery practices will be 

investigated within the larger community of public agencies. (4) Investigate factors 

that specifically contribute to unsuccessful case closure among consumers of VR 

services. This component studies recent VR unsuccessful closures and their counselors, and the study has particular sensitivity to the role of ‘‘hidden’’ substance 

abuse among unsuccessful closures.

Rehabilitation Research and Training Center on Workplace Supports and Job

Retention 

Paul Wehman, Ph.D., Virginia Commonwealth University, Richmond, VA; Project 

Number: 1467; Start Date: November 1, 2004; Length: 60 months.

Abstract: The purpose of the RRTC on Workplace Supports and Job Retention is 

to study those supports which are most effective in the workplace for assisting persons with disabilities to maintain employment and advance their careers. Research 

includes two long-term prospective randomized experimental control research 

projects: (1) determining the efficacy of public/private partnerships, and (2) determining the efficacy of business mentoring and career based interventions with college students with disabilities. The RRTC is partnered with Manpower, Inc., several 

community rehabilitation programs, and the VCU Business Roundtable. Additional 

projects look at disability management practices, extended employment supports, job 

discrimination in employment retention, benefits planning and assistance, and 

workplace supports. These studies are done in conjunction with Equal Employment 

Opportunity Commission, the Society of Human Resource Professionals, and the 

U.S. Chamber of Commerce.

Aging-Related Changes in Impairment for Persons Living with Physical Disabilities 

Bryan J. Kemp, Ph.D., Los Amigos Research & Education Institute, Inc., Downey, 

CA; Project Number: 266; Start Date: August 1, 2003; Length: 60 months.

Abstract: This project is a combined effort of Rancho Los Amigos National Rehabilitation Center and the University of California at Irvine, with other collaborators 

including the Center for Disability in the Health Professions at Western University 

and two Rehabilitation Engineering Research Centers. This project evolves from the 

fact that persons who have a disability are now living into middle age and late life 

in ever-increasing numbers. However, many of these people appear to be experiencing premature age-related changes in health and functioning. The project tests 

a model for improved understanding of these problems and interventions to help alleviate them. Persons who are experiencing these kinds of problems and their families are included in all center projects. The training, dissemination, and technical 

assistance activities include clinical training of current and future health providers, 

current and future researchers, persons with disabilities, their families, and policymakers. Both traditional methods of one-on-one and group training as well as technology-based distance training techniques are used to reach national audiences and 

underserved populations.

Rehabilitation Research and Training Center in Neuromuscular Diseases

(RRTC/NMD) 

Craig McDonald, M.D., University of California, Davis, Davis, CA; Project Number: 

273; Start Date: December 1, 2003; Length: 60 months.

Abstract: The purpose of the Rehabilitation Research and Training Center in Neuromuscular Diseases (RRTC/NMD) is to enhance the health, function, and quality 

of lives of persons with neuromuscular diseases (NMD). The goals of this project are 

to: (1) develop a program for multicenter rehabilitation research in NMD through 

the Cooperative International Neuromuscular Research Group (CINRG); (2) conduct 

research that continues to address rehabilitation needs, particularly related to exercise, nutrition, pain, secondary conditions, and the quality of life of individuals with 

neuromuscular diseases; (3) develop and evaluate new or emerging technologies and 

interventions that provide the information needed to improve employment, community integration, and quality of life outcomes for this population of individuals with 

disabilities; (4) develop and evaluate appropriate health promotion and wellness programs that enhance the ability of individuals with neuromuscular disease to be 

physically active and participate in recreational activities; and (5) conduct a comprehensive program of training, dissemination, utilization, and technical assistance 

activities that are well-anchored in the research program and address the needs

of stakeholders.

49

Rehabilitation Research and Training Center on Spinal Cord Injury: Promoting 

Health and Preventing Complications through Exercise 

Suzanne L. Groah, M.D., National Rehabilitation Hospital/MedStar Research Institute, Washington, DC; Project Number: 270; Start Date: December 1, 2003; Length: 

60 months.

Abstract: This project systematically and comprehensively addresses the role and 

impact of physical activity in the prevention of secondary conditions in people with 

spinal cord injury (SCI). Initially, the project establishes critical, yet-undefined 

physiological responses to exercise in SCI and comprehensively examines cardiovascular disease risk in individuals with SCI applying accepted guidelines used in 

the able-bodied population. The project develops exercise formats specifically designed according to severity of SCI and chronicity of SCI to address the prevention 

of and knowledge regarding osteoporosis and other secondary conditions. In addition, the project determines whether regular exercise is related to fewer secondary 

conditions. These research findings feed into four training activities that include a 

peer mentoring program for newly injured people with SCI, a consumer-driven education curriculum for physical therapy and medical students, a state-of-science and 

training conference, and the development of a virtual resource network on exercise 

and prevention. The RRTC is a collaborative effort of clinical and disability researchers, SCI consumer organizations, and independent living advocates. The 

RRTC maintains a Live Journal site at http://rrtc-sci.livejournal.com/

and a Webcast on Exercise and Physical Activity for Persons with SCI

at http://nrhfoundry.medstar.net/mediasite/viewer/?cid=d8381286-2ad2-4fed-922c31464b0cc049.

RRTC on Technology Promoting Integration for Stroke Survivors: Overcoming

Social Barriers 

Elliot J. Roth, M.D., Rehabilitation Institute Research Corporation, Chicago, IL; 

Project Number: 275; Start Date: October 1, 2003; Length: 60 months.

Abstract: This project develops and evaluates a sequence of robotic training and 

assistive devices that are designed with the idea of promoting efficient function in 

the workplace or at home, and with the further intent that they form a basis for 

the development of appropriate technologies to allow people with disabilities ready 

access to existing facilities in the community. At each stage the project engages engineering students as a means to provide intensive effort for development of novel 

designs, but also to provide valuable opportunities for training students in the 

themes related to recovery of function and community integration of people with disabilities. Other projects at this center include: the use of emotionally expressive and 

narrative writing to facilitate coping and adaptation after stroke; computerized 

training for conversational scripts that facilitate access to the community and workforce; and a consumer-directed, dynamic assessment methodology for evaluating 

community living and work participation environments and technologies for use by 

people who have had a stroke. In addition to these projects, the RRTC develops and 

evaluates a comprehensive plan for training directed to stroke survivors and their 

families, students, researchers, clinicians, and service providers. These approaches 

are implemented through a variety of mechanisms, including continuing education 

courses, Web-based presentations, and intensive training in our research facilities.

Missouri Arthritis Rehabilitation Research and Training Center (MARRTC) 

Jerry C. Parker, Ph.D., University of Missouri, Columbia, MO; Project Number: 274; 

Start Date: October 1, 2003; Length: 60 months.

Abstract: The purpose of the Missouri Arthritis Rehabilitation Research and 

Training Center (MARRTC) is to provide leadership at the national level in support 

of three key objectives: to reduce pain and disability, to improve physical fitness and 

quality of life, and to promote independent living and community integration for 

persons with arthritis of all ages in the United States. State-of-the-science rehabilitation research addresses the needs of persons with arthritis in the following areas: 

(1) home and community-based self-management programs, (2) benefits of exercise 

and physical fitness, and (3) technologies available to the broad populations of persons with arthritis in the environments where they live, learn, work, and play. The 

MARRTC conducts training and capacity-building programs for critical stakeholders 

within the arthritis disability arena, including consumers, family members, service 

providers, and policymakers. Additionally, the MARRTC provides technical assistance for persons with arthritis and other stakeholders in order to promote utilization of arthritis-related, disability research. The MARRTC also provides widespread 

dissemination of informational materials to persons with disabilities, their repVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00053 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
50

resentatives, service providers, and other target audiences (e.g., editors

and reporters).

Rehabilitation Research and Training Center on Traumatic Brain Injury

Interventions 

Wayne A. Gordon, Ph.D., Mount Sinai School of Medicine, New York, NY; Project 

Number: 1464; Start Date: October 1, 2004; Length: 60 months.

Abstract: The research program includes two randomized clinical trials (RCTs) 

and two projects supportive of better everyday interventions and better research: 

Research Study 1 (R1) is an RCT of a treatment for depression: cognitive behavioral 

therapy, adapted to address the unique cognitive and behavioral challenges of people with TBI that often pose barriers to treating depression, a major factor in reducing post-TBI quality of life, is compared to supportive therapy. In R2, a second RCT, 

a standard day treatment program is compared to a similar program (Executive 

Plus), augmented with modules to improve executive functioning and attention 

training. R3, Support for Evidence-Based Practice, evaluates all published research 

on post-TBI interventions and assessment of outcomes; it serves as a national resource for disseminating the results. It also implements three participatory action 

research-based analyses of high priority areas, including meta-analyses if appropriate. In addressing improved outcome measurement, R4 focuses on the PART instrument, a measure of participation currently being tested within eight TBI Model 

Systems. R4 focuses on creating a subjective approach to serve as a complement to 

the PART’s current focus on objective assessment. A major focus of the RRTC is 

placed on capacity building of clinical and research professionals to address the need 

for better day-to-day interventions in the lives of people with TBI. Often their medical needs are misread, their brain injury goes unidentified, and they find services 

and accommodations inappropriate. Capacity building focuses on students early in 

their educational career—to help shape career choice and points of view; graduate 

and post-graduate students; and practicing ‘‘gate keepers’’ in the community, primarily psychologists and physicians.

Rehabilitation Research and Training Center on Health and Wellness in Long Term 

Disability 

Gloria Krahn, Ph.D., M.P.H., Oregon Health and Science University, Portland, OR; 

Project Number: 1459; Start Date: October 1, 2004; Length: 60 months.

Abstract: The vision of the RRTC is to contribute to the reduction of health disparities for person with disabilities through an integrated program of research, 

training, technical assistance, and dissemination. The Center has three inter-related 

strands of work to address its three intended outcomes/goals: (1) identify strategies 

to overcome barriers that impede access to routine healthcare for individuals with 

disabilities; (2) identify interventions in areas such as exercise, nutrition, pain management, or complementary and alternative therapies that promote health and 

wellness and minimize the occurrence of secondary conditions for persons with disabilities; and (3) develop improved status measurement tool(s) to assess health and 

well-being of individuals with disabilities regardless of functional ability. In order 

to achieve these outcomes, the RRTC conducts a coordinated program of research 

and training activities using a logic model framework. RRTC projects summarize 

and validate existing research findings on barriers to health care access as well as 

rigorously test and compare new strategies to overcoming identified barriers. The 

RRTC also examines and evaluates the practices of exemplary generic and specialized health promotion programs for people with disabilities in order to create an evidence-based set of evaluation and planning criteria. In addition, the RRTC organizes 

and uses panels to assess current health status measurement tools and develops or 

refines measures to more accurately reflect the health and well-being of people living with disabilities. Throughout these activities the RRTC disseminates informational materials and provide technical assistance to individuals with disabilities, 

their representatives, providers, and other interested parties.

Multiple Sclerosis Rehabilitation Research and Training Center 

George H. Kraft, M.D., University of Washington, Seattle, WA; Project Number: 109; 

Start Date: October 1, 2003; Length: 60 months.

Abstract: This center conducts rehabilitation research that: (1) Develops new 

interventions and practices in the areas of disease suppression, strength enhancement, preserving employment, depression management, and pain control; (2) collects 

data from an extensive survey and explores complex interactions among multiple 

variables, models factors that predict differing levels of participation by people with 

MS, and proposes points of intervention that modify changes in function; and (3) faVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
51

cilitates enhanced participation through training, technical assistance, and dissemination through professional meetings, publications, and a State-of-the-Science conference. In addition, a Web-based knowledgebase provides technical assistance to individuals with MS and healthcare providers with respect to caregiver issues, financial and insurance planning, self-sufficiency and coping, and assistive technology.

Rehabilitation Research and Training Center on Personal Assistance Services 

Charlene Harrington, Ph.D., R.N., University of California, San Francisco, San 

Francisco, CA; Project Number: 267; Start Date: July 1, 2003; Length: 60 months.

Abstract: This project provides research, training, dissemination, and technical assistance on issues of personal assistance services (PAS) in the United States. Center 

projects focus on: (1) the relationship between formal and informal PAS and 

caregiving support, and the role of AT in complementing PAS; (2) policies and programs, barriers, and new models for PAS in the home and community; (3) workforce 

development, recruitment, retention, and benefits; and (4) workplace PAS models 

that eliminate barriers to formal and informal PAS and AT at work. The Center is 

based at the University of California, San Francisco, and includes the Topeka Independent Living Resource Center, InfoUse, the Paraprofessional Healthcare Institute, 

the Institute for the Future of Aging Services, as well as faculty members at the 

University of Maryland, Baltimore County Policy Sciences Graduate Program, the 

West Virginia University Job Accommodation Network, and the University of Michigan’s Institute of Gerontology and the Department Health Management and Policy. 

A Blue Ribbon Advisory Committee of PAS users, disability advocates, business 

leaders, independent living center leaders, and academics provide guidance to the 

project.

Rehabilitation Research and Training Center for Children’s Mental Health 

Robert Friedman, Ph.D., University of South Florida, Tampa, FL; Project Number: 

1454; Start Date: October 1, 2004; Length: 60 months.

Abstract: The Research and Training Center Children’s Mental Health conducts 

an integrated set of research projects designed, in the short run, to enhance knowledge about effective implementation of systems of care, and, in the long run, to 

make it possible for children with serious emotional disturbances to live, learn, 

work, and thrive in their own communities. The Center has developed a theory of 

factors that contribute to effective implementation; within that theory is a strong 

emphasis on the importance of understanding from a systemic perspective the interrelationship between the different factors, and their relationship to the community 

culture and context in which a service delivery system exists. The Center has a set 

of six interconnected research projects that use both quantitative and qualitative 

methods, and are holistic in their focus, to further test and develop its theory. The 

Center translates new knowledge from research into change in policy and practice 

through a targeted program of training, consultation, technical assistance, publication, and dissemination. To support these efforts, the Center maintains dissemination partnerships with a range of organizations committed to help present research 

findings in formats well-suited for key audiences of state and local policymakers, 

family organizations, researchers, and representatives of related service sectors.

Rehabilitation Research and Training Center on Aging with Developmental

Disabilities 

Tamar Heller, Ph.D., University of Illinois at Chicago, Chicago, IL; Project Number: 

276; Start Date: October 1, 2003; Length: 60 months.

Abstract: The mission of the RRTCADD is to have a sustained beneficial impact 

on the health and community inclusion of adults with intellectual and developmental disabilities (I/DD) as they age through a coordinated set of research, training, and dissemination activities. Major goals are: (1) improving health and function 

of adults with I/DD, (2) enhancing caregiving supports and transition planning 

among older caregivers and other family members, and (3) promoting aging and disability friendly environments that enable adults with I/DD to participate in community life. Each goal is addressed through coordinated and complementary sets of activities within the core areas. Projects promoting health and functioning include: examination of age-related changes, epidemiological surveys, research on health care 

utilization, and development of community-based health promotion interventions. To 

enhance caregiving supports and transition planning, RRTCADD research includes 

epidemiological surveys on family demographic and health characteristics, including 

families of minority backgrounds and families of persons with dual diagnoses of I/

DD and psychiatric impairments; sibling roles and interventions in transition planning; and consumer direction in family support. Projects examining aging and disVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00055 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
52

ability-friendly environments include research to identify features of communities 

and residences that hinder and assist community integration as people with I/DD 

age, state policies regarding nursing home use, and dementia care in family homes 

and other community residences. Training and dissemination activities involve collaborations with national provider, professional, and consumer organizations to enhance skills and to promote progressive interventions and policies.

Rehabilitation Research and Training Center on Full Participation in Independent 

Living 

Glen W. White, Ph.D., The University of Kansas, Lawrence, KS; Project Number: 

107; Start Date: January 1, 2001; Length: 60 months.

Abstract: Through research, training, and dissemination, this project makes available person-environment strategies that enable full participation in society by persons with disabilities from diverse cultures, varying socioeconomic strata, and 

emerging disability populations. This mission is implemented through multiple research and training activities that are influenced by independent living (IL) philosophy and values; for example, participatory action research is emphasized, in which 

consumers take an active role throughout the research process. The RRTC develops, 

tests, and uses measurement tools to investigate the interactional relationship between personal and environmental factors and their effects on full participation in 

IL by the designated populations. Based on the project’s Analytical Research Framework, the four core areas of intervention development and testing include: (1) increasing the knowledge base about the emerging universe of disability, (2) community participation and wellness, (3) cultural IL accommodations, and (4) personal 

and systems advocacy.

Rehabilitation Research and Training Center on Measurement and Interdependence 

in Community Living RRTC/MICL 

Glen W. White, Ph.D., The University of Kansas, Lawrence, KS; Project Number: 

1721; Start Date: October 1, 2006; Length: 60 months.

Abstract: The goal of the Research and Training Center on Measurement and 

Interdependence in Community Living (RRTC/MICL) is to increase the independence and participation of people with disabilities in their communities through the 

development and implementation of scientifically sound, theoretically driven, and 

evidence-based interventions. RRTC/MICL researchers accomplish this through six 

core projects. Two research projects, one on community participation and a second 

on economic utility, involve development of theory-driven measurement tools. The 

remaining four projects include the application of these measurement tools as part 

of their methods and procedures. Two of these projects are interventions and two 

develop model assessments. The first assessment project uses secondary analysis to 

develop and implement a model for assessing the economic utility and health-related 

outcomes of participants enrolled in Home and Community-Based Service (HCBS) 

waivers. The second assessment project evaluates the effects of different independent living advocacy-service models to determine the comparative effectiveness 

of different models in increasing community participation. The first intervention 

project examines the effectiveness of personal assistance services and enhanced 

training to increase consumer participation in the community. Finally, the second 

intervention project is a multisite study that examines the effects of a consumerled grassroots approach in identifying and removing barriers to increase community 

participation. Together, these projects represent a comprehensive, integrated, and 

robust set of activities that recognize that ‘‘disability’’ is an interaction between the 

characteristics of an individual and his or her environment.

Opening Doors for Children with Disabilities and Special Health Care Needs 

Judith S. Palfrey, M.D., Children’s Hospital, Boston, MA; Project Number: 1643; 

Start Date: October 1, 2005; Length: 60 months.

Abstract: This rehabilitation research and training center (RRTC) on children 

with disabilities who have special health care needs (CYDS) tests the effectiveness 

of two intensive interventions, integrated transition planning and community participation in recreation and fitness, and demonstrates the viability of a screening 

tool to promote access to services and supports for traditionally underserved communities. Research activities include two intervention projects that use randomized 

controlled designs to improve the educational and recreational activities of CYDS 

and a demonstration project to improve the early identification of CYDS from traditionally underserved communities. Research Study 1 investigates the use of a regional interagency team that integrates innovative practices in education, social 

services, and medical support for transition aged students. Research Study 2 builds 

53

off of innovative practices in recreation and volunteer training to examine a model 

that integrates CYDS into community recreation activities. Research Study 3 models the integration of a reliable screening mechanism into the flow of activity at a 

busy, urban neighborhood health center. The RRTC is a collaboration of the Massachusetts Consortium for Children with Special Health Care Needs, the Parent Advocacy Coalition for Educational Rights (PACER), and six Multicultural Community 

Based Organizations that serve traditionally underrepresented communities. RRTC 

staff and collaborators include nationally and internationally known experts in pediatrics, nursing, public policy, education, family advocacy, rehabilitation, and community organizing.

Rehabilitation Research and Training Center Recovery and Recovery Oriented

Psychiatric Rehabilitation for Persons with Long Term Mental Illness 

Marianne Farkas, Sc.D.; E. Sally Rogers, Sc.D., Boston University, Boston, MA; 

Project Number: 1453; Start Date: November 1, 2004; Length: 60 months.

Abstract: This project focuses on the concepts and dimension of recovery and the 

various factors that inhibit and facilitate recovery from long-term mental illness by 

a comprehensive and meritorious set of research projects and training, technical assistance, and dissemination activities. The research and the training, dissemination, 

and technical assistance programs are organized into the following three programmatic areas of investigation and development: concepts and dimensions of recovery; factors enhancing recovery, and factors inhibiting recovery. The research 

projects are designed to have an impact on the field at multiple levels, including 

the personnel level as well as the program and system levels. Research projects use 

a participatory research process with significant input from consumers and other 

stakeholders, and culminate in dissemination, training, or technical assistance activities to maximize the input of the research program. The Training, Dissemination, and Technical Assistance (TDTA) projects are designed to provide exposure, experience, and expertise levels of knowledge transfer. The TDTA program produces 

new technologies in recovery and psychiatric rehabilitation, as well as increases the 

likelihood that researchers, service providers, and others use the cumulative knowledge developed by the RRTC. The RRTC is tied together by its programmatic focus 

on three specific core areas, strengthened by the use of appropriate research strategies, and assisted by a vigorous program of training, technical assistance, and dissemination activities designed to maximize the impact of the RRTC at all levels in 

the field of psychiatric rehabilitation.

Research and Training Center on Community Living (RTC/CL) 

Charlie Lakin, Ph.D., University of Minnesota, Minneapolis, MN; Project Number: 

271; Start Date: October 1, 2003; Length: 60 months.

Abstract: The Center conducts research, training, technical assistance, and dissemination to enhance inclusion and self-determination of citizens with intellectual 

and developmental disabilities (ID/DD). The research program has six outcome 

areas: policy studies, data base supports for full participation, self-determination 

and consumer-control, workforce development, and quality assessment and improvement systems. The research program within the priority areas includes: (1) research 

syntheses of the state of knowledge and practice; (2) secondary analyses of high 

quality, topically relevant national and state data sets; (3) case studies of best practices; (4) evaluation of demonstration efforts to improve policy and practice; (5) survey and interview studies of critical issues; and (6) group process studies with key 

constituencies. An integrated intramural training program addresses the development of skilled disability researchers and community service professionals. Outreach 

training programs provide training and technical assistance to agencies and individuals providing support to people with ID/DD, including members of their families. 

The College of Direct Support provides online interactive multimedia training to 

thousands of direct support professionals across the U.S. Outreach programs include 

conferences and workshops for a wide variety of national, regional, and state audiences, a state-of-the-art conference, annual ‘‘Reinventing Quality’’ conference, and 

intensive technical assistance with community organizations, including advocacy 

and self-advocacy organizations. The Center disseminates practical information to 

targeted audiences through its internal publication program that includes: IMPACT, 

Policy Research Brief, DD Data Brief, and Frontline Initiative. It maintains high 

standards for scholarly productivity and publication through books, journal articles 

and technical reports. About 18,000 people visit Center Web sites each month for 

access to view publications or other information on best practices in person-centered 

services (‘‘QualityMall.org’’), national statistics on services and expenditures, the direct support workforce, and other contemporary topics.

54

Rehabilitation Research and Training Center for Community Integration for Individuals with Disabilities, Strengthening Family and Youth Participation in Child 

and Adolescent Mental Health Services 

Barbara Friesen, Ph.D., Portland State University, Portland, OR; Project Number: 

1458; Start Date: October 1, 2004; Length: 60 months.

Abstract: This project conducts research, training, and technical assistance activities to study and promote effective, community-based, culturally competent, family 

centered, individualized, and strength-based services for children and youth with 

emotional or behavioral disorders and their families. Projects include: (1) ‘‘Community Integration (CI) of Transition-Age Youth,’’ designed to gain understanding of 

CI and related concepts from the perspectives of transition-age youth, young adults, 

and caregivers; (2) ‘‘Transforming Futures: Research on Expanding the Career Aspirations of Youth with Mental and Emotional Disorders,’’ explores transition experiences; (3) ‘‘Partnerships in Individualized Planning’’ develops an intervention to increase youth and family member participation in the individualized service planning 

process, a conceptual framework for understanding recovery in children’s mental 

health, and ways to reduce stigma; (4) ‘‘Work-Life Integration’’ addresses CI for 

adult caregivers of children and youth with emotional disorders, specifically around 

maintaining employment. It is designed to influence human resource professionals’ 

practice, and aims to reduce stigma and increase organizations’ family friendliness; 

(5) ‘‘Transforming Transitions to Kindergarten’’ focuses on the preschool-kindergarten transition for young children with challenging behaviors. It develops and 

tests an intervention promoting children’s successful school entry while empowering 

caregivers; (6) ‘‘Practice-Based Evidence: Building Effectiveness from the Ground 

Up,’’ conducts a case study in partnership with a Native American youth organization and the National Indian Child Welfare Association, and addresses the need to 

study practices that are believed to be helpful, but for which little evidence exists.

Rehabilitation Research and Training Center Promoting Community Integration of 

Individuals with Psychiatric Disabilities 

Mark Salzer, Ph.D., University of Pennsylvania, Philadelphia, PA; Project Number: 

268; Start Date: October 1, 2003; Length: 60 months.

Abstract: The goal of this Center is to ensure that people with psychiatric disabilities not only move from institutional care to more integrated settings but also are 

free to choose to participate in a wide range of roles in their communities. The Center’s 5-year mission focuses on three core areas: (1) Factors Associated with Community Integration develops a coherent conceptual framework for community integration and identifies key factors, intervention models, and appropriate instrumentation and research methodologies; (2) Policies Associated with Community Integration identifies, develops, and assesses the effectiveness of a range of public policies 

and system strategies promoting community integration and engage key stakeholders in learning about and utilizing the Center’s findings; and (3) Intervention 

Supports that Assist Community Integration identifies, develops, and assesses the 

effectiveness of support service interventions promoting community integration, and 

provides training, technical assistance, and dissemination based on those initiatives 

to change behaviors and practices of key stakeholders. This Center capitalizes upon 

the longstanding history of collaboration among three Philadelphia-based central 

partners: The University of Pennsylvania, the peer-operated Mental Health Association of Southeastern Pennsylvania, and The Matrix Center at Horizon House, Inc.

Rehabilitation and Training Center on Community Integration of Persons with TBI 

Angelle M. Sander, Ph.D.; Margaret Struchen, Ph.D., The Institute for Rehabilitation and Research (TIRR), Houston, TX; Project Number: 272; Start Date: November 

1, 2003; Length: 60 months.

Abstract: The research program of this project includes: development and evaluation of a social network mentoring program; an investigation of racial/ethnic differences in acceptance of disability, community integration needs, barriers, and supports; a distance learning program to train family members in rural areas as paraprofessionals; assessment of employers’ attitudes toward persons with TBI and a 

pilot educational intervention to reduce attitudinal barriers in the workplace; a randomized clinical trial to assess the effectiveness of a brief substance abuse intervention; a qualitative exploration of intimacy following TBI; and a study investigating 

the role of social communication abilities and environmental factors on social integration. Training projects include: a National Information, Educational Resources, 

Dissemination, and Technical Assistance Center for the Community Integration of 

Individuals with TBI; development of educational materials for increasing community awareness of TBI and reducing attitudinal barriers; adoption of a social action 

55

network program from disability studies for improving positive identity; partnering 

with artists in the community to implement a Center for Creative Expressions for 

Persons with TBI; training of community healthcare professionals in the community 

integration needs of persons with TBI; a rehabilitation fellowship in community integration of persons with TBI; and a state-of-the-science conference and book on 

community integration.

REHABILITATION ENGINEERING RESEARCH CENTERS OF THE NATIONAL INSTITUTE

FOR DISABILITY AND REHABILITATION RESEARCH

RERC on Spinal Cord Injury: Keep Moving: Technologies to Enhance Mobility and 

Function for Individuals with Spinal Cord Injury 

Philip Requejo, Ph.D.; Robert Waters, M.D., Los Amigos Research and Education Institute, Inc. (LAREI), Downey, CA; Project Number: 483; Start Date: November 1, 

2002; Length: 60 months.

Abstract: This RERC improves the lives of individuals with SCI by promoting 

their health, safety, independence, and active engagement in daily activities. Activities include: (1) monitoring trends and evolving product concepts that represent future directions for technologies in SCI, (2) conducting research to advance the state 

of knowledge, (3) disseminating the information to the population, (4) developing 

and testing prototype devices that are useful and effective and transferring them 

to the marketplace, (5) advancing employment opportunities for individuals with 

SCI, and (6) developing ways to expand research capacity in the field of SCI. The 

R&D program is focused on a key issue for individuals with SCI, the need to maintain mobility for as long as possible in order to enhance independent function. A 

survey of the user population determines where areas of greatest need exist. An active Mobile Arm Support for adults allows those with limited arm function greater 

independence. The shoulder-preserving wheelchair, gait training robotic assist device, and adaptive exercise equipment are all specifically geared to preserve or enhance mobility in individuals with SCI. A project on optimized wheelchair suspension keeps people mobile by increasing comfort and reducing tissue loading.

Rehabilitation Engineering Research Center: Develop and Evaluate Technology for 

Low Vision, Blindness, and Multi-Sensory Loss 

John A. Brabyn, Ph.D., The Smith-Kettlewell Eye Research Institute, San Francisco, CA; Project Number: 1646; Start Date: August 1, 2006; Length: 60 months.

Abstract: This Center conducts a program of research and development to enhance the independence of blind, visually impaired, and deaf-blind individuals. Research includes investigation of assessment methods to guide rehabilitation of infant 

cortical visual impairment; practical innovations in assessment and interventions 

for elders with visual impairments; and development of independent assessment 

guidelines for emerging visual prostheses. The Center also conducts research in access to graphical information for blind, visually impaired, and deaf-blind persons, 

developing tools for rapid screen overview, auditory and tactile graph presentation, 

image classification, and on-demand production of tactile street maps. To address 

signage and travel information, the project is investigating information interfaces 

for travelers who are blind or visually impaired, and innovative computer vision 

methods to find and read existing print signs and labels. To address the rising barriers to accessing visual displays and appliances for employment and daily living, 

there is a designer education campaign and development of a universal talking 

LCD/LED display reader, practical consumer tools, and jobsite adaptations for employees who are blind or visually impaired. Other projects include development of 

a new-generation robotic finger-spelling hand for deaf-blind communication, and 

pilot investigations of difficulties in lipreading and sign language reading experienced by those with combined auditory and visual impairment.

Rehabilitation Engineering Research Center for the Advancement of Cognitive

Technologies (RERC–ACT) 

Cathy Bodine, University of Colorado, Denver, CO; Project Number: 1451; Start 

Date: November 1, 2004; Length: 60 months.

Abstract: The goal of this RERC is to research, develop, evaluate, implement, and 

disseminate innovative technologies and approaches that will have a positive impact 

on the way in which individuals with significant cognitive disabilities function within their communities and workplace. The Center incorporates: (1) a consumer-driven 

model for identifying the most significant barriers to independent living and workforce; (2) an approach that is balanced and uses both well-established and newly 

emerging technologies in its development projects; (3) a focus both on functional limVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00059 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
56

itations and specific disabilities; and (4) mutually beneficial partnerships with private industry and public agencies. Research activities include: Needs, knowledge, 

barriers, and uses of AT by persons with cognitive disabilities; technology for remote 

family support for people with cognitive disabilities; influences on AT use, non-use, 

and partial, and inappropriate use by persons with traumatic brain injury; AT enhancement of written expression for children and adults; needs assessment for creating affordable, context-aware technologies; and technology to promote decisionmaking skills and self-determination for students with cognitive disabilities. Development activities include: Design, implementation, and deployment of context aware 

technologies for persons with cognitive disabilities residing in community living environments; development of HealthQuest, an Internet-based product that enables individuals with intellectual disabilities to become active participants in their own 

health care; XML repository of common tasks; batteryless micropower sensors for 

context aware technologies; perceptive animated interfaces for workforce training; 

and environmentally appropriate behavioral cues for individuals with TBI.

Rehabilitation Engineering Research Center on Hearing Enhancement 

Matthew H. Bakke, Ph.D., Gallaudet University, Washington, DC; Project Number: 

484; Start Date: October 1, 2003; Length: 60 months.

Abstract: The mission of this RERC is to build and test components of a new, innovative model of aural rehabilitation tools, services, and training, in order to improve assessment and fitting of hearing technologies and to increase the availability, 

knowledge, and use of hearing enhancement devices and services. Component A: (1) 

develops and evaluates new methods for field evaluation and fitting of hearing aids; 

(2) develops and evaluates techniques to enhance auditory self-monitoring; and (3) 

develops methods for predicting the speech-to-interference ratio and intelligibility of 

speech for a hearing aid when used with a wireless telephone. Component B conducts a needs assessment survey of people who use hearing technologies and evaluates the use of Bluetooth technology as a means of improving and expanding wireless connection to a hearing aid. Component C investigates environmental factors 

affecting children’s speech recognition abilities in classroom settings. Component D 

investigates the use of distortion product otoacoustic emission and reflectance for diagnosis of hearing loss and tinnitus; and creates and standardizes sets of synthesized nonsense syllables for use in hearing aid research. Component E develops 

a new, innovative model for the delivery of aural rehabilitation services to adults 

with hearing loss. In addition the RERC conducts a program of training and dissemination that will reach a diverse audience of people, both consumers

and professionals.

Rehabilitation Engineering Research Center on Technology for Successful Aging 

William C. Mann, Ph.D., University of Florida, Gainesville, FL; Project Number: 

475; Start Date: October 1, 2001; Length: 60 months.

Abstract: The RERC-Tech-Aging conducts research, development, education, and 

information dissemination work on technology for successful aging. Projects of the 

RERC focus on the closely related areas of communications, home monitoring, and 

‘‘smart’’ technologies. The technology driving the focus for this RERC is developing 

rapidly and requires an understanding of current and emerging technology areas, 

including wireless technology, computers, sensors, user interfaces, control devices, 

and networking. Successful integration of this technology into products and systems 

for older persons requires an understanding of their complex health, independence, 

and quality-of-life issues. The RERC-Tech-Aging tests currently available home 

monitoring products and demonstrates their effectiveness in relation to independence, quality of life, and health related costs. The RERC-Tech-Aging also identifies 

needs and barriers to home monitoring and communication technology, and addresses needs of special populations including rural-living, elders, and people aging with 

disability. The RERC-Tech-Aging brings together national expertise to meet this 

challenge, including major universities, industry leaders working in this area, major 

aging or aging-related organizations, major Federal agencies that relate to funding 

or services in this area, other NIDRR-funded RERCs and RRTCs, and service-related organizations that assist in identifying study participants.

Rehabilitation Engineering Research Center for Wireless Technologies 

Helena Mitchell, Ph.D., Georgia Institute of Technology, Atlanta, GA; Project Number: 1671; Start Date: October 1, 2006; Length: 60 months.

Abstract: The Rehabilitation Engineering Research Center for Wireless Technologies’ mission is to: (1) promote equitable access to and use of wireless technologies by persons with disabilities; and (2) encourage adoption of Universal Design 

57

in future generations of wireless technologies. To accomplish these aims, the RERC 

is organized into three main project sections: The Research Section is comprised of 

four research initiatives: Facilitating User Centered Research is designed to establish a research portal that communicates to industry the needs of people with disabilities for wireless technologies. Customer-driven Usability Assessment enhances 

the usability of future generations of cell phones and other wireless products by developing a methodology for assessing their usability by representative users with 

disabilities. Collaborative Policy Approaches to Promote Equitable Access develops, 

implements, and evaluates specific policy initiatives related to accessible wireless 

technologies and services. Advanced Auditory Interfaces develops, tests, and disseminates guidelines for the design of advanced auditory interfaces for cell phones 

and other handheld electronic devices. The Development Section includes four 

projects that promote equitable access to and use of wireless technologies by persons 

with disabilities through the development of prototype designs: Alternative Interfaces continues its work on the V2 standards for universal remote consoles and 

Real-time Location-based Information Services expands on previous work on the 

RERC’s personal captioning system by addressing the needs of patrons with vision 

or hearing impairments in three different venues—exhibit spaces, airports, and hospitals. Development of Wireless Emergency Communications and Ensuring Access 

to Emergency Assistance both focus on the area of wireless emergency communications for people with disabilities; developing wireless communication technology to 

be used by emergency personnel to contact individuals with disabilities, and by people with disabilities to signal the need for assistance. The Training and Dissemination Section promotes the synthesis of new knowledge into practice with the RERC’s 

State of the Science conference and a number of initiatives designed to educate consumers, providers, and other professionals, including: university courses, an annual 

student design competition, conference tutorials and workshops, all geared toward 

access and usability of mobile wireless technologies.

Rehabilitation Engineering Research Center on Wheeled Mobility 

Stephen H. Sprigle, Ph.D., Georgia Institute of Technology, Atlanta, GA; Project 

Number: 491; Start Date: November 1, 2003; Length: 60 months.

Abstract: The goal of this RERC is to undertake a major shift in the way wheeled 

mobility is conceptualized and understood, from the design of assistive devices that 

enable some individuals to perform some activities, to the design of a broad range 

of interventions that enable as many individuals as possible to actively engage and 

participate in everyday community life. Research activities include: (1) User Needs 

and Design Input uses participatory focus groups to identify needs of wheelchair 

users; (2) User Needs of Older Adults assesses the needs of older adults living at 

home and in other residential settings; (3) Effects of Environment and Mobility 

Technology on Participation and Activity measures the influences of environmental 

barriers and specialized wheelchair technology on participation and activity in everyday life; (4) Efficacy of Animation and Visualization Training uses computer simulation techniques to investigate their efficacy in improving mobility training; and 

(5) Clinical and Functional Implications of Seating Standards and Guidelines studies the relationship between standardized measures of cushion performance and actual impact on wheelchair users. Development efforts include: (1) development and 

marketing of new mobility devices in collaboration with industry design partners; 

(2) development of a wheelchair for frail elders that can be used in any residential 

environment; (3) interventions to overcome barriers to participation including guidelines and technologies to help wheelchair users overcome environmental and technological barriers; (4) development of animation and visualization training through 

computer simulations to improve training in transfers and outdoor mobility; and (5) 

development of valid wheelchair cushion test methods which enables clinicians to 

prescribe appropriate wheelchair cushions based on positioning and

aload distribution.

Rehabilitation Engineering Research Center on Workplace Accommodations 

Karen Milchus; Jon Sanford, Georgia Institute of Technology, Center for Assistive 

Technology & Environmental Access, Atlanta, GA; Project Number: 480; Start Date: 

November 1, 2002; Length: 60 months.

Abstract: This RERC identifies, designs, and develops devices and systems to enhance the workplace productivity of people with disabilities. Universal design is a 

primary focus of the Center: making the design of products and environments usable by all workers to the greatest extent possible, without the need for adaptation 

or specialized design. The RERC’s research projects evaluate existing workplace 

products and services and determine areas where further product development is 

58

needed. The Center also studies archival materials to identify factors that contribute 

to successful or unsuccessful outcomes, and analyzes policies and practices that may 

influence the nature and availability of workplace accommodations for persons with 

disabilities. The RERC’s development activities focus on Remote Services and Universal Design in the Workplace. The Remote Services projects investigate ways that 

remote technologies such as videoconferencing and telework can be used to facilitate 

employment and provide technical support services to people with disabilities. The 

Universal Design projects work with manufacturers to develop new generations of 

universally designed and accessible products. Digital human modeling tools developed by the project provide visualizations of products or systems with human interaction and movement and reduce the need for preliminary physical prototypes. 

Products are developed for workers in office, manufacturing, retail/sales, service industry, and other environments. Finally, training, technical assistance, and dissemination activities on workplace accommodations and universal design promote the 

transfer of new knowledge into practice.

RERC on Rehabilitation Robotics and Telemanipulation: Machines Assisting

Recovery from Stroke (MARS) 

W. Zev Rymer, M.D., Ph.D., Rehabilitation Institute Research Corporation, Chicago, 

IL; Project Number: 481; Start Date: November 1, 2002; Length: 60 months.

Abstract: MARS–RERC focuses its research and development on restoring function in hemispheric stroke survivors. Five projects assess different approaches that 

have the potential to improve performance of the upper extremity, and one project 

attempts to restore gait and fluid locomotion to the lower extremities. These projects 

include: the ARM Guide, a robotic therapy for force training of the upper extremity 

in chronic hemiparetic stroke; Lokomat-Gait restoration in hemiparetic stroke patients using goal-directed, robotic-assisted treadmill training; Augmented Reality 

Robotic Rehabilitation, which is in the development of a robotic system with an augmented reality interface for rehabilitation retraining of arm function for brain-injured individuals; Robotic Assisted Finger Extension, rehabilitation of finger extension in chronic hemiplegia; and T–WREX, a home-based telerehabilitation system 

for improving functional hand and arm movement recovery following stroke utilizing 

an anti-gravity orthosis and video games to track progress. In addition to these 

projects, MARS–RERC’s purpose is to train undergraduate engineering students, 

medical students, physician residents, graduate students in engineering and neuroscience, and allied health clinicians, including physical and occupational therapists 

in the area of rehabilitation robotics. The broad intent of MARS–RERC is to develop 

robotic devices or machines that assist the therapist in providing treatments that 

are rationally based, intensive, and long in duration. This project is a collaboration 

of the Rehabilitation Institute of Chicago (RIC), the Catholic University of America 

(CUA) and National Rehabilitation Hospital in Washington, DC, the University of 

Illinois at Chicago (UIC), and the University of California at Irvine (UCI).

Rehabilitation Engineering Research Center in Prosthetics and Orthotics 

Steven A. Gard, Ph.D., Northwestern University, Chicago, IL; Project Number: 490; 

Start Date: October 1, 2003; Length: 60 months.

Abstract: This Center conducts ten research projects, three of which are pilot 

studies. In the area of human locomotion the objectives are to conduct quantitative 

studies that include non-disabled gait, modeling of gait, roll-over shape influence on 

transtibial amputee gait, gait initiation, shock absorption studies, the role of the 

spine in walking, transfemoral socket design studies, and evaluation of stance-control orthotic knee joints. Pilot studies, where preliminary data is not available, are 

proposed on partial foot prosthesis/orthosis systems, on evaluation of Ankle Foot 

Orthoses and on the design of a Shape & Roll foot for children. Six developmental 

projects include a simple gait monitoring instrument (Direct Ultrasound Ranging 

System), a new prosthetic ankle joint that adapts to inclines, and a manual through 

which individuals in low-income countries can make their own artificial feet. In addition, two upper-limb prosthetics development projects are proposed that deal with 

reaching, manipulation, and grasping. Finally, an outcomes measurement tool is developed for prosthetics and orthotics (P&O) facilities in their reporting to the American Board of Certification. The vision for this RERC is to improve the quality of 

life for persons who use prostheses and orthoses through creative applications of 

science and engineering to the P&O field. The goal is to uncover new knowledge and 

understanding in P&O and to bring more quantification to the field, which will enable them to develop new concepts and devices to improve the quality, cost-effectiveness, and delivery of P&O fittings.

59

Rehabilitation Engineering Research Center on Recreational Technologies and

Exercise Physiology Benefiting Persons with Disabilities (RERC RecTech) 

James H. Rimmer, Ph.D., University of Illinois at Chicago, Chicago, IL; Project 

Number: 479; Start Date: November 1, 2002; Length: 60 months.

Abstract: This program researches access to recreational opportunities and physical endurance of people with disabilities, targeting four primary areas: (1) increased 

access to fitness and recreation environments; (2) interventions to increase physical 

activity and recreation participation; (3) adherence strategies to reduce physical activity relapse and dropout rates; and (4) randomized clinical trials to evaluate improvements in health and function. Research and development projects include: (1) 

a comprehensive needs assessment that involves ongoing assessment of consumer 

needs as they pertain to existing and emerging recreational and fitness technologies; 

(2) research on the use of information technology and a newly designed environmental accessibility instrument for facilitating access to recreational and fitness environments and promoting improved health and function; (3) research on the use of 

‘‘teleexercise’’ technology for promoting participation and for monitoring intensity 

and physiological/psychological outcomes of home-based exercise programs; (4) research and development of technology to create virtual exercise environments to promote greater adherence to exercise and thereby improved health and function; (5) 

development of technology to allow users adaptive control of exercise machines; (6) 

development of broadly applicable aftermarket accessory kits for adapting existing 

cardiovascular exercise equipment for use by people with disabilities and determining the efficacy of the new adaptations in improving fitness; and (7) development 

of an online RecTech solutions database of currently available recreational and fitness technologies to make available solutions more accessible to consumers. Two 

training projects promote capacity building for future recreation, fitness, exercise 

physiology, engineering, and rehabilitation professionals, and two additional training projects support professional development.

Rehabilitation Engineering Research Center on Technology Access for Landmine

Survivors 

Yeongchi Wu, M.D.; Kim Reisinger, Ph.D., Center for International Rehabilitation, 

Chicago, IL; Project Number: 487; Start Date: November 1, 2003; Length: 60 

months.

Abstract: The Center strives to improve the quality and availability of amputee 

and rehabilitation services for landmine survivors by focusing on the development 

of ‘‘appropriate technology,’’ i.e., technology that is most suitable to the limited technical and human resources available in most mine-affected regions through the application of research methodologies, the development of mobility aids, and the creation of educational materials, all of which are designed specifically for mine-affected populations and disseminated through a network of rehabilitation service providers in mine-affected regions. Laboratory-based research projects investigate 

issues of importance relating to transtibial alignment, ischial containment socket 

trim lines as they relate to the gait of transfemoral amputees, and the evaluation 

of a non-toxic resin for the direct lamination of prosthetic sockets. Field-based research evaluates an anatomically based transtibial alignment methodology and a 

wheelchair prototype manufacturing and dissemination strategy. Development 

projects, many of which contain research components, can be classified into two 

areas: those that improve the service delivery through improved fabrication techniques, and those that develop appropriate prosthetic components and mobility aids. 

In order to promote the successful transfer of techniques and technologies that are 

developed, the RERC creates training materials that describe the manufacture, assembly, and use of the technique or devices developed under the research and development program. Additionally, because the current number of trained prosthetic 

technicians in developing countries is far from sufficient to adequately meet the 

needs of landmine survivors, the center produces education and training materials 

covering the basic science of prosthetics and orthotics. All materials are adapted to 

the specific languages, culture, and needs of the mine-affected regions served by the 

RERC and distributed through a blended distance learning network.

Rehabilitation Engineering Research Center on Wheelchair Transportation Safety 

Lawrence W. Schneider, Ph.D. (Michigan); Patricia Karg, Ph.D. (Pittsburgh); Gina 

Bertocci, Ph.D. (Louisville), University of Michigan, Ann Arbor, MI; Project Number: 

1672; Start Date: November 1, 2006; Length: 60 months.

Abstract: Research conducted by the RERC on Wheelchair Transportation Safety 

(RERC WTS) advances the safety, usability, and independence of people who remain 

seated in their wheelchairs when traveling in motor vehicles. Research and developVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00063 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
60

ment projects involve close collaboration with manufacturers, transit providers, vehicle modifiers, clinicians, and consumers to ensure quick translation of results into 

meaningful solutions that benefit travelers with mobility disabilities. Projects range 

from developing innovative solutions for forward-facing and rear-facing wheelchair 

passenger stations in large accessible transit vehicles, to investigating issues of 

school-bus transportation for children seated in WC–19 compliant and noncompliant 

wheelchairs, and to improving frontal- and rear-crash protection for occupants in 

private vehicles. Continuing research from previous grants, the RERC WTS extends 

the in-depth investigations of adverse events involving wheelchair-seated travelers, 

but also conducts a study of the transportation experience of wheelchair users in 

large public transit vehicles, including the process of entering and exiting the vehicle, accessing the wheelchair station, securing the wheelchair and restraining the 

occupant, and traveling to and from destinations. In addition to conducting research 

and development in six project areas, RERC WTS staff engages in information dissemination, training of future researchers, transferring innovative technology concepts to the marketplace, developing and revising voluntary industry standards, and 

convening the second State-of-the-Science Workshop on Wheelchair Transportation 

Safety. The RERC is a partnership of the University of Michigan Transportation Research Institute, the University of Pittsburgh, the University of Louisville, and the 

University of Colorado.

Rehabilitation Engineering Research Center on Children with Orthopedic Disabilities 

Richard A. Foulds, Ph.D., New Jersey Institute of Technology, Newark, NJ; Project 

Number: 1560; Start Date: November 1, 2005; Length: 60 months.

Abstract: The Rehabilitation Engineering Research Center on Technology for Children with Orthopedic Disabilities focuses on research and development assisting 

children to achieve their full potential as productive citizens. The work plan includes a roster of projects designed to enhance the physical skills of these children 

to be successful in learning, playing, and living independently. This project includes 

three research and three development projects, as well as training projects serving 

the needs of children, families, students, and professionals. Project selection is driven by the RERC on Children with Orthopedic Disabilities’ vision of RERCs as a 

source of innovation and of new technologies designed to address the serious problems faced by children with disabilities. This project is a collaboration of New Jersey 

Institute of Technology, the Childrens’ Specialized Hospital, and Rutgers University, 

bringing together two academic departments of biomedical engineering with the Nation’s largest pediatric rehabilitation hospital.

Rehabilitation Engineering Research Center on Technology Transfer (T2RERC) 

Steve Bauer, Ph.D., State University of New York (SUNY) at Buffalo, Buffalo, NY; 

Project Number: 489; Start Date: October 1, 2003; Length: 60 months.

Abstract: The activities of this project transfer and commercialize new and improved assistive devices, conduct research to improve technology transfer practice, 

and support other stakeholders involved in the technology transfer process. Four research projects investigate innovative ways to facilitate and improve the process of 

technology transfer for all stakeholders: (1) Identify Innovative Technology Transfer 

Practices—draws critical success factors from examples of retrospective and prospective AT transfer case studies in various sectors; (2) Identify Innovative Technology 

Transfer Policies—traces the outputs and outcomes of Federal transfer programs 

supporting AT related projects and assesses their efficacy; (3) Facilitate AT Industry 

Innovation through Focused Market Research—provides a context for transfer opportunities involving the AT industry and for public policy decision making; and (4) 

Assess the Efficacy of Transferred Products—determines the extent to which products previously transferred through the T2RERC impact the functional capabilities 

of consumers. Four development projects increase the number and quality of successful transfers from RERC’s and other sources: (1) Transfer Products through a 

Supply Push Approach—facilitates the movement of new or improved prototype inventions to the marketplace through licenses, sales, or entrepreneurial ventures; (2) 

Transfer Technologies through a Demand Pull Approach—validates technology 

needs within the AT industry and introduces advanced technology solutions to address those needs; (3) Improve the Accessibility of New Mainstream Products—extends participatory research to integrate consumers’ functional requirements into 

the design of new mainstream products; and (4) Facilitate RERC Transfer Activity 

Through Informatics—establishes a pilot informatics infrastructure and assesses its 

utility for increasing communication, collaboration, and transfers between RERC’s.

61

Rehabilitation Engineering and Research Center (RERC) on Universal Design and 

the Built Environment at Buffalo 

Edward Steinfeld, Arch.D., State University of New York (SUNY) at Buffalo, Buffalo, NY; Project Number: 1561; Start Date: November 1, 2005; Length: 60 months.

Abstract: The RERC on Universal Design and the Built Environment is engaging 

the public and private sectors across four broad domains of the built environment: 

(1) community infrastructure, (2) public buildings, (3) housing, and (4) products. The 

RERC–UD generates strategically important research, development, education, and 

dissemination deliverables, to advance the fields of rehabilitation engineering and 

environmental design. The RERC–UD deliverables integrate universal design principles within the generally accepted models, methods, and metrics of design and engineering professionals in the building and manufacturing industries. Research 

projects document the efficacy of existing universally designed environments, and 

generate critical human factors data essential to resolving design and engineering 

problems. Development projects create evidence-based guidelines to implement universal design concepts within the tools of the design professions, and formulate 

methods to evaluate the usability of designs for people with mobility, sensory, and 

cognitive impairments. The usefulness of the guidelines and evaluation methods are 

demonstrated by applying them to the development of innovative products and environments with industry partners. Training activities emphasize online certificate 

programs in universal design for design professionals, builders, manufacturers, and 

consumer advocates; a Web portal and site for students and educators; and graduate 

programs that train researchers in advanced methods. Dissemination outputs include traditional refereed and trade publications, an extensive Web site with 

downloadable information products and design tools, model home demonstrations in 

local communities across the country, and outreach activities with professional, 

business, and standards development organizations. The RERC–UD’s state-of-thescience conference includes stakeholders in a plan to elevate universal design to an 

integral component of the mainstream design and engineering disciplines.

Rehabilitation Engineering Research Center on Communication Enhancement 

Frank DeRuyter, Ph.D., Duke University, Durham, NC; Project Number: 488; Start 

Date: November 1, 2003; Length: 60 months.

Abstract: The mission of this RERC is to assist people who use augmentative and 

alternative (AAC) technologies in achieving their goals across environments. The 

goals and objectives of the RERC are to advance and promote AAC technologies 

through the outputs and outcomes of research and development activities and to 

support individuals who use, manufacture, and recommend these technologies in 

ways they value. Research projects cover the following areas: (1) improving AAC 

technology to better support societal roles; (2) enhancing AAC access by reducing 

cognitive/linguistic load; and (3) enhancing AAC usability and performance. Projects 

address issues of literacy, telework, specialized vocabulary, contextual scenes and 

intelligent agents, improving interface performance, and monitoring and simulating 

communication performance. Development activities include: (1) technology and policy watch; (2) new interfaces; and (3) reducing the cognitive/linguistic burden on 

AAC users. Activities address monitoring emerging technologies, standards, and 

policies; technologies to supplement intelligibility of residual speech, dysarthric 

speech, and gesture recognition; brain interface; AAC WebCrawling; and enhancing 

the role of listeners in AAC interactions.

National Center for Accessible Public Transportation 

Katharine Hunter-Zaworski, Ph.D., Oregon State University, Corvallis, OR; Project 

Number: 485; Start Date: October 1, 2003; Length: 60 months.

Abstract: This RERC addresses the need for improvements in the accessibility of 

public transportation. This center is both important and timely because of major 

changes in the travel industry, and the need to adapt to those changes in a way 

that provides safe and dignified travel for persons with disabilities. The transportation focus of this RERC is inter-city travel via air, rail, and bus. Air, rail, and 

over-the-road buses (OTRB) account for nearly all of the inter-city public transportation. Accessibility issues focus on persons with mobility, agility, and hearing disabilities and account for a large percentage of persons with disabilities. Two areas 

of research are addressed: (1) the biomechanics of wheelchair transfers in confined 

spaces; and (2) the perceptions, reactions, and attitudes of subjects toward existing 

and proposed accessibility solutions. The biomechanics studies include the use of a 

sophisticated eight-camera motion analysis system in conjunction with force plates 

to determine the motions and forces involved in dependent and independent transfers in confined spaces, such as an aircraft aisle. The survey-based study includes 

62

comprehensive surveys of groups that are directly involved with accessibility issues 

including travelers with disabilities, non-travelers with disabilities, and employees 

of airlines and airports. Drawing on results of their research, the RERC focuses on 

four development topics: (1) vehicle boarding technologies; (2) real time passenger 

information and communications systems; (3) accessible lavatories; and (4) passenger assistance training tools and techniques. The accessible lavatory project has 

two main components; regulations and new designs for the next generation of 

aircarft.

Rehabilitation Engineering Research Center on Telerehabilitation 

David M. Brienza, Ph.D., University of Pittsburgh, Pittsburgh, PA; Project Number: 

1450; Start Date: December 1, 2004; Length: 60 months.

Abstract: The vision of this RERC is to serve people with disabilities by researching and developing methods, systems, and technologies that support remote delivery 

of rehabilitation and home health care services for individuals who have limited 

local access to comprehensive medical rehabilitation outpatient and communitybased services. Research and development activities include: (1) Telerehabilitation 

Infrastructure and Architecture: development of an informatics infrastructure and 

architecture that builds on existing programs and technologies of the University of 

Pittsburgh Medical Center’s e-Health System, supports the RERC’s research and development activities, meets HIPAA requirements, provides a test-bed for third party 

telerehabilitation applications, and can be used as a model for future telerehabilitation infrastructure; (2) Telerehabilitation Clinical Assessment Modeling: development of a conceptual model for matching consumers with telerehabilitation technology. The model is user-oriented and driven by consumer experiences regarding 

satisfaction, simplicity, and reimbursability of telerehabilitation; (3) Teleassessment 

for the Promotion of Communication Function in Children with Disabilities: development of a Web-based teleassessment infrastructure that links therapists and child 

participants, allowing therapeutic content to be adapted to the child’s individual 

progress and abilities; (4) Remote Wheeled Mobility Assessment: determines if individuals with mobility impairments can obtain appropriate prescriptions for wheeled 

mobility devices through the use of a telerehabilitation system based upon information and telecommunications technologies; (5) Behavioral Monitoring and Job Coaching in Vocational Rehabilitation: researches technologies to conduct remote delivery 

of rehabilitation services to individuals who have limited access to rehabilitation 

services that are necessary to participate in and achieve education and employment 

outcomes in their community; and (6) Remote Accessibility Assessment of the Built 

Environment: determines the effectiveness of a remote accessibility assessment system in evaluating the built environment of wheeled mobility device users.

Rehabilitation Engineering Research Center on Wheelchair Transportation Safety 

Patricia Karg, University of Pittsburgh, Pittsburgh, PA; Project Number: 477; Start 

Date: November 1, 2001; Length: 60 months.

Abstract: This RERC aims to improve the safety of wheelchair users who remain 

seated in their wheelchair while using public and private motor-vehicle transportation. RERC tasks investigate and develop new wheelchair tiedown and occupant 

restraint system technologies, including wheelchair-integrated restraints and universal docking concepts, that enable wheelchair users to secure and release their 

wheelchair independently and quickly, and use an effective occupant restraint system without the need for assistance. The RERC also researches the issues and factors involved in providing improved occupant protection to wheelchair-seated drivers 

and passengers in rear and side impacts, and uses a multifaceted approach, including in-depth investigations of real-world accidents, to investigate the incidence, severity, and causes of injuries to wheelchair-seated occupants in different sizes of vehicles and in different types of crashes and non-impact incidents experienced during 

vehicle motion. In particular, this RERC explores the need for, and suitability of, 

using different levels of wheelchair securement and occupant restraint in larger 

public transit vehicles, with the goal of recommending and developing equipment 

and systems that provide for a safe ride and that are more compatible with the 

operational needs of the transit environment. The program includes a comprehensive research and development effort that involves consumers, manufacturers, students, clinicians, transport providers, and rehabilitation technology experts. The 

RERC also has active programs of information dissemination, training, and technology transfer using personnel, mechanisms, and facilities that have been previously established at the University of Pittsburgh/University of Michigan.

63

Rehabilitation Engineering Research Center on Accessible Medical Instrumentation 

Jack Winters, Ph.D.; Molly Follette Story, M.S. , Marquette University, Milwaukee, 

WI; Project Number: 482; Start Date: November 1, 2002; Length: 60 months.

Abstract: The RERC on Accessible Medical Instrumentation: (1) increases knowledge of, access to, and utilization of healthcare instrumentation and services by individuals with disabilities; (2) increases awareness of and access to employment in the 

healthcare professions by individuals with disabilities; and (3) serves as a national 

center of excellence for this priority topic area. Specific research projects include: (1) 

needs analysis for people with disabilities as both recipients and providers of 

healthcare services, and for manufacturers of healthcare instrumentation; (2) 

usability analyses to determine what makes certain medical instrumentation either 

exemplary or problematic yet essential to healthcare service delivery; (3) accessibility and universal usability analysis to identify classification and measurement approaches that could be used to explore metrics for accessibility of medical instrumentation; and (4) policy analyses to explore how medical policies affect healthcare 

utilization and employment in the healthcare professions of persons with disabilities. Specific development projects include: (1) development of tools for usability 

and accessibility analysis; (2) development of modified and new accessible medical 

instrumentation; (3) monitoring of, and involvement in development of, emerging, 

accessible healthcare technologies; and (4) development of design guidelines for accessible medical instrumentation and model policies for healthcare service delivery.

Rehabilitation Engineering Research Center on Telecommunication Access 

Gregg C. Vanderheiden, Ph.D. (Trace); Judy Harkins, Ph.D. (Gallaudet University), 

University of Wisconsin/Madison, Madison, WI; Project Number: 1435; Start Date: 

October 1, 2004; Length: 60 months.

Abstract: The focus of this RERC is on advancing accessibility and usability in 

existing and emerging telecommunications products for people with all types of disabilities. Telecommunications accessibility is addressed along all three of its major 

dimensions: user interface, transmission (including digitization, compression, etc.), 

and modality translation services (relay services, gateways, etc.). Research and development projects cover three areas: (1) development of tools, techniques, and performance-based measures that can be used to evaluate current and evolving telecommunication strategies including visual communication and cognitive access; (2) 

solving the problems faced by individuals using hearing aids or cochlear implants 

with digital phones (including development of tools that users can employ to match 

appropriate hearing technologies with telecommunication technologies); and (3) improving access to emerging telecommunications for people with visual, hearing, 

physical, and cognitive disabilities’ particularly digital and IP-based systems including emergency communication. The RERC looks at advances that have both shortand long-term outcomes related to assistive technologies (AT), interoperability, and 

universal design of telecommunications. In addition, the RERC provides technical 

assistance to government, industry, and consumers, training for industry, and education for new researchers in this field. The RERC is a collaboration of the Trace 

Center at the University of Wisconsin and the Technology Access Program at Gallaudet University.

Rehabilitation Engineering Research Center on Universal Interface and Information 

Technology Access 

Gregg C. Vanderheiden, Ph.D., University of Wisconsin/Madison, Madison, WI; 

Project Number: 486; Start Date: October 1, 2003; Length: 60 months.

Abstract: The focus of this RERC is on both access to information (e.g., content) 

in its various forms, as well as access to interfaces used within content and by electronic technologies in general. The research and development program is carefully 

designed to provide an interwoven set of projects that together advance accessibility 

and usability in a fashion that takes into account, and supports, the full range of 

access strategies used by manufacturers and people with disabilities. These strategies range from enhancing the design of mainstream products that can be used by 

individuals with different ability sets to enhancing the ability of users to deal with 

the information and interfaces as they encounter them. Key to these projects are 

the development of new models and approaches for characterization of the functional requirements of current and future interfaces, and a better understanding of 

the type, diversity, and similarity of functional limitations across etiologies and disabilities. Research activities include: model generation and initial pilot studies for 

the characterization of interface requirements (current and emerging) and cross-disability user abilities; abstract user interfaces and human interface sockets; emerging 

technologies and future research needs; and accessible real-time visual information 

64

presentation in meetings and virtual meetings. Development projects include: tools 

to facilitate the incorporation of cross-disability interface features in public information technologies; tools to facilitate AT–IT interoperability; server-based and ‘‘virtual 

assistive technology’’; and support for national and international standards and 

guidelines efforts.

NATIONAL CENTER FOR MEDICAL REHABILITATION RESEARCH (NCMRR) PROJECTS LIST

Project Number Description 

F31—Predoctoral Individual National 

Research Service Award: 

1F31HD053986–01 .................................. COWAN, RACHEL E 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

PREDOCTORAL FELLOWSHIPS FOR STUDENTS WITH DISABILITIES 

SHINOWARA, NANCY 

5F31HD049319–02 .................................. AJIBOYE, ABIDEMI B 

NORTHWESTERN UNIVERSITY 

MINORITY PREDOCTORAL FELLOWSHIP PROGRAM 

QUATRANO, LOUIS A 

5F31HD049326–02 .................................. JAGODNIK, KATHLEEN M 

CASE WESTERN RESERVE UNIVERSITY 

UPPER EXTREMITY CONTROL USING REINFORCEMENT LEARNING 

NITKIN, RALPH M

F32—Postdoctoral Individual National 

Research Service Award:

3F32HD047099–02S1 .............................. LOVERING, RICHARD M. 

UNIVERSITY OF MARYLAND BALT PROF SCHOOL 

THE ROLE OF CYTOKERATINS IN SKELETAL MUSCLE INJURY 

NITKIN, RALPH M 

5F32HD049217–02 .................................. KLUZIK, JOANN 

KENNEDY KRIEGER RESEARCH INSTITUTE, INC. 

LEARNING POSTURAL DYNAMICS IN A NOVEL REACHING TASK 

QUATRANO, LOUIS A

K01—Research Scientist Development 

Award—Research & Training:

1K01HD049476–01A2 .............................. ZACKOWSKI, KATHLEEN 

KENNEDY KRIEGER RESEARCH INSTITUTE, INC. 

MECHANISMS OF LOCOMOTOR RECOVERY IN MULTIPLE SCLEROSIS 

SHINOWARA, NANCY 

1K01HD049593–01A1 .............................. PURSER, JAMA L 

DUKE UNIVERSITY 

CANDIDATE GENES AND LONGITUDINAL DIABILITY PHENOTYPES 

NITKIN, RALPH M 

1K01HD050369–01A1 .............................. MORTON, SUSANNE M 

UNIVERSITY OF MARYLAND BALT PROF SCHOOL 

EFFECT OF CONTRALATERAL LEG ON MOTOR OUTPUT POST STROKE 

ANSEL, BETH 

1K01HD050582–01A1 .............................. REISMAN, DARCY S 

UNIVERSITY OF DELAWARE 

LOCOMOTOR ADAPTATIONS FOLLOWING STROKE 

NITKIN, RALPH M 

5K01HD042057–06 .................................. AGUILAR, GUILLERMO 

UNIVERSITY OF CALIFORNIA RIVERSIDE 

PORT WINE STAIN TREATMENT FOR INFANTS AND YOUNG CHILDREN 

NITKIN, RALPH M 

5K01HD042491–04 .................................. LUDEWIG, PAULA M 

UNIVERSITY OF MINNESOTA TWIN CITIES 

BIOMECHANICALLY BASED SHOULDER REHABILITATION STRATEGIES 

NITKIN, RALPH M 

5K01HD043352–04 .................................. SALSICH, GRETCHEN B 

SAINT LOUIS UNIVERSITY 

PATELLOFEMORAL PAIN: TIBIOFEMORAL ROTATION IMPAIRMENTS 

NITKIN, RALPH M 

65

Project Number Description 

5K01HD045293–03 .................................. MURPHY, SUSAN L 

UNIVERSITY OF MICHIGAN AT ANN ARBOR 

CLINICAL STRATEGIES TO REDUCE OSTEOARTHRITIS DISABILITY 

NITKIN, RALPH M 

5K01HD046602–02 .................................. KALPAKJIAN, CLAIRE ZABELLE 

UNIVERSITY OF MICHIGAN AT ANN ARBOR 

MENOPAUSAL TRANSITION IN WOMEN WITH SPINAL CORD INJURY 

NITKIN, RALPH M 

5K01HD046682–02 .................................. OSTIR, GLENN V 

UNIVERSITY OF TEXAS MEDICAL BR GALVESTON 

ASSESSING QUALITY OF LIFE FOR REHABILITATION PATIENTS 

QUATRANO, LOUIS A 

5K01HD047148–02 .................................. QUANEY, BARBARA M 

UNIVERSITY OF KANSAS MEDICAL CENTER 

MOTOR PERFORMANCE AND CORTICAL CHANGES IN CHRONIC STROKE 

NITKIN, RALPH M 

5K01HD047669–02 .................................. LANG, CATHERINE E 

WASHINGTON UNIVERSITY 

MECHANISMS UNDERLYING LOSS OF HAND FUNCTION AFTER STROKE 

ANSEL, BETH 

5K01HD048437–02 .................................. EARHART, GAMMON M 

WASHINGTON UNIVERSITY 

PARKINSONIAN GAIT DISORDERS: MECHANISMS AND TREATMENT 

NITKIN, RALPH M

K02—Research Scientist Development 

Award—Research:

5K02HD044099–04 .................................. YEATES, KEITH O 

CHILDREN’S RESEARCH INSTITUTE 

OUTCOMES OF TRAUMATIC BRAIN INJURY IN CHILDREN 

QUATRANO, LOUIS A 

5K02HD045354–03 .................................. HALEY, STEPHEN M 

BOSTON UNIVERSITY 

COMPUTER ADAPTIVE TESTING OF FUNCTIONAL STATUS 

QUATRANO, LOUIS A 

7K02HD045354–04 .................................. HALEY, STEPHEN M 

BOSTON UNIVERSITY MEDICAL CAMPUS 

COMPUTER ADAPTIVE TESTING OF FUNCTIONAL STATUS 

QUATRANO, LOUIS A

K08—Clinical Investigator Award:

1K08HD049459–01A2 .............................. SNOW, LEANN 

UNIVERSITY OF MINNESOTA TWIN CITIES 

SKELETAL MUSCLE PLASTICITY POST-STROKE 

NITKIN, RALPH M 

1K08HD049616–01A2 .............................. EVANS, MELISSA C 

VIRGINIA COMMONWEALTH UNIVERSITY 

ARTERIAL CELL SIGNALING IN VASODILATORY SHOCK. 

NICHOLSON, CAROL E 

1K08HD051609–01A1 .............................. FAIRCHILD, KAREN D 

UNIVERSITY OF VIRGINIA CHARLOTTESVILLE 

HYPOTHERMIA ENHANCES INFLAMMATORY CYTOKINE EXPRESSION VIA NF-KAPPA B 

NICHOLSON, CAROL E 

1K08HD052619–01 .................................. BURNS, ANTHONY S 

THOMAS JEFFERSON UNIVERSITY 

THE LOWER MOTOR NEURON & SPINAL CORD INJURY: IMPLICATIONS FOR REHABILITATION 

NITKIN, RALPH M 

1K08HD052885–01 .................................. SHEW, STEPHEN BRIAN 

UNIVERSITY OF CALIFORNIA LOS ANGELES 

EFFECT OF CYSTEINE ON GLUTATHIONE PRODUCTION IN CRITICALLY ILL

NEONATES 

NITKIN, RALPH M 

66

Project Number Description 

5K08HD044558–03 .................................. DE PLAEN, ISABELLE G 

CHILDREN’S MEMORIAL HOSPITAL (CHICAGO) 

MECHANISMS OF ACUTE BOWEL INJURY ROLE OF NF-KB 

NICHOLSON, CAROL E

K12—Physician Scientist Award

(Program):

2K12HD001097–11 .................................. WHYTE, JOHN 

MOSS REHABILITATION HOSPITAL 

REHABILITATION MEDICINE SCIENTIST TRAINING (RMST) PROGRAM 

NITKIN, RALPH M 

5K12HD047349–03 .................................. DEAN, JONATHAN MICHAEL 

UNIVERSITY OF UTAH 

PEDIATRIC CRITICAL CARE SCIENTIST DEVELOPMENT PROGRAM 

NICHOLSON, CAROL E

K23—Mentored Patient-Oriented

Research Devel Award:

1K23HD049472–01A1 .............................. RAGHAVAN, PREETI 

MOUNT SINAI SCHOOL OF MEDICINE OF NYU 

INTERHEMISPHERIC TRANSFER OF GRASP CONTROL AFTER STROKE 

ANSEL, BETH 

1K23HD049552–01A2 .............................. VARGUS-ADAMS, JILDA N 

CHILDREN’S HOSPITAL MED CTR (CINCINNATI) 

TOWARDS IMPROVED CLINICAL TRIALS IN CEREBRAL PALSY 

NICHOLSON, CAROL E 

5K23HD041040–05 .................................. KEENAN, HEATHER T 

UNIVERSITY OF UTAH 

OUTCOMES OF TRAUMATIC BRAIN INJURY 

NICHOLSON, CAROL E 

5K23HD042014–05 .................................. TRAUTNER, BARBARA W 

BAYLOR COLLEGE OF MEDICINE 

E. COLI FOR PREVENTION OF CATHETER UTI IN SCI PATIENTS 

NITKIN, RALPH M 

5K23HD042128–04 .................................. LENGENFELDER, JEAN 

KESSLER MEDICAL REHAB RES & EDUC CORP 

USING FMRI TO IDENTIFY ENCODING DEFICITS IN TBI 

NITKIN, RALPH M 

5K23HD042702–04 .................................. CHEN, CHRISTINE C 

NEW YORK UNIVERSITY 

MEASURING HAND FUNCTION—DEVELOPMENT OF OUTCOME MEASURE 

QUATRANO, LOUIS A 

5K23HD043843–04 .................................. BERGER, RACHEL P 

CHILDREN’S HOSP PITTSBURGH/UPMC HLTH SYS 

USING BIOCHEMICAL MARKERS TO DETECT ABUSIVE HEAD TRAUMA 

NICHOLSON, CAROL E 

5K23HD044425–04 .................................. SCHAECHTER, JUDITH DIANE 

MASSACHUSETTS GENERAL HOSPITAL 

FMRI AND TMS OF MOTOR RECOVERY AFTER HEMIPARETIC STROKE 

NITKIN, RALPH M 

5K23HD044632–04 .................................. VAVILALA, MONICA S 

UNIVERSITY OF WASHINGTON 

HEMODYNAMICS AND OUTCOME IN PEDIATRIC BRAIN INJURY 

NICHOLSON, CAROL E 

5K23HD046489–03 .................................. WATSON, R SCOTT 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

CONSEQUENCES OF SURVIVING CRITICAL ILLNESS IN CHILDHOOLD 

NICHOLSON, CAROL E 

5K23HD046690–02 .................................. WALZ, NICOLAY C 

CHILDREN’S HOSPITAL MED CTR (CINCINNATI) 

SOCIAL DEVELOPMENT FOLLOWING PRESCHOOL BRAIN INJURY 

NITKIN, RALPH M 

67

Project Number Description 

5K23HD047634–03 .................................. MORRIS, MARILYN C 

COLUMBIA UNIVERSITY HEALTH SCIENCES 

EXCEPTION FROM INFORMED CONSENT IN PEDIATRICS 

NICHOLSON, CAROL E 

5K23HD048637–02 .................................. MARINO, BRADLEY S 

CHILDREN’S HOSPITAL OF PHILADELPHIA 

TESTING THE PEDIATRIC CARDIAC QUALITY OF LIFE INVENTORY 

NICHOLSON, CAROL E 

5K23HD048817–02 .................................. ZUPPA, ATHENA F 

CHILDREN’S HOSPITAL OF PHILADELPHIA 

IMPROVING DRUG DEVELOPMENT FOR THE CRITICALLY ILL CHILD 

NICHOLSON, CAROL E

K24—Midcareer Investigator Awd in

Patient-Oriented Res:

5K24HD041504–04 .................................. STEVENSON, RICHARD D 

UNIVERSITY OF VIRGINIA CHARLOTTESVILLE 

GROWTH AND PHYSICAL MATURATION IN CEREBRAL PALSY 

NITKIN, RALPH M 

5K24HD043819–03 .................................. CAMPAGNOLO, DENISE I 

ST. JOSEPH’S HOSPITAL AND MEDICAL CENTER 

HEALTH AND IMMUNITY FOLLOWING SPINAL CORD INJURY 

NITKIN, RALPH M 

K25—Mentored Quantitative Research 

Career Development: 

1K25HD048643–01A1 .............................. MONSON, KENNETH L 

UNIVERSITY OF CALIFORNIA SAN FRANCISCO 

VASCULAR MECHANOTRANSDUCTION IN TRAUMATIC BRAIN INJURY 

NICHOLSON, CAROL E 

5K25HD043993–02 .................................. ERIM, ZEYNEP 

REHABILITATION INSTITUTE OF CHICAGO 

IMPAIRED MOTOR UNIT CONTROL IN BRAIN AND SPINAL INJURY 

NITKIN, RALPH M 

5K25HD044720–04 .................................. PERREAULT, ERIC J 

NORTHWESTERN UNIVERSITY 

REFLEX CONTROL OF MULTI-JOINT MECHANICS FOLLOWING STROKE 

NITKIN, RALPH M 

5K25HD047194–02 .................................. STERGIOU, NICK 

UNIVERSITY OF NEBRASKA OMAHA 

NONLINEAR ANALYSIS OF POSTURAL FUNCTION IN INFANTS 

NICHOLSON, CAROL E

P01—Research Program Projects:

5P01HD033988–10 .................................. JENSEN, MARK P 

UNIVERSITY OF WASHINGTON 

MANAGEMENT OF CHRONIC PAIN IN REHABILITATION MEDICINE 

QUATRANO, LOUIS A

R01—Research Project:

1R01AR052113–01A1 .............................. WEINSTEIN, STUART L 

UNIVERSITY OF IOWA 

BRACING IN ADOLESCENT IDIOPATHIC SCOLIOSIS (BRAIST) 

SHINOWARA, NANCY 

1R01HD046570–01A2 .............................. MOSSBERG, KURT A 

UNIVERSITY OF TEXAS MEDICAL BR GALVESTON 

PHYSICAL WORK CAPACITY AFTER TRAUMATIC BRAIN INJURY 

ANSEL, BETH 

1R01HD047242–01A2 .............................. MCALLISTER, THOMAS W 

DARTMOUTH COLLEGE 

RCT METHYLPHENIDATE & MEMORY/ATTENTION TRAINING IN TBI 

ANSEL, BETH 

1R01HD047516–01A2 .............................. ISKANDAR, BERMANS 

UNIVERSITY OF WISCONSIN MADISON 

FOLIC ACID ENHANCES REPAIR MECHANISM IN THE ADULT CNS 

SHINOWARA, NANCY 

68

Project Number Description 

1R01HD047709–01A2 .............................. VAN DILLEN, LINDA 

WASHINGTON UNIVERSITY 

CLASSIFICATION—DIRECTED TREATMENT OF LOW BACK PAIN 

SHINOWARA, NANCY 

1R01HD047761–01A2 .............................. CHENG, MEI-FANG 

RUTGERS, THE STATE UNIV OF NJ-NEWARK 

BRAIN DAMAGE AND RECOVERY OF FUNCTION IN THE ADULT SYSTEM 

ANSEL, BETH 

1R01HD048741–01A2 .............................. BASTIAN, AMY J. 

KENNEDY KRIEGER RESEARCH INSTITUTE, INC. 

HUMAN LOCOMOTOR PLASTICITY IN HEALTH AND DISEASE 

ANSEL, BETH 

1R01HD048946–01A2 .............................. YEATES, KEITH 

CHILDREN’S RESEARCH INSTITUTE 

SOCIAL OUTCOMES IN PEDIATRIC TRAUMATIC BRAIN INJURY 

ANSEL, BETH 

1R01HD049471–01A2 .............................. SUMAN, OSCAR E 

UNIVERSITY OF TEXAS MEDICAL BR GALVESTON 

EXERCISE AND QUALITY OF LIFE IN SEVERELY BURNED CHILDREN 

NICHOLSON, CAROL E 

1R01HD049774–01A2 .............................. MULROY, SARA J 

LOS AMIGOS RESEARCH/EDUCATION INSTITUTE 

SHOULDER PAIN IN SCI: A LONGITUDINAL STUDY 

SHINOWARA, NANCY 

1R01HD051844–01A1 .............................. PROTAS, ELIZABETH J 

UNIVERSITY OF TEXAS MEDICAL BR GALVESTON 

GAIT AND STEP TRAINING TO PREVENT FALLS IN PARKINSON’S DISEASE 

SHINOWARA, NANCY 

1R01HD052127–01 .................................. CRISCO, JOSEPH J 

RHODE ISLAND HOSPITAL (PROVIDENCE, RI) 

3–D MULTI-ARTICULAR MODELS OF THE CARPUS 

SHINOWARA, NANCY 

2R01HD032943–06A2 .............................. DILLER, LEONARD 

NEW YORK UNIVERSITY SCHOOL OF MEDICINE 

PROBLEM-SOLVING TREATMENT/ADULT/ACQUIRED BRAIN DAMAGE 

QUATRANO, LOUIS A 

2R01HD037433–05A1 .............................. CAVANAGH, PETER R 

CLEVELAND CLINIC LERNER COL/MED-CWRU 

DESIGN CRITERIA FOR THERAPEUTIC FOOTWARE IN DIABETES 

QUATRANO, LOUIS A 

2R01HD037985–05 .................................. SNYDER-MACKLER, LYNN 

UNIVERSITY OF DELAWARE 

DYNAMIC STABILITY OF THE ACL DEFICIENT KNEE 

SHINOWARA, NANCY 

2R01HD040289–05A1 .............................. BASTIAN, AMY J 

KENNEDY KRIEGER RESEARCH INSTITUTE, INC. 

MECHANISMS AND REHABILITATION OF CEREBELLAR ATAXIA 

NITKIN, RALPH M 

3R01HD034273–10S1 .............................. TAUB, EDWARD 

UNIVERSITY OF ALABAMA AT BIRMINGHAM 

A TREATMENT FOR EXCESS MOTOR DISABILITY IN THE AGED 

ANSEL, BETH 

3R01HD045798–03S2 .............................. CHIARAVALLOTI, NANCY D. 

KESSLER MEDICAL REHAB RES & EDUC CORP 

IMPROVING LEARNING IN MS: A RANDOMIZED CLINICAL TRIAL 

QUATRANO, LOUIS A 

3R01HD048628–01A1S1 .......................... FROEHLICH-GROBE, KATHERINE 

UNIVERSITY OF KANSAS MEDICAL CENTER 

A RANDOMIZED EXERCISE TRIAL FOR WHEELCHAIR USERS 

QUATRANO, LOUIS A 

5R01AR048781–06 .................................. AGARWAL, SUDHA 

OHIO STATE UNIVERSITY 

EXERCISE DRIVEN MOLECULAR MECHANISMS OF JOINT REPAIR 

NITKIN, RALPH M 

69

Project Number Description 

5R01EB001672–04 .................................. WEIR, RICHARD FERGUS FFRENCH 

NORTHWESTERN UNIVERSITY 

MULTIFUNCTION PROSTHESIS CONTROL USING IMPLANTED SENSORS 

SHINOWARA, NANCY 

5R01HD030149–11 .................................. SIPSKI, MARCA L 

UNIVERSITY OF ALABAMA AT BIRMINGHAM 

EFFECTS OF SCI ON FEMALE SEXUAL RESPONSE 

SHINOWARA, NANCY 

5R01HD031476–08 .................................. KAUFMAN, KENTON R. 

MAYO CLINIC COLL OF MEDICINE, ROCHESTER 

MICROSENSOR FOR INTRAMUSCULAR PRESSURE MEASUREMENT 

QUATRANO, LOUIS A 

5R01HD032116–12 .................................. ALVAREZ-BUYLLA, ARTURO 

UNIVERSITY OF CALIFORNIA SAN FRANCISCO 

ORIGINS OF NEW NEURONS AND GLIA IN THE POSTNATAL BRAIN 

NITKIN, RALPH M 

5R01HD034273–11 .................................. TAUB, EDWARD 

UNIVERSITY OF ALABAMA AT BIRMINGHAM 

A TREATMENT FOR EXCESS MOTOR DISABILITY IN THE AGED 

ANSEL, BETH 

5R01HD035047–07 .................................. STUIFBERGEN, ALEXA K 

UNIVERSITY OF TEXAS AUSTIN 

HEALTH PROMOTION FOR WOMEN WITH FIBROMYALGIA 

QUATRANO, LOUIS A 

5R01HD036019–13 .................................. FRIEDMAN, RHONDA B 

GEORGETOWN UNIVERSITY 

COGNITIVELY BASED TREATMENTS OF ACQUIRED DYSLEXIAS 

QUATRANO, LOUIS A 

5R01HD036020–09 .................................. CHEN, XIANG YANG 

WADSWORTH CENTER 

SUPRASPINAL CONTROL OF SPINAL CORD PLASTICITY 

SHINOWARA, NANCY 

5R01HD036895–07 .................................. MUELLER, MICHAEL J 

WASHINGTON UNIVERSITY 

VISUALIZING DIABETIC FEET TO OPTIMIZE ORTHOTIC FITTING 

QUATRANO, LOUIS A 

5R01HD037661–05 .................................. RIVERA, PATRICIA A 

UNIVERSITY OF ALABAMA AT BIRMINGHAM 

PROBLEM-SOLVING FOR CAREGIVERS OF WOMEN W/ DISABILITIES 

QUATRANO, LOUIS A 

5R01HD037880–07 .................................. COLLINS, JAMES J 

BOSTON UNIVERSITY 

NONLINEAR DYNAMICS AND ENHANCED SENSORIMOTOR FUNCTION 

ANSEL, BETH 

5R01HD038107–06 .................................. KRUPP, LAUREN B 

STATE UNIVERSITY NEW YORK STONY BROOK 

INTERVENTIONS TO IMPROVE MEMORY IN PATIENTS WITH MS 

ANSEL, BETH 

5R01HD038582–05 .................................. BUCHANAN, THOMAS S 

UNIVERSITY OF DELAWARE 

FES AND BIOMECHANICS: TREATING MOVEMENT DISORDERS 

QUATRANO, LOUIS A 

5R01HD038878–06 .................................. LAWLOR, MARY C 

UNIVERSITY OF SOUTHERN CALIFORNIA 

BOUNDARY CROSSINGS: RE-SITUATING CULTURAL COMPETENCE 

QUATRANO, LOUIS A 

5R01HD040692–04 .................................. TAUB, EDWARD 

UNIVERSITY OF ALABAMA AT BIRMINGHAM 

RANDOMIZED CONTROLLED TRIAL OF PEDIATRIC CI THERAPY 

NICHOLSON, CAROL E 

5R01HD040909–04 .................................. HENRY, SHARON M 

UNIVERSITY OF VERMONT & ST AGRIC COLLEGE 

MECHANISMS OF SPECIFIC TRUNK EXERCISES IN LOW BACK PAIN 

SHINOWARA, NANCY 

70

Project Number Description 

5R01HD041055–05 .................................. SNYDER-MACKLER, LYNN 

UNIVERSITY OF DELAWARE 

NMES FOR OLDER INDIVIDUALS AFTER TOTAL KNEE ARTHROPLASTY 

SHINOWARA, NANCY 

5R01HD041487–05 .................................. FIELD-FOTE, EDELLE C. 

UNIVERSITY OF MIAMI-MEDICAL SCHOOL 

COMPARISON OF POST-SCI LOCOMOTOR TRAINING TECHNIQUES 

SHINOWARA, NANCY 

5R01HD041490–04 .................................. BRIENZA, DAVID M. 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

RCT ON PREVENTING PRESSURE ULCERS WITH SEAT CUSHIONS 

QUATRANO, LOUIS A 

5R01HD042141–05 .................................. GARSHICK, ERIC HARVARD 

UNIVERSITY (MEDICAL SCHOOL) 

RESPIRATORY FUNCTION AND ILLNESS IN SPINAL CORD INJURY 

SHINOWARA, NANCY 

5R01HD042385–05 .................................. LEVINE, BRIAN T 

ROTMAN RESEARCH INSTITUTE 

THE NEUROANATOMY OF COGNITION IN TRAUMATIC BRAIN INJURY 

NITKIN, RALPH M 

5R01HD042527–05 .................................. CLARK, JANE E. 

UNIVERSITY OF MARYLAND COLLEGE PK CAMPUS 

ADAPTIVE SENSORIMOTOR CONTROL IN CHILDREN WITH DCD 

NICHOLSON, CAROL E 

5R01HD042588–04 .................................. STINEMAN, MARGARET G 

UNIVERSITY OF PENNSYLVANIA 

DO AMPUTEES BENEFIT FROM REHABILITATION SERVICES? 

QUATRANO, LOUIS A 

5R01HD042705–03 .................................. MARTIN, ANATOLE D 

UNIVERSITY OF FLORIDA 

RESPIRATORY MUSCLE TRAINING IN VENTILATOR DEPENDENT PTS. 

ANSEL, BETH 

5R01HD042729–05 .................................. WADE, SHARI L 

CHILDREN’S HOSPITAL MED CTR (CINCINNATI) 

CHILD AND FAMILY SEQUELAE OF PRESCHOOL BRAIN INJURY 

QUATRANO, LOUIS A 

5R01HD042838–05 .................................. JENSEN, MARK P 

UNIVERSITY OF WASHINGTON 

REHABILITATION OF SPINAL CORD INJURY-RELATED PAIN 

SHINOWARA, NANCY 

5R01HD043137–04 .................................. KUIKEN, TODD A 

REHABILITATION INSTITUTE OF CHICAGO 

EMG PROPAGATION IN PLANAR MUSCLES FOR PROSTHESIS CONTROL 

QUATRANO, LOUIS A 

5R01HD043249–03 .................................. LAZAR, RONALD M 

COLUMBIA UNIVERSITY HEALTH SCIENCES 

NEUROCHEMICAL CHALLENGE IN HUMAN STROKE RECOVERY 

ANSEL, BETH 

5R01HD043323–04 .................................. MOHR, DAVID C 

NORTHERN CALIFORNIA INSTITUTE RES & EDUC 

A CONTROLLED TRIAL OF CBT FOR MS INFLAMMATION 

QUATRANO, LOUIS A 

5R01HD043378–04 .................................. LYSACK, CATHERINE L 

WAYNE STATE UNIVERSITY 

COMMUNITY LIVING AFTER SPINAL CORD INJURY 

SHINOWARA, NANCY 

5R01HD043499–05 .................................. LEWIS, CORA E 

UNIVERSITY OF ALABAMA AT BIRMINGHAM 

LAXITY AND MALALIGNMENT IN A LARGE COHORT STUDY OF OA 

SHINOWARA, NANCY 

5R01HD043500–05 .................................. SHARMA, LEENA 

NORTHWESTERN UNIVERSITY 

LAXITY AND MALALIGNMENT IN A LARGE COHORT STUDY OF OA 

SHINOWARA, NANCY 

71

Project Number Description 

5R01HD043501–05 .................................. TORNER, JAMES C 

UNIVERSITY OF IOWA 

LAXITY AND MALALIGMENT IN A LARGE COHORT STUDY OF OA 

SHINOWARA, NANCY 

5R01HD043502–05 .................................. NEVITT, MICHAEL C 

UNIVERSITY OF CALIFORNIA SAN FRANCISCO 

LAXITY AND MALALIGNMENT IN A LARGE COHORT STUDY OF OA 

SHINOWARA, NANCY 

5R01HD043770–04 .................................. SCHENKMAN, MARGARET L 

UNIVERSITY OF COLORADO DENVER/HSC AURORA 

EXERCISE, PHYSICAL FUNCTION, AND PARKINSON’S DISEASE 

SHINOWARA, NANCY 

5R01HD043859–03 .................................. LEE, SAMUEL C 

UNIVERSITY OF DELAWARE 

STRENGTH TRAINING USING NMES FOR CHILDREN WITH CP 

NICHOLSON, CAROL E 

5R01HD043943–03 .................................. DAROUICHE, RABIH O 

BAYLOR COLLEGE OF MEDICINE 

PREVENTION OF UTI IN PERSONS WITH SPINAL CORD INJURY 

SHINOWARA, NANCY 

5R01HD043988–04 .................................. HAPP, MARY E 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

IMPROVING COMMUNICATION WITH NONSPEAKING ICU PATIENTS 

ANSEL, BETH 

5R01HD043991–04 .................................. SCHWARTZ, MYRNA F 

ALBERT EINSTEIN HEALTHCARE NETWORK 

AAC PROCESSING SUPPORT FOR SPOKEN LANGUAGE IN APHASIA 

ANSEL, BETH 

5R01HD044295–04 .................................. ZHANG, LI-QUN 

REHABILITATION INSTITUTE OF CHICAGO 

NEUROMECHANICAL CHANGES CAUSED BY STROKE & STRETCHING 

ANSEL, BETH 

5R01HD044444–02 .................................. AW, MARY C 

MCMASTER UNIVERSITY 

FAMILY-CENTRED FUNCTIONAL THERAPY FOR CEREBRAL PALSY 

NICHOLSON, CAROL E 

5R01HD044772–04 .................................. WOLF, WILLIAM A 

UNIVERSITY OF ILLINOIS AT CHICAGO 

DRUG-ENHANCED REHABILITATION IN RECOVERY FROM STROKE 

NITKIN, RALPH M 

5R01HD044775–04 .................................. PARENT, JACK M 

UNIVERSITY OF MICHIGAN AT ANN ARBOR 

AUGMENTATION OF NEUROGENESIS AND RECOVERY AFTER STROKE 

NITKIN, RALPH M 

5R01HD044816–02 .................................. CHAE, JOHN 

CASE WESTERN RESERVE UNIVERSITY 

FES FOR FOOT-DROP IN HEMIPARESIS 

ANSEL, BETH 

5R01HD044830–04 .................................. EDGERTON, V. REGGIE 

UNIVERSITY OF CALIFORNIA LOS ANGELES 

SEROTONERGIC FACILITATION & ROBOTICS IN SPINAL LEARNING 

NITKIN, RALPH M 

5R01HD044831–04 .................................. HODGE, CHARLES J 

UPSTATE MEDICAL UNIVERSITY 

CORTICAL PLASTICITY: MECHANISMS AND MODULATION 

NITKIN, RALPH M 

5R01HD045343–03 .................................. KREBS, HERMANO IGO 

MASSACHUSETTS INSTITUTE OF TECHNOLOGY 

THE EFFECT OF PROXIMAL AND DISTAL TRAINING ON STROKE REC 

QUATRANO, LOUIS A 

5R01HD045364–03 .................................. DUHAIME, ANN-CHRISTINE 

DARTMOUTH COLLEGE 

TRAUMA TO IMMATURE BRAIN: RESPONSE REPAIR & TREATMENT 

NICHOLSON, CAROL E 

72

Project Number Description 

5R01HD045412–03 .................................. DUNLOP, DOROTHY D 

NORTHWESTERN UNIVERSITY 

FUNCTIONAL LIMITATION, ARTHRITIS, DEPRESSION, & RACE 

QUATRANO, LOUIS A 

5R01HD045512–03 .................................. THOMAS, JAMES S 

OHIO UNIVERSITY ATHENS 

PREDICTING RECURRENCE OF LOW BACK PAIN—STUDY #2 SHINOWARA, NANCY 

5R01HD045639–03 .................................. STERNAD, DAGMAR 

PENNSYLVANIA STATE UNIVERSITY-UNIV PARK 

VARIABILITY AND STABILITY IN SKILL ACQUISITION 

SHINOWARA, NANCY 

5R01HD045694–02 .................................. ALONSO, ESTELLA M 

CHILDREN’S MEMORIAL HOSPITAL (CHICAGO) 

FUNCTIONAL OUTCOMES IN PEDIATRIC LIVER TRANSPLANTATION 

NICHOLSON, CAROL E 

5R01HD045751–02 .................................. LIGHT, KATHYE E 

UNIVERSITY OF FLORIDA 

EXAMINING PARAMETERS OF CONSTRAINT-INDUCED THERAPY 

ANSEL, BETH 

5R01HD045798–03 .................................. CHIARAVALLOTI, NANCY D. 

KESSLER MEDICAL REHAB RES & EDUC CORP 

IMPROVING LEARNING IN MS: A RANDOMIZED CLINICAL TRIAL 

QUATRANO, LOUIS A 

5R01HD045834–03 .................................. GREENDALE, GAIL A 

UNIVERSITY OF CALIFORNIA LOS ANGELES 

THE YOGA FOR HYPERKPHOSIS TRIAL 

ANSEL, BETH 

5R01HD045968–02 .................................. CLARK, ROBERT S. 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

GENDER-SPECIFIC TREATMENT OF PEDIATRIC CARDIAC ARREST 

NICHOLSON, CAROL E 

5R01HD046442–02 .................................. ALEXANDER, MICHAEL P 

BETH ISRAEL DEACONESS MEDICAL CENTER 

COGNITION AND FUNCTIONAL RECOVERY AFTER CARDIAC ARREST 

ANSEL, BETH 

5R01HD046700–02 .................................. KLINE, ANTHONY E 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

NOVEL REHABILITATIVE APPROACHES FOR RECOVERY FROM TBI 

ANSEL, BETH 

5R01HD046740–02 .................................. DOBKIN, BRUCE H 

UNIVERSITY OF CALIFORNIA LOS ANGELES 

FMRI PREDICTOR MODEL FOR STROKE LOCOMOTOR REHABILITATION 

QUATRANO, LOUIS A 

5R01HD046774–03 .................................. MURRAY, WENDY M 

PALO ALTO INSTITUTE FOR RES & EDU, INC. 

BIOMECHANICAL MODELING OF TENDON TRANSFER IN TETRAPLEGIA 

QUATRANO, LOUIS A 

5R01HD046814–03 .................................. DELP, SCOTT L 

STANFORD UNIVERSITY 

SIMULATION-BASED TREATMENT PLANNING FOR GAIT DISORDERS 

QUATRANO, LOUIS A 

5R01HD046820–03 .................................. KAUTZ, STEVEN A 

UNIVERSITY OF FLORIDA 

INTERMUSCULAR COORDINATION OF HEMIPARETIC WALKING 

QUATRANO, LOUIS A 

5R01HD046922–03 .................................. TING, LENA H 

GEORGIA INSTITUTE OF TECHNOLOGY 

NEUROMECHANICAL MODELING OF POSTURAL RESPONSES 

QUATRANO, LOUIS A 

5R01HD047447–02 .................................. MOORE, JASON H. 

DARTMOUTH COLLEGE 

GENETICS BASIS OF TRAUMA RECOVERY 

NITKIN, RALPH M 

73

Project Number Description 

5R01HD047569–02 .................................. DEWALD, JULIUS P 

NORTHWESTERN UNIVERSITY 

THE ROLE OF THE CORTEX IN DISCOORDINATION AFTER STROKE 

ANSEL, BETH 

5R01HD048051–03 .................................. VANDENBORNE, KRISTA H 

UNIVERSITY OF FLORIDA 

MOLECULAR SIGNATURES OF MUSCLE REHABILITATION 

NITKIN, RALPH M 

5R01HD048162–03 .................................. WAGNER, AMY K 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

DOPAMINE GENETIC VARIANTS MODULATING RECOVERY AFTER TBI 

NITKIN, RALPH M 

5R01HD048176–03 .................................. MCALLISTER, THOMAS 

DARTMOUTH COLLEGE 

ROLE OF CANDIDATE ALLELES IN COGNITIVE OUTCOME AFTER TBI 

NITKIN, RALPH M 

5R01HD048179–03 .................................. DIAZ-ARRASTIA, RAMON R 

UNIVERSITY OF TEXAS SW MED CTR/DALLAS 

GENETIC FACTORS IN OUTCOME FROM TRAUMATIC BRAIN INJURY 

NITKIN, RALPH M 

5R01HD048501–02 .................................. LIEBER, RICHARD L 

UNIVERSITY OF CALIFORNIA SAN DIEGO 

DIRECT DETERMINATION OF LOWER EXTREMITY OF MUSCLE DESIGN 

SHINOWARA, NANCY 

5R01HD048628–02 .................................. FROEHLICH-GROBE, KATHERINE 

UNIVERSITY OF KANSAS LAWRENCE 

A RANDOMIZED EXERCISE TRIAL FOR WHEELCHAIR USERS 

QUATRANO, LOUIS A 

5R01HD048781–02 .................................. AN, KAI-NAN 

MAYO CLINIC COLL OF MEDICINE, ROCHESTER 

BIOMECHANICS OF WHEELCHAIR PROPULSION 

SHINOWARA, NANCY 

5R01HD048924–02 .................................. OSTRY, DAVID J 

MC GILL UNIVERSITY 

MOTOR CONTROL OF HUMAN ARM STIFFNESS 

NITKIN, RALPH M 

5R01HD049773–02 .................................. ABBAS, JAMES J 

ARIZONA STATE UNIVERSITY 

ADAPTIVE ELECTRICAL STIMULATION FOR LOCOMOTOR RETRAINING 

SHINOWARA, NANCY 

5R01HD049777–02 .................................. CHAE, JOHN 

CASE WESTERN RESERVE UNIVERSITY 

ELECTRICAL STIMULATION FOR UPPER LIMB RECOVERY IN STROKE 

ANSEL, BETH 

5R01HD050385–02 .................................. DAHLQUIST, LYNNDA M 

UNIVERSITY OF MARYLAND BALT PROF SCHOOL 

VIRTUAL REALITY AND ACUTE PAIN MANAGEMENT FOR CHILDREN 

QUATRANO, LOUIS A 

5R01HD052891–02 .................................. RIMMER, JAMES H 

UNIVERSITY OF ILLINOIS AT CHICAGO 

BUILDING HEALTH EMPOWERMENT ZONES FOR PEOPLE WITH DISABILITIES 

QUATRANO, LOUIS A 

5R01NS050506–02 .................................. DUNCAN, PAMELA W. 

UNIVERSITY OF FLORIDA 

LOCOMOTOR EXPERIENCE APPLIED POST-STROKE (LEAPS) 

NITKIN, RALPH M 

7R01EB001672–05 .................................. WEIR, RICHARD FERGUS FFRENCH 

REHABILITATION INSTITUTE OF CHICAGO 

MULTIFUNCTION PROSTHESIS CONTROL USING IMPLANTED SENSORS 

SHINOWARA, NANCY

74

Project Number Description 

R03—Small Research Grants:

1R03HD044534–01A2 .............................. CAURAUGH, JAMES H 

UNIVERSITY OF FLORIDA 

SUBACUTE STROKE RECOVERY: BIMANUAL COORDINATION TRAINING 

ANSEL, BETH 

1R03HD049408–01A1 .............................. SAWAKI, LUMY 

WAKE FOREST UNIVERSITY, HEALTH SCIENCES 

DRIVING NEUROPLASTICITY WITH NERVE STIMULATION AND MODIFIED CIT 

NITKIN, RALPH M 

1R03HD049735–01A1 .............................. BONINGER, MICHAEL L 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

WHEELCHAIR PROPULSION TRAINING 

SHINOWARA, NANCY 

1R03HD049885–01A1 .............................. CLENDANIEL, RICHARD A 

DUKE UNIVERSITY 

COMPENSATORY MECHANISMS FOLLOWING VESTIBULAR LOSS 

ANSEL, BETH 

1R03HD050530–01A1 .............................. MODLESKY, CHRISTOPHER M 

UNIVERSITY OF DELAWARE 

VITAMIN K AND BONE IN CHILDREN WITH CEREBRAL PALSY 

NITKIN, RALPH M 

1R03HD050532–01A1 .............................. SHARKEY, NEIL A 

PENNSYLVANIA STATE UNIVERSITY-UNIV PARK 

AN OBJECTIVE EVALUATION OF SEGMENTED FOOT MODELS 

SHINOWARA, NANCY 

1R03HD051717–01A1 .............................. CHEN, YUYING 

UNIVERSITY OF ALABAMA AT BIRMINGHAM 

INTERVENTION ON WEIGHT CONTROL OF PERSONS:SPINAL INJURY 

QUATRANO, LOUIS A 

1R03HD051825–01 .................................. KRAMER, ANDREW M 

UNIVERSITY OF COLORADO DENVER/HSC AURORA 

TWO-YEAR OUTCOMES OF OLDER PERSONS WITH STROKE 

ANSEL, BETH 

1R03HD053135–01 .................................. HILLSTROM, HOWARD J 

HOSPITAL FOR SPECIAL SURGERY 

DEVELOPMENT OF A GEOMETRIC FOREFOOT MODEL: A TOOL FOR CLINICAL DECISION MAKING 

SHINOWARA, NANCY 

1R03HD053163–01A1 .............................. BOYD, LARA A 

UNIVERSITY OF KANSAS MEDICAL CENTER 

COMPENSATORY BRAIN ACTIVATION AFTER STROKE 

NITKIN, RALPH M 

5R03HD046930–02 .................................. STEFANATOS, GERRY A. 

ALBERT EINSTEIN HEALTHCARE NETWORK 

NEUROPHYSIOLOGICAL EFFECTS OF AMPHETAMINE APHASIA 

ANSEL, BETH 

5R03HD048457–02 .................................. BOGNER, JENNIFER A 

OHIO STATE UNIVERSITY 

SELF-REGULATION IN CO-OCCURRING TBI AND SUBSTANCE ABUSE 

ANSEL, BETH 

5R03HD048465–02 .................................. COOPER, RORY A 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

ADVANCED 3D CONTROL TECHNIQUES FOR POWERED WHEELCHAIRS 

SHINOWARA, NANCY 

5R03HD048481–02 .................................. JARIC, SLOBODAN 

UNIVERSITY OF DELAWARE 

HAND FUNCTION IN MULTIPLE SCLEROSIS 

QUATRANO, LOUIS A 

5R03HD050591–02 .................................. SCHWEIGHOFER, NICOLAS 

UNIVERSITY OF SOUTHERN CALIFORNIA 

TASK PRACTICE SCHEDULES TO ENHANCE RECOVERY AFTER STROKE 

ANSEL, BETH 

75

Project Number Description 

7R03HD053163–02 .................................. BOYD, LARA A 

UNIVERSITY OF BRITISH COLUMBIA 

COMPENSATORY BRAIN ACTIVATION AFTER STROKE 

NITKIN, RALPH M

R13—Conferences:

1R13HD048157–01A1 .............................. CREPEAU, ELIZABETH B 

MERICAN OCCUPATIONAL THERAPY ASSN 

HABITS AND REHABILITATION: PROMOTING PARTICIPATION 

QUATRANO, LOUIS A 

1R13NS056636–01 .................................. GRIGGS, ROBERT C 

UNIVERSITY OF ROCHESTER 

NOVEL TREATMENT FOR MUSCLE DISEASE: FUELING THE PIPELINE AND FINDING 

THE PRODUCT 

SHINOWARA, NANCY 

2R13DC006295–04 .................................. TOMPKINS, CONNIE A 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

RESEARCH SYMPOSIUM IN CLINICAL APHASIOLOGY 

ANSEL, BETH

R21—Exploratory/Developmental Grants:

1R21HD046628–01A2 .............................. HEISS, DEBORAH G 

OHIO STATE UNIVERSITY 

EFFICACY OF THERAPEUTIC EXERCISE FOR RECURRENT BACK PAIN 

QUATRANO, LOUIS A 

1R21HD047405–01A1 .............................. MATSUOKA, YOKY 

UNIVERSITY OF WASHINGTON 

ROBOTIC STROKE REHABILITATION USING PERCEPTUAL FEEDBACK 

ANSEL, BETH 

1R21HD047756–01A2 .............................. WHITALL, JILL 

UNIVERSITY OF MARYLAND BALT PROF SCHOOL 

BILATERAL AND UNILATERAL TRAINING IN CHRONIC STROKE 

ANSEL, BETH 

1R21HD049842–01A2 .............................. KIPKE, DARYL R 

UNIVERSITY OF MICHIGAN AT ANN ARBOR 

CORTICAL CONTROL USING MULTIPLE SIGNAL MODALITIES 

NITKIN, RALPH M 

1R21HD050457–01A1 .............................. ARUIN, ALEXANDER S 

UNIVERSITY OF ILLINOIS AT CHICAGO 

COMPELLED BODY WEIGHT SHIFT THERAPY IN INDIVIDUALS WITH STROKE

RELATED 

SHINOWARA, NANCY 

1R21HD050717–01A1 .............................. RIVIERE, CAMERON N 

CARNEGIE-MELLON UNIVERSITY 

NONLINEAR FILTERING OF ATHETOID MOVEMENT 

SHINOWARA, NANCY 

1R21HD051861–01 .................................. CERMAK, SHARON 

BOSTON UNIVERSITY 

PHYSICAL ACTIVITY, FITNESS AND OBESITY IN CHILDREN WITH COORDINATION 

DISORDERS 

SHINOWARA, NANCY 

1R21HD051988–01 .................................. SUGAR, THOMAS G 

ARIZONA STATE UNIVERSITY 

ROBOTIC SPRING ANKLE FOR GAIT ASSISTANCE 

SHINOWARA, NANCY 

1R21HD052197–01A1 .............................. LEWIS, GWYN N 

REHABILITATION INSTITUTE OF CHICAGO 

THE UTILITY OF RTMS TO ENHANCE HAND FUNCTION IN STROKE 

NITKIN, RALPH M 

1R21HD053669–01 .................................. ENGLISH, ARTHUR W 

EMORY UNIVERSITY 

PROTEOGLYCAN DEGRADATION AND FUNCTIONAL RECOVERY AFTER PERIPHERAL 

NERVE INJURY 

NITKIN, RALPH M 

76

Project Number Description 

5R21HD045841–03 .................................. WARE, JOHN E 

UALITYMETRIC, INC. 

DYNAMIC ASSESSMENT OF PEDIATRIC HEALTH AND FUNCTIONING 

QUATRANO, LOUIS A 

5R21HD045855–03 .................................. GRAY, DAVID B 

WASHINGTON UNIVERSITY 

REHABILITATION OUTCOMES, COMMUNITY PARTICIPATION AND ICF 

QUATRANO, LOUIS A 

5R21HD045864–03 .................................. SATISH, USHA G 

UPSTATE MEDICAL UNIVERSITY 

SIMULATION BASED MAPPING OF DECISION MAKING IN CHILDREN 

QUATRANO, LOUIS A 

5R21HD045869–03 .................................. VELOZO, CRAIG A 

UNIVERSITY OF FLORIDA 

DEVELOPING A COMPUTER ADAPTIVE TBI COGNITIVE MEASURE 

QUATRANO, LOUIS A 

5R21HD045873–03 .................................. BONATO, PAOLO 

SPAULDING REHABILITATION HOSPITAL 

FIELD MEASURES OF FUNCTIONAL TASKS FOR CIT INTERVENTION 

QUATRANO, LOUIS A 

5R21HD045881–03 .................................. STINEMAN, MARGARET G 

UNIVERSITY OF PENNSYLVANIA 

VIRTUAL RECOVERY SIMULATION 

QUATRANO, LOUIS A 

5R21HD045882–03 .................................. YORKSTON, KATHRYN M 

UNIVERSITY OF WASHINGTON 

DEVELOPING A SCORE OF COMMUNICATIVE PARTICIPATION 

QUATRANO, LOUIS A 

5R21HD045887–03 .................................. RILEY, BARTH B 

UNIVERSITY OF ILLINOIS AT CHICAGO 

A DYNAMIC DISABILITY SPECIFIC PHYSICAL ACTIVITY SCALE 

QUATRANO, LOUIS A 

5R21HD046540–02 .................................. LEVY, CHARLES E 

UNIVERSITY OF FLORIDA 

THE IMPACT OF POWER-ASSIST WHEELCHAIR ON QOL 

QUATRANO, LOUIS A 

5R21HD046844–02 .................................. MAKHSOUS, MOHSEN 

REHABILITATION INSTITUTE OF CHICAGO 

PRESSURE RELIEF SYSTEM FOR PREVENTING PRESSURE ULCERS 

QUATRANO, LOUIS A 

5R21HD046876–02 .................................. HORNBY, T GEORGE 

REHABILITATION INSTITUTE OF CHICAGO 

PHYSICAL AND PHARMACOLOGICAL EFFECTS ON MOVEMENT IN SCI 

SHINOWARA, NANCY 

5R21HD046903–02 .................................. SAPIENZA, CHRISTINE M 

UNIVERSITY OF FLORIDA 

EXPIRATORY MUSCLE TRAINING IN PATIENTS WITH PARKINSON’S 

SHINOWARA, NANCY 

5R21HD046938–02 .................................. MOSES, PAMELA A 

UNIVERSITY OF CALIFORNIA SAN DIEGO 

WHITE MATTER DIFFUSION MRI IN CHILDREN WITH EARLY STROKE 

ANSEL, BETH 

5R21HD047263–02 .................................. COHEN, LINDSEY L 

GEORGIA STATE UNIVERSITY 

AUTOMATED TRAINING FOR PEDIATRIC PAIN MANAGEMENT 

QUATRANO, LOUIS A 

5R21HD047463–02 .................................. THOMAS, NEAL J 

PENNSYLVANIA STATE UNIV HERSHEY MED CTR 

SURFACTANT PROTEIN VARIANTS IN PEDIATRIC LUNG INJURY 

NICHOLSON, CAROL E 

5R21HD047643–02 .................................. HERMANN, GERLINDA E 

LSU PENNINGTON BIOMEDICAL RESEARCH CTR 

THROMBIN AND CNS: GASTRIC DYSFUNCTION AFTER HEAD TRAUMA 

ANSEL, BETH 

77

Project Number Description 

5R21HD047754–02 .................................. FRIED-OKEN, MELANIE 

OREGON HEALTH & SCIENCE UNIVERSITY 

AAC REHABILITATION FOR CONVERSATION IN DEMENTIA 

ANSEL, BETH 

5R21HD048566–02 .................................. VALERO-CUEVAS, FRANCISCO J 

CORNELL UNIVERSITY ITHACA 

DEVELOPING A CLINICALLY USEFUL MEASURE OF DYNAMIC PINCH 

QUATRANO, LOUIS A 

5R21HD048742–02 .................................. MORGAN, DON W 

MIDDLE TENNESSEE STATE UNIVERSITY 

UNDERWATER TREADMILL TRAINING IN SPASTIC DIPLEGIA 

SHINOWARA, NANCY 

5R21HD048944–02 .................................. DAMIANO, DIANE L 

WASHINGTON UNIVERSITY 

EFFECTS OF MOTOR-ASSISTED CYCLING IN CEREBRAL PALSY 

SHINOWARA, NANCY 

5R21HD048972–02 .................................. HASTINGS, MARY K 

WASHINGTON UNIVERSITY 

BOTULINUM TOXIN EFFECTS ON PLANTAR ULCER RECURRENCE 

QUATRANO, LOUIS A 

5R21HD049019–03 .................................. WITTENBERG, GEORGE 

UNIVERSITY OF MARYLAND BALT PROF SCHOOL 

MOTOR-FUNCTIONAL NEUROANATOMY IN CEREBRAL PALSY 

NICHOLSON, CAROL E 

5R21HD049020–02 .................................. GIORDANO, LOUIS A 

DUKE UNIVERSITY 

BEHAVIOR ANALYSIS OF CHRONIC LOW BACK PAIN 

QUATRANO, LOUIS A 

5R21HD049135–02 .................................. CHASE, THERESA M 

CRAIG HOSPITAL 

MASSAGE TO REDUCE PAIN IN PEOPLE WITH SPINAL CORD INJURY 

SHINOWARA, NANCY 

5R21HD049662–02 .................................. VAN DEN BOGERT, ANTONIE J 

CLEVELAND CLINIC LERNER COL/MED-CWRU 

INTELLIGENT CONTROL OF UPPER EXTREMITY NEURAL PROSTHESES 

QUATRANO, LOUIS A 

5R21HD049832–02 .................................. VAVILALA, MONICA S 

CHILDREN’S HOSPITAL AND REG MEDICAL CTR 

CEREBRAL EDEMA IN PEDIATRIC DIABETIC KETOACIDOSIS 

NICHOLSON, CAROL E 

5R21HD049883–02 .................................. LEWIS, GWYN N 

REHABILITATION INSTITUTE OF CHICAGO 

BILATERAL ACTIVATION IN UPPER-LIMB STROKE REHABILITATION 

ANSEL, BETH 

5R21HD049893–02 .................................. WANG, JIONGJIONG 

UNIVERSITY OF PENNSYLVANIA 

HEMODYNAMIC NEUROIMAGING OF PEDIATRIC STROKE 

NICHOLSON, CAROL E 

5R21HD050655–02 .................................. ODDSSON, LARS I E 

BOSTON UNIVERSITY 

TREATMENT OF MOTOR FUNCTION AND BALANCE- A NEW TOOL 

SHINOWARA, NANCY 

5R21HD050707–02 .................................. MATHERN, GARY W 

UNIVERSITY OF CALIFORNIA LOS ANGELES 

CORTICAL PLASTICITY AFTER HEMISPHERECTOMY 

NITKIN, RALPH M 

7R21HD046938–03 .................................. MOSES, PAMELA A 

SAN DIEGO STATE UNIVERSITY 

WHITE MATTER DIFFUSION MRI IN CHILDREN WITH EARLY STROKE 

ANSEL, BETH

R24—Resource-Related Research 

Projects:.

78

Project Number Description 

5R24HD050821–02 .................................. RYMER, WILLIAM Z 

REHABILITATION INSTITUTE OF CHICAGO 

ENGINEERING FOR NEUROLOGIC REHABILITATION 

NITKIN, RALPH M 

5R24HD050836–02 .................................. WHYTE, JOHN 

ALBERT EINSTEIN HEALTHCARE NETWORK 

RESEARCH METHODS FOR COGNITIVE REHABILITATION 

NITKIN, RALPH M 

5R24HD050837–02 .................................. LIEBER, RICHARD L 

UNIVERSITY OF CALIFORNIA SAN DIEGO 

NATIONAL CENTER FOR MUSCLE REHABILITATION RESEARCH 

NITKIN, RALPH M 

5R24HD050838–02 .................................. SELZER, MICHAEL E 

UNIVERSITY OF PENNSYLVANIA 

CENTER FOR EXPERIMENTAL NEUROREHABILITATION TRAINING 

NITKIN, RALPH M 

5R24HD050845–02 .................................. BREGMAN, BARBARA S 

GEORGETOWN UNIVERSITY 

NATIONAL CAPITAL AREA REHIBILIATION RESEARCH NETWORK 

NITKIN, RALPH M 

5R24HD050846–02 .................................. HOFFMAN, ERIC P 

CHILDREN’S RESEARCH INSTITUTE 

INTEGRATED MOLECULAR CORE FOR REHABILITATION MEDICINE 

NITKIN, RALPH M 

R34—Clinical Trial Planning Grant: 

1R34HD050531–01A1 .............................. MOLER, FRANK W 

UNIVERSITY OF MICHIGAN AT ANN ARBOR 

PLANNING HYPOTHERMIA TRIAL FOR PEDIATRIC CARDIAC ARREST 

NICHOLSON, CAROL E

R37—Method to Extend Research in 

Time (MERIT) Award:

5R37HD031550–25 .................................. GOSHGARIAN, HARRY G 

WAYNE STATE UNIVERSITY 

FUNCTIONAL PLASTICITY IN THE MAMMALIAN SPINAL CORD 

NITKIN, RALPH M 

5R37HD037100–08 .................................. OLNEY, JOHN W 

WASHINGTON UNIVERSITY 

ACUTE BRAIN INJURY, MECHANISMS AND CONSEQUENCES 

NITKIN, RALPH M

R41—Small Business Technology Transfer (STTR) Grants—Phase I:

1R41HD052318–01A1 .............................. HALEY, STEPHEN M 

CRECARE, LLC 

COMPUTER ADAPTIVE TESTING OF PEDIATRIC SELF-CARE AND SOCIAL FUNCTION 

QUATRANO, LOUIS A 

5R41HD047726–02 .................................. BARBOUR, RANDALL LOCKE 

PHOTON MIGRATION TECHNOLOGIES CORP 

OPTICAL TOMOGRAPHY FOR DIAGNOSIS OF NEC 

NICHOLSON, CAROL E 

5R41HD049224–02 .................................. RIMMER, JAMES H 

EXERSTRIDER PRODUCTS, INC. 

UNIVERSAL EXERCISE KITS FOR MANUAL WHEELCHAIR USERS 

SHINOWARA, NANCY 

R42— Small Business Technology 

Transfer (STTR) Grants—Phase II: 

4R42HD051240–02 .................................. PESHKIN, MICHAEL A 

CHICAGO PT, LLC 

DEVICE FOR OVERGROUND GAIT/BALANCE TRAINING POST-STROKE 

SHINOWARA, NANCY 

5R42HD043664–03 .................................. ZHANG, LI-QUN 

REHABTEK, LLC 

DEVELOPING AN INTELLIGENT & PORTABLE STRETCHING DEVICE 

SHINOWARA, NANCY

79

Project Number Description 

R43—Small Business Innovation Research Grants (SBIR)—Phase I:

1R43HD047493–01A2 .............................. PITKIN, MARK R 

POLY-ORTH INTERNATIONAL 

NEW IIZAROV TECHNIQUE FOR PEDIATRIC CRITICAL CARE 

NICHOLSON, CAROL E 

1R43HD049211–01A1 .............................. GOLDIE, JAMES H 

INFOSCITEX CORPORATION 

ROBOTICALLY-AIDED HAND REHABILITATION 

QUATRANO, LOUIS A 

1R43HD049960–01A1 .............................. THROPE, GEOFFREY B 

NDI MEDICAL, LLC 

NEUROSTIMULATION FOR ELBOW EXTENSION IN TETRAPLEGIA 

SHINOWARA, NANCY 

1R43HD050006–01A1 .............................. HARTMAN, ERIC C 

CUSTOMKYNETICS, INC. 

STIMULATION-AUGMENTED EXERCISE AND NEUROMOTOR THERAPY 

SHINOWARA, NANCY 

1R43HD051014–01A1 .............................. GREELEY, HAROLD P 

CREARE, INC. 

PHYSICAL ACTIVITY MONITOR 

QUATRANO, LOUIS A 

1R43HD052310–01 .................................. SCHERER, MARCIA J 

INSTITUTE/MATCHING PERSON & TECHNOLOGY 

IMPROVING MATCH OF PERSON/ASSISTIVE COGNITIVE TECHNOLOGY 

QUATRANO, LOUIS A 

1R43HD052311–01 .................................. RICHTER, W MARK 

MAX MOBILITY 

OPTIPUSH WHEELCHAIR TRAINING SYSTEM 

SHINOWARA, NANCY 

1R43HD052313–01 .................................. VEATCH, BRADLEY D 

ADA TECHNOLOGIES, INC. 

A BIOACTUATOR-DRIVEN ANKLE DORSIFLEXOR UNIT 

QUATRANO, LOUIS A 

1R43HD052327–01 .................................. TOWNSEND, WILLIAM T 

BARRETT TECHNOLOGY, INC. 

ADVANCED ROBOTIC DEVICE FOR THE SAFE REHABILITATION FOR STROKE AND 

BRAIN INJURY 

QUATRANO, LOUIS A 

1R43HD053196–01 .................................. HERMES, MATTHEW E 

TURBO WHEELCHAIR COMPANY, INC. 

LIGHTWEIGHT, COMPLIANT MANUAL WHEELCHAIR HIGH-TONE CHILD 

SHINOWARA, NANCY 

1R43HD053211–01 .................................. SCHAEFER, PHILIP R 

VORTANT TECHNOLOGIES, LLC 

A LIP READING CLICK DEVICE FOR DISABLED COMPUTER USERS 

SHINOWARA, NANCY 

1R43HD054091–01 .................................. VEATCH, BRADLEY D 

ADA TECHNOLOGIES, INC. 

A LOW-COST UPPER-EXTREMITY PROSTHESIS FOR UNDER-SERVED POPULATIONS 

QUATRANO, LOUIS A 

1R43HD054262–01 .................................. SELBIE, W. SCOTT 

C-MOTION, INC. 

ANALYTICAL TOOLS FOR OPTIMIZING NEUROREHABILITATION OF GAIT 

SHINOWARA, NANCY 

1R43HD054313–01 .................................. EDELL, DAVID J 

INNERSEA TECHNOLOGY 

ULTRA-LOW-POWER WIRELESS IMPLANT STIMULATOR FOR PROSTHESIS SENSORY 

FEEDBACK 

QUATRANO, LOUIS A 

1R43HD055110–01A1 .............................. FLYNN, LOUIS L 

LIGHTNING PACKS, LLC GENERATION OF ELECTRICITY BY NORMAL HUMAN MOVEMENT 

SHINOWARA, NANCY 

80

Project Number Description 

5R43HD044271–02 .................................. GREEN, STEVE C 

GREEN TECHNOLOGIES, INC. 

A MANUAL STANDUP WHEELCHAIR 

QUATRANO, LOUIS A 

5R43HD047071–02 .................................. AXELSON, PETER WILLIAM 

BENEFICIAL DESIGNS, INC. 

OPTIFIT WHEELCHAIR FITTING SYSTEM 

SHINOWARA, NANCY 

5R43HD047086–02 .................................. GIUFFRIDA, JOSEPH P 

LEVELAND MEDICAL DEVICES, INC. 

ADAPATIVE WIRELESS COMPUTER MOUSE FOR MOVEMENT DISORDERS 

SHINOWARA, NANCY 

5R43HD049251–02 .................................. MERZENICH, MICHAEL M 

POSIT SCIENCE CORPORATION 

BRAIN PLASTICITY BASED TRAINING FOR FOCAL DYSTONIA 

SHINOWARA, NANCY 

5R43HD051061–02 .................................. RENSING, NOA M 

MICROOPTICAL ENGINEERING CORPORATION 

VISIONKEY+: ADVANCED EYE ACTIVATED KEYBOARD 

QUATRANO, LOUIS A 

8R43HD054291–02 .................................. RIFKIN, JEROME R 

TENSEGRITY PROSTHETICS, INC. 

TENSEGRITY FOOT WITH COORDINATED JOINT MOTION 

SHINOWARA, NANCY

R44—Small Business Innovation Research Grants (SBIR)—Phase II:

1R44HD050047–01A1 .............................. TUEL, STEPHEN M 

PHASE V PHARMACEUTICALS, INC. 

TIZANIDINE FORMULATION FOR SPASTICITY WITH DYSPHAGIA 

QUATRANO, LOUIS A 

1R44HD053176–01 .................................. JAKOBS, THOMAS 

INVOTEK, INC. 

RELIABLE/SAFE LASER POINTING-PEOPLE LOCKED-IN SYNDROME 

QUATRANO, LOUIS A 

1R44HD054401–01 .................................. RICHTER, W MARK 

MAX MOBILITY 

ERGOCHAIR SMART MANUAL WHEELCHAIR 

SHINOWARA, NANCY 

2R44HD037776–02A1 .............................. HAMILTON, PATRICK 

S.E.P., LTD 

AN AMBULATORY LORDOSIMETER FOR POSTURE CONTROL 

QUATRANO, LOUIS A 

2R44HD040023–02A2 .............................. LOPRESTI, EDMUND F 

AT SCIENCES 

SMART WHEELCHAIR COMPONENT SYSTEM 

QUATRANO, LOUIS A 

2R44HD042334–02 .................................. BENJAMIN, MALVERN J 

RHEOMEDIX, INC. 

PULMONARY AIRFLOW MONITOR IN TRACHEOSTOMIZED CHILDREN 

QUATRANO, LOUIS A 

2R44HD046319–02 .................................. KLEDARAS, JOANNE B 

PRAXIS, INC. 

MONETARY EQUIVALENCE: READINESS INSTRUCTIONAL TRACK (PHASE II) 

QUATRANO, LOUIS A 

2R44HD047044–02 .................................. JAKOBS, THOMAS 

INVOTEK, INC. 

SPEECH SUPPLEMENTED WORD PREDICTION PROGRAM 

QUATRANO, LOUIS A 

2R44HD049205–02 .................................. KYLSTRA, BART 

DAEDALUS WINGS, INC. 

POWER PROPULSION ATTACHMENT FOR MANUAL WHEELCHAIRS 

SHINOWARA, NANCY 

81

Project Number Description 

5R44HD033942–05 .................................. WYATT, CATHERINE 

MEALTIME PARTNERS, INC. 

ADD REGULATORY COMPLIANCE AND COST (REV A) 

QUATRANO, LOUIS A 

5R44HD035793–06 .................................. MEGINNISS, STEVE M 

MAGIC WHEELS, INC. 

TWO-SPEED MANUAL WHEELCHAIR WHEEL 

QUATRANO, LOUIS A 

5R44HD039962–03 .................................. BONINGER, RONALD M 

THREE RIVERS HOLDINGS, LLC 

DEVELOPMENT OF AN ERGONOMIC MANUAL WHEELCHAIR PUSHRIM 

QUATRANO, LOUIS A 

5R44HD041805–03 .................................. KOENEMAN, JAMES B 

KINETIC MUSCLES, INC. 

CLINICAL ASSESSMENT OF A MASSED PRACTICE THERAPY DEVICE 

SHINOWARA, NANCY 

5R44HD041820–04 .................................. HARTMAN, ERIC C 

CUSTOMKYNETICS, INC. 

ADAPTIVE STIMULATOR FOR EXERCISE AND REHABILITATION 

QUATRANO, LOUIS A 

5R44HD042367–03 .................................. VAIDYANATHAN, RAVI 

THINK-A-MOVE, LTD 

AN EAR DEVICE ENABLING HANDS FREE WHEELCHAIR CONTROL 

QUATRANO, LOUIS A 

5R44HD042892–03 .................................. IRVINE, BLAIR 

OREGON CENTER FOR APPLIED SCIENCE, INC. 

TRAINING PARENTS TO ADVOCATE FOR STUDENTS WITH TBI 

QUATRANO, LOUIS A 

5R44HD043513–03 .................................. SEARS, HAROLD H 

MOTION CONTROL, INC. 

ELECTRIC HEAVY-DUTY WORK HAND 

QUATRANO, LOUIS A 

5R44HD043516–03 .................................. GREEN, STEVE C 

GREEN TECHNOLOGIES, INC. 

A MODAL RECIPROCATING PUSHRIM DRIVE WHEELCHAIR 

QUATRANO, LOUIS A 

5R44HD043567–03 .................................. KYLSTRA, BART 

DAEDALUS WINGS, INC. 

MANUAL WHEELCHAIR UTILIZING SINGLE LEVER FOR PROPULSION 

SHINOWARA, NANCY 

5R44HD044288–03 .................................. BEHRMANN, GREGORY P 

EM PHOTONICS, INC. 

FIBER OPTICAL MICRO-SENSOR FOR MEASURING TENDON FORCES 

QUATRANO, LOUIS A 

5R44HD047119–03 .................................. BOONE, DAVID A 

CYMA CORPORATION 

COMPUTERIZED PROSTHETIC ALIGNMENT SYSTEM (COMPAS) 

QUATRANO, LOUIS A 

5R44HD049252–03 .................................. TUEL, STEPHEN M 

PHASE V PHARMACEUTICALS, INC. 

BACLOFEN FORMULATION FOR SPASTICITY WITH DYSPHAGIA 

QUATRANO, LOUIS A 

5R44HD051157–03 .................................. GOODWIN, DIANNE M 

BLUE SKY DESIGN, INC. 

ACCESSIBLE MOUNTING AND POSITIONING TECHNOLOGY 

SHINOWARA, NANCY

T15—Continuing Education Training 

Program:

1T15HD050255–01A1 .............................. BLACKMAN, JAMES A 

UNIVERSITY OF VIRGINIA CHARLOTTESVILLE 

NIH GRANT PREP. WORKSHOPS FOR REHABILITATION RESEARCH 

NITKIN, RALPH M

82

Project Number Description 

T32—Institutional National Research 

Service Award:

1T32HD049303–01A1 .............................. FINEMAN, JEFFREY R 

UNIVERSITY OF CALIFORNIA SAN FRANCISCO 

RESEARCH TRAINING IN PEDIATRIC CRITICAL CARE MEDICINE 

NICHOLSON, CAROL E 

1T32HD049350–01A1 .............................. LEVIN, HARVEY S 

BAYLOR COLLEGE OF MEDICINE 

MENTORED RESEARCH TRAINING IN REHABILITATION SCIENCE 

NITKIN, RALPH M 

2T32HD007422–16 .................................. TATE, DENISE G 

UNIVERSITY OF MICHIGAN AT ANN ARBOR 

U MICHIGAN MED REHABILITATION RESEARCH TRAINING PROGRAM 

NITKIN, RALPH M 

2T32HD007539–06 .................................. OTTENBACHER, KENNETH J 

UNIVERSITY OF TEXAS MEDICAL BR GALVESTON 

INTERDISCIPLINARY PREDOCTORAL REHABILITATION RESEARCH TRAINING 

NITKIN, RALPH M 

2T32HD040686–06A1 .............................. KOCHANEK, PATRICK M 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

PEDIATRIC NEUROINTENSIVE CARE AND RESUSCITATION RESEARCH 

NICHOLSON, CAROL E 

5T32HD007414–14 .................................. JOHNSTON, MICHAEL V 

KENNEDY KRIEGER RESEARCH INSTITUTE, INC. 

RESEARCH TRAINING IN BRAIN INJURY REHABILITATION 

NITKIN, RALPH M 

5T32HD007418–15 .................................. RYMER, WILLIAM Z 

NORTHWESTERN UNIVERSITY 

PATHOPHYSIOLOGY AND REHABILITATION OF NEURAL DYSFUNCTION 

NITKIN, RALPH M 

5T32HD007425–15 .................................. SALCIDO, RICHARD 

UNIVERSITY OF PENNSYLVANIA 

RESEARCH TRAINING IN NEUROLOGICAL REHABILITATION 

NITKIN, RALPH M 

5T32HD007434–14 .................................. MUELLER, MICHAEL J 

WASHINGTON UNIVERSITY 

DOCTORAL TRAINING PROGRAM IN MOVEMENT SCIENCE 

NITKIN, RALPH M 

5T32HD007447–14 .................................. BASFORD, JEFFREY R 

MAYO CLINIC COLL OF MEDICINE, ROCHESTER 

MAYO REHABILITATION RESEARCH TRAINING CENTER 

NITKIN, RALPH M 

5T32HD007459–13 .................................. BREGMAN, BARBARA S 

GEORGETOWN UNIVERSITY 

TRAINING IN RECOVERY OF FUNCTION AFTER CNS INJURY 

NITKIN, RALPH M 

5T32HD007490–09 .................................. BINDER-MACLEOD, STUART A. 

UNIVERSITY OF DELAWARE 

PT/PHD PREDOCTORAL TRAINING PROGRAM 

NITKIN, RALPH M 

5T32HD041899–04 .................................. RODGERS, MARY M 

UNIVERSITY OF MARYLAND BALT PROF SCHOOL 

ADVANCE REHABILITATION RESEARCH TRAINING PROJECT 

NITKIN, RALPH M 

5T32HD043730–04 .................................. VANDENBORNE, KRISTA H 

UNIVERSITY OF FLORIDA 

TRAINING IN REHABILITATION AND NEUROMUSCULAR PLASTICITY 

NITKIN, RALPH M

U01—Research Project (Cooperative 

Agreements):

3U01AR052171–02S1 .............................. AMTMANN, DAGMAR 

UNIVERSITY OF WASHINGTON 

UW CENTER ON OUTCOMES RESEARCH IN REHABILITATION (RMI) 

QUATRANO, LOUIS A 

83

Project Number Description 

5U01AR052171–03 .................................. AMTMANN, DAGMAR 

UNIVERSITY OF WASHINGTON 

UW CENTER ON OUTCOMES RESEARCH IN REHABILITATION(RMI) 

QUATRANO, LOUIS A 

5U01HD042652–04 .................................. DIAZ-ARRASTIA, RAMON R 

UNIVERSITY OF TEXAS SW MED CTR/DALLAS 

TRAUMATIC BRAIN INJURY CLINICAL TRIALS NETWORK 

ANSEL, BETH 

5U01HD042653–05 .................................. TEMKIN, NANCY R 

UNIVERSITY OF WASHINGTON 

TRAUMATIC BRAIN INJURY CLINICAL TRIALS NETWORK 

ANSEL, BETH 

5U01HD042678–05 .................................. ZAFONTE, ROSS 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

TRAUMATIC BRAIN INJURY CLINICAL TRIALS NETWORK 

ANSEL, BETH 

5U01HD042686–04 .................................. TIMMONS, SHELLY D 

UNIVERSITY OF TENNESSEE HEALTH SCI CTR 

TRAUMATIC BRAIN INJURY CLINICAL TRIALS NETWORK 

ANSEL, BETH 

5U01HD042687–05 .................................. NOVACK, THOMAS 

UNIVERSITY OF ALABAMA AT BIRMINGHAM 

TRAUMATIC BRAIN INJURY CLINICAL TRIALS NETWORK 

ANSEL, BETH 

5U01HD042689–05 .................................. BULLOCK, M ROSS 

VIRGINIA COMMONWEALTH UNIVERSITY 

TRAUMATIC BRAIN INJURY CLINICAL TRIALS NETWORK 

ANSEL, BETH 

5U01HD042736–04 .................................. EISENBERG, HOWARD M. 

UNIVERSITY OF MARYLAND BALT PROF SCHOOL 

TRAUMATIC BRAIN INJURY CLINICAL TRIALS NETWORK 

ANSEL, BETH 

5U01HD042738–05 .................................. JALLO, JACK 

TEMPLE UNIVERSITY 

TRAUMATIC BRAIN INJURY CLINICAL TRIALS NETWORK 

ANSEL, BETH 

5U01HD042823–05 .................................. RIEDEWALD, WILLIAM T 

COLUMBIA UNIVERSITY 

HEALTH SCIENCES 

TRAUMATIC BRAIN INJURY CLINICAL TRIALS NETWORK-DCC 

ANSEL, BETH 

5U01HD049934–02 .................................. DEAN, JONATHAN MICHAEL 

UNIVERSITY OF UTAH 

CENTRAL DATA MANAGEMENT AND COORDINATING CENTER 

NICHOLSON, CAROL E

U10—Cooperative Clinical Research 

(Cooperative Agreements):

5U10HD049945–02 .................................. ZIMMERMAN, JERRY J 

CHILDREN’S HOSPITAL AND REG MEDICAL CTR 

1ST TIER DRUGS+THEOPHYLLINE IN PEDIATRIC SEVERE ASTHMA 

NICHOLSON, CAROL E 

5U10HD049981–02 .................................. POLLACK, MURRAY M 

CHILDREN’S RESEARCH INSTITUTE 

ASSESSMENT AND PREDICTION OF FUNCTIONAL STATUS 

NICHOLSON, CAROL E 

5U10HD049983–02 .................................. CARCILLO, JOSEPH A 

UNIVERSITY OF PITTSBURGH AT PITTSBURGH 

METOCLOPRAMIDE PREVENTS PICU NOSOCOMIAL INFECTION 

NICHOLSON, CAROL E 

5U10HD050009–02 .................................. ANAND, KANWALJEET S 

ARKANSAS CHILDREN’S HOSPITAL RES INST 

PCCM NETWORK: REMEDIES FOR OPIOID TOLERANCE & WITHDRAWAL 

NICHOLSON, CAROL E 

84

Project Number Description 

5U10HD050012–02 .................................. NEWTH, CHRISTOPHER J 

CHILDREN’S HOSPITAL LOS ANGELES 

PHYSIOLOGICALLY GUIDED VENTILATOR STRATEGIES IN CHILDREN 

NICHOLSON, CAROL E 

5U10HD050096–02 .................................. MEERT, KATHLEEN L 

WAYNE STATE UNIVERSITY 

COLLABORATIVE PEDIATRIC CRITICAL CARE RESEARCH NETWORK 

NICHOLSON, CAROLE

U13—Conference (Cooperative Agreement):

5U13NS043180–05 .................................. SANGER, TERENCE D 

STANFORD UNIVERSITY 

NIH TASK FORCE ON CHILDHOOD MOTOR DISORDERS 

ANSEL, BETH 

Question 2. What would be the key components for a successful collaboration with 

the VA? 

Response. I recommend creating an enduring administrative structure for ongoing 

collaboration. A Coordinating Council should be established and staffed by the VA, 

and include representation from the DOD and the organizations that represent the 

civilian rehabilitation hospitals and the specialty of Physical Medicine and Rehabilitation. At a minimum, the American Medical Rehabilitation Providers Association 

(AMRPA), the American Hospital Association (AHA), the Federation of American 

Hospitals (FAH), and the American Academy of Physical Medicine and Rehabilitation (AAPM&R) should be invited to participate. The charge to this Council should 

include the following:

• Work collaboratively to create a short-term and long-term sustainable plan for 

how to allow the civilian provider community to augment, strengthen, and complement the DOD and VA in providing medical rehabilitation services (both inpatient and outpatient) to current and former members of the armed services who 

qualify. • Establish attributes and criteria to define rehabilitation service delivery capacity (both qualitatively and quantitatively) for specific disabling conditions, including, 

but not limited to:

Æ TBI 

Æ SCI 

Æ Amputation 

Æ Burn 

Æ Low Vision 

Æ Hearing Impairment 

Æ Post Traumatic Stress Disorder (PTSD)

• Determine the DOD, VA, and civilian care delivery settings that are capable of 

providing services that meet or exceed these criteria. 

• Establish the relative locations of VA and civilian programs, with the hope of 

identifying locations where collaboration might be possible, and where the civilian 

sector could broaden access for servicemembers. 

• Define which areas of the VA and DOD need enhancement through cooperating 

with civilian providers. 

• Create or adopt a qualifying and contracting methodology to allow civilian providers to contract with the DOD and/or VA. 

• Identify the appropriate payment methods and practices to utilize the civilian 

providers and provide adequate and timely reimbursement for the services they 

offer. 

• Establish the research questions and activities needed to better understand the 

rehabilitation care delivery needs of these servicemembers, and how to improve the 

efficiency and effectiveness of the collaboration to achieving more successful outcomes. 

• Oversee the implementation and operation of the collaboration and refine it 

over time as appropriate.

Question 3. What difference in care and support do you anticipate in serving returning veterans, rather than the Institute’s existing patients? Would your facilities 

have the expertise to also deal with TBI, PTSD, or other unique health and readjustment issues for returning veterans? 

85

Response. Kessler Institute for Rehabilitation currently provides comprehensive 

care and treatment for patients who are identical to those being injured in our country’s service. Our multidisciplinary team includes:

• Physiatrists and Neurologists, who are expert at diagnosing and treating the 

behavioral, cognitive and medical problems these patients face. 

• Neuropsychologists to assess, treat and support brain injured patients and their 

families. 

• Rehabilitation Psychologists, who can assess and treat PTSD, substance abuse, 

adjustment to disability and the other common psychological problems associated 

with health catastrophes. 

• Rehabilitation Nurses, who can manage wound care, provide bladder and bowel 

retraining, contribute to restoring function for real world application, and provide 

patient and family education. 

• Physical Therapists, Occupational Therapists, Speech Language Pathologists 

and many other disciplines to effectively address the range of physical and functional problems individuals face, as well as goals to be achieved. 

• Prosthetists and Orthotists to provide prostheses and orthoses, including C-legs 

and other state-of-the-art devices. 

• Rehabilitation Technologists to provide sophisticated power wheelchairs, electronic environmental control systems, computer access and other high tech devices 

that are needed by the most severely injured and disabled.

Our West Orange campus has the current capacity to care for 48 TBI inpatients 

and 48 SCI inpatients at any given time. Our outpatient programs include therapies 

by all the disciplines mentioned above, as well as a specialized Cognitive Rehabilitation Program that provides individually tailored, multidisciplinary care for patients 

with TBI scheduled a few times a week or as intensively as a day hospital, depending on needs and goals. We offer similar services at our Saddle Brook and Chester 

campuses as well. 

We operate two additional programs of special interest: a program for Severe Disorders of Consciousness (SDOC), and a dual-diagnosis program for patients with 

concomitant TBI and SCI. The SDOC program offers highly innovative and advanced evaluative and treatment services for the most severely brain injured patients. This program is having a remarkable impact on many or our patients. Our 

dual-diagnosis program is also capable of handling other combinations of disabling 

conditions, such as amputations that occur in addition to a TBI. 

In addition to the clinical services we offer, we serve as a major research and educational center for TBI, SCI and other rehabilitation conditions. For example, with 

our partners, the Kessler Medical Rehabilitation Research and Education Center 

(KMRREC) and UMDNJ-New Jersey Medical School, we are funded as an SCI 

Model System. We have been previously funded as a TBI Model System, and are 

currently reapplying for that award as well. 

These and other resources make the medical and rehabilitation care we would 

provide to injured servicemembers excellent, goal directed, and efficient. What 

would differ from our typical patient experience are the insurance, funding and administrative aspects of working with the VA or military under whatever contract 

mechanisms that would be developed. We do have experience in working with 

TRICARE already, so that would not be an issue. 

I suspect that all these matters would be favorably accommodated if there were 

an identified case manager from the VA or DOD, who would be actively engaged 

and involved with us in a way that would enable the economic and other administrative needs of the patients and their families to be dealt with efficiently and effectively. 

I am sure that the capabilities I described of Kessler Institute for Rehabilitation 

are also available at a number of other centers that have become specialized in 

managing the most complexly injured and disabled patients. From my conversations 

with the leadership of many rehabilitation programs, I am certain a strong enthusiasm exists to offer their capacity to enhance access to care by our servicemembers.

Chairman AKAKA. Thank you very much, Dr. Gans. 

I want to tell you that your testimonies have been excellent. 

Director Duckworth, you testified that the prosthetics service at 

Walter Reed is better than VA care, and, Dr. Gans, your Institute 

is consistently ranked as one of the top rehabilitation facilities in 

this country. I would like for both of you to comment. What do we 

need to do to make VA care the very best? 

86

Ms. DUCKWORTH. Senator Akaka, I think for those programs that 

are already in existence in the VA, the polytrauma centers, the 

blind rehabilitation program, the spinal cord injury centers that 

are already state-of-the-art certainly maintain, but also give them 

more funds so that they can really reach out and do the job that 

they are trying to do. 

For those programs where the VA is behind, such as the prosthetics program, to try to help them catch up at this point, it is too 

late into the war; it is too late into the game. And you would negatively affect the new amputees who are within their first 2 years 

of amputation. Allow those new patients to go back to Walter Reed 

or to go to a civilian prosthetist. That way you also maintain the 

quality of care for the veterans already in the system. I cannot 

really speak as much about the rehabilitation programs, but I 

know that the rehab program, the spinal rehab, the blind rehab 

centers, and the polytrauma centers in the VA are certainly stateof-the-art and capable of doing the job. 

Chairman AKAKA. Dr. Gans? 

Dr. GANS. I think coordination and cooperation is the key. Very 

happily, we had the opportunity to have a conversation with the 

New Jersey VA just last week regarding the traumatic brain injury 

patients and are now starting discussions about how we can be 

useful as a service delivery supplement to their resources and how 

we can cooperate. Many of the VAs are medical school facilities. 

They are training centers. We have all sorts of interactions between the civilian community and the VA. And we can build upon 

those strengths to provide educational programs, to provide resources, identify where the private sector has knowledge and expertise that could be tapped by the VA to help build and strengthen 

programs, where it simply does not make sense because the need 

is to transient, and to let the VA contract out with the private sector for specialized services. The high-tech kinds of prosthetic devices that are being discussed are really very high-end, very complicated, sophisticated devices. The military experience has dramatically expanded our knowledge and ability about how to use 

these devices in the civilian sector as well, and it is a small enough 

number in the size of the entire health care community that that 

kind of expertise really does need to be concentrated in centers of 

excellence that should be shared resources. 

Chairman AKAKA. It seems as though VA is geared toward older 

patients. We are concerned that younger veterans may be having 

difficulties as a minority within the VA system. 

Mr. Pruden and Director Duckworth, have you seen improvement 

in the ability of VA health care providers to treat younger patients 

returning from Iraq and Afghanistan? And do you think that VA, 

on the whole, is now ready to manage this younger population? Mr. 

Pruden? 

Mr. PRUDEN. Sir, I believe that the VA is doing a lot and making 

a lot of steps toward that goal, but they are not there yet. 

I had an infection last spring due to a bacteria that I picked up 

in Iraq called acinetobacter, and when I came back in 2003, there 

had not been very many cases of this at all in the United States, 

this particular strain. It has become very common now to see it in 

blast injuries coming back from Iraq and Afghanistan. Infectious 

87

Disease at Walter Reed is very familiar with this problem. But 

when I went to Infectious Disease at the local VA, they had no idea 

what I was talking about. So I brought them printouts from CDC 

and showed them what was going on. Long story short, I wound 

up coming back to Walter Reed and having treatment here for that, 

a regimen of antibiotics. But the Infectious Disease chief down 

there said, ‘‘If you had stayed here, we would have had to amputate your foot.’’ That was my other leg, and I definitely wanted to 

keep that one. 

You know, they are not quite there yet. I think there is a lot of 

information that needs to be grasped, specifically with regards to 

diseases endemic to Central Asia and Iraq, where these guys are 

going to be picking up things, also with regards to the types of 

blast injuries and, again, TBI, PTSD, those kinds of things. They 

need to be more educated and prepared for us. 

Chairman AKAKA. Thank you. 

Director? 

Ms. DUCKWORTH. Mr. Chairman, I think in some programs the 

VA certainly has state-of-the-art capability, and I would like to cite 

again this spinal cord injury center in Hines and the blind rehab 

center. Those are, in fact, two places where Walter Reed sends its 

patients for rehabilitation, so those are certainly up there. Those 

other programs with information sharing such as learning about 

these bacteria—I also suffer. I think about 90 percent of us now 

have this bacteria. That is an easy information-sharing kind of 

thing. But other things, traumatic brain injury, some of these 

things, the high-tech prosthetics, we do not have the time to play 

catch-up, not when the care is needed now with the traumatic 

brain injury patients. As Mrs. Mettie was saying, you lose ground 

so quickly that you may never regain if they do not access that 

high-quality care right away. And in those instances, I think a cooperative agreement between DOD, VA, and civilian practitioners, 

civilian providers, is critical because when you lose ground that 

early into your injury, you may never regain that ground back. 

Chairman AKAKA. Thank you. My time in the first round has expired. 

Senator Craig? 

Senator CRAIG. Well, thank you very much, Mr. Chairman. 

I am a little overwhelmed with all of your testimony, and I say 

that in the positive sense, as someone who, in cooperation with this 

Chairman and he with me when I was Chairman, has spent a 

great deal of time attempting to make VA better, and we think we 

have. 

You are saying something that I began to recognize a year ago, 

and it resulted in the introduction of legislation, S. 815, a few 

weeks ago. And I think, Tammy, you have said it well. There is no 

time to catch up. There is a huge private sector capability out there 

that is needed now, today. It was needed yesterday. And all of you 

are speaking to that. 

But here is our problem. I did not condemn. I simply offered 

some degree of observation as to what the Ranking Member here 

Patty Murray is doing. That is catch-up money. And it may not be 

well used today in a way that it should be used. And I do not say 

that in any condemnation of the VA at all. 

88

What we have is a wonderful health care delivery system within 

the VA, but you are speaking of its limitations. And yet every organization that is out there in support of it is also in defense of it. 

And when I offer a way for those who cannot get the public service, 

the VA service they need, a way to gain the private sector access, 

I am roundly criticized as someone who wants to tear down the 

current system or not adequately fund it. I think quite the opposite. 

Your response to an opportunity to have those who are eligible 

for VA health care to also have, if they are service-connected disabled, access to selected and/or other private facilities, you have all 

given testimony to it at this moment. Your reaction to a piece of 

legislation that would qualify a veteran or an active servicemember 

for that kind of potential health care. 

Ms. DUCKWORTH. Senator Craig, I certainly would support that; 

however, not at the expense of more funds going to the VA. I have 

to respectfully disagree with you that what Senator Murray is proposing is catch-up money. It is money that is badly needed in the 

system. At the same time as that funding, we also need access to 

private practices. As I mentioned earlier, we have a large generation of Vietnam veterans entering the system that we need to be 

ready to care for them as well. So we need both. The VA is already 

underfunded, and to take away those funds that they need to do 

their job so that they can support those state-of-the-art facilities—

the blind rehab, the spinal cord, taking care of our older veterans—

you know, it is not an either/or. We need both. 

Senator CRAIG. Well, you know, I appreciate that. Please go 

ahead, Jonathan. 

Mr. PRUDEN. Sir, I do not know if I have a good answer for you. 

I agree with Major Duckworth’s statement that the VA needs more 

funds to adequately address the needs of veterans currently. 

I think great care has to be taken. Like you said, if they leave 

in droves, we will know something else. And I do not believe they 

will leave in droves, either, but if they do—or there is a significant 

number that leave, I guess my question is: What happens to VA 

if a significant number do choose the private practice? That would 

be a concern for me. 

Senator CRAIG. Yes, please. 

Ms. METTIE. An observation that I have made throughout this 

past year is for the acute care——

Senator CRAIG. Just a moment. Mr. Chairman, do we know what 

the noise source is here? 

We are either under construction or destruction. 

[Laughter.] 

Senator CRAIG. Please continue, and hover close to that mike. 

Ms. METTIE. All right. Something I have noticed in the acute 

care is that if there could be an established place for these soldiers 

to go to in the beginning, instead of saying you have got to go to 

a nursing home, we do not know what progress they are going to 

make, and those first 6, 8 months, they make tremendous progress. 

My son had leaps and bounds in April and May. He was tapping 

his toe to music. He would raise his hand to anybody who walked 

in the room. We lost it all in May. Nobody knows why. 

89

So we look at that part and say we need more aggressive therapy 

in the beginning, but also, now that we are a year down the road, 

I look at Palo Alto and previously was told, well, we are filled, you 

cannot get in. Over half of the beds are empty because they do not 

have adequate staff. They do not have enough therapists to work 

with the patients. So how are we going to help all of these TBIinjured soldiers if they do not have the staff to work with them? 

Senator CRAIG. Well said. Thank you. 

Doctor Gans? 

Dr. GANS. Senator, as I mentioned earlier, the VA is a very important health care delivery system for those who use it, and it is 

also an important resource for medical education, for research, and 

I certainly would not want to see that harmed in any way. I think 

that my perspective is that we can augment and complement, and 

for those unique specialized and relatively rare things where there 

are pockets of capacity and expertise outside of the VA, where it 

does not really make sense to re-establish a large capacity that is 

going to be only transiently needed, it makes much more sense to 

just collaborate and cooperate. My perspective is let’s come up with 

a plan. Let’s have the leadership of the civilian community and the 

veterans and the military plan together and identify those areas 

where augmentation and complementation make sense, plan together where it makes sense for the private sector to help support 

the development of the reinvigorated larger capacity within the 

system, but just have it make sense and serve the common good. 

Senator CRAIG. Well, Doctor, I think you have said it better than 

I did. I appreciate that very much. 

My time is up. Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Craig. 

Senator Murray? 

Senator MURRAY. Thank you very much, and thank you so much 

to all of you for really excellent testimony and helping us wade 

through these challenges that we have in front of us. I do not think 

any of us disagree that once you get into the VA system, you get 

good care, and it is critical that we get to the point, Tammy, where 

we are not having to play catch-up, because these men and women 

are there, they are coming back, and we have to have the capacity 

to do that. 

There is a system in place that does allow us to contract out 

within the VA for care. Oftentimes, people do not know about it. 

Nobody has told them. The paperwork gets lost. And I think we 

have to be very careful not to just say, well, abandon the VA, we 

will go to private care, when, Dr. Gans, you very precisely told us 

that that kind of capacity is already a problem within the private 

system of care, and we do not want to pass people off. They get 

stuck like Denise did at a private facility that was not capable of 

dealing with them, and the paperwork gets behind, and the payments do not get there, and we do not support the resources that 

are needed for private care. So there are a lot of dangerous red 

flags as we look at how we deal with this. 

But our responsibility here is to make sure that the VA has the 

capacity it needs for the men and women who are coming back 

today and for our older veterans as they are, as you precisely told 

us, now really getting into our VA system as well. 

90

Tammy, I wanted to ask you in particular—you mentioned testing, and I am deeply concerned that we are not within the military 

testing soldiers for—I think you said PTSD and TBI in particular. 

You mentioned several other things. Ninety percent of our soldiers 

are coming back with this bacterial infection. Is that being tested 

for? 

Ms. DUCKWORTH. You get the infection, and it is very quickly you 

are known to have it. It is just in the soil over there, and it gets 

in your wounds. About 90 percent—I think that was the number 

I was given when I was going through Walter Reed—who come 

through with open wounds have this infection in some form or another. 

Senator MURRAY. And were you recommending that they get 

tested when they went into the VA? Or were you recommending 

that they get tested before they were separated from the military? 

Ms. DUCKWORTH. I think that when they enter the VA system, 

there needs to be another round of comprehensive testing for traumatic brain injury, post-traumatic stress disorder, vision, and hearing, because as scientists found out, a lot of the polytrauma patients who come through, they are tested for everything else, and 

sometimes they forgot—‘‘Oh, maybe we need to check their vision.’’ 

And they are finding that 60 percent of the patients who have entered Hines polytrauma center have had some form of functional 

vision loss that was not——

Senator MURRAY. But wouldn’t it make sense that they get tested before they leave the military—if we get an adequate system 

that makes sure that our military and our VA records are copacetic, another challenge. But wouldn’t it make sense that they get 

that testing before they are ever separated? 

Ms. DUCKWORTH. Yes, ma’am, but for some of these injuries, TBI 

and post-traumatic stress disorder, they may not reoccur for a 

while, PTSD especially, and this is where the 2-year rule is so vitally important, because with the vets of this war, if they do not 

get care for war-related illnesses for 2 years——

Senator MURRAY. Well, some of our veterans who are returning 

when they get separated, if they are not tested, may not think of 

going to a VA facility and may show up, you know, 6 months later 

not being able to remember. 

Ms. DUCKWORTH. They should be tested both times. 

Mr. PRUDEN. Can I comment on that, ma’am? I have been working with some guys over the past few years who came back from 

3rd ID with me. Several of them were injured in 2005. One of these 

young men lost both his legs. The guy beside him was killed. He 

was unconscious for an unknown amount of time. I believe he suffers from PTSD and has substance abuse issues, which I think may 

have masked some of the symptoms of TBI. His mother tells me 

he cannot remember anything he used to be able to remember. 

It was not until 2 weeks ago now, after almost 2 years in DOD 

care, that we got him into the VA system, enrolled, and he is just 

now—we just got him back up to Walter Reed to be screened for 

a TBI just 2 weeks ago. 

Senator MURRAY. After 2 years of being out? 

Mr. PRUDEN. Yes, ma’am, and yet he was unconscious—and it 

was after I talked to him, I said, ‘‘Do you think you might have a 

91

TBI?’’ And he said, ‘‘Well, you know, I don’t think so. I am OK.’’ 

And his Mom said, ‘‘But you can’t remember anything.’’ Sometimes 

soldiers are not willing or able to understand what is going on with 

them, and especially if they have a TBI and PTSD. And it takes 

someone coming along and saying, ‘‘Maybe we should screen you 

for this.’’

Senator MURRAY. Yes. Mr. Chairman, I am going to have to run 

to the floor. But I think part of what we do is mandatory testing 

before they separate as well as when they enter the VA because we 

are losing a lot of people out there. That is critical. 

Before I run, Denise, if you wanted to comment on that? 

Ms. METTIE. I just wanted to interject something quickly. My son 

spent 15 months in Iraq the first time. When he got back, they did 

a quick PTSD test, and he suffered extreme PTSD. They said they 

could not medicate him because he would not be deployable again 

and that——

Senator MURRAY. If they medicated him, he would not be——

Ms. METTIE. If they medicated——

Senator MURRAY. So they did not because——

Ms. METTIE. No, and so he self-medicated by alcohol. He could 

not sleep at night, and this was what he did for the whole year 

until he was redeployed. And one of his comments, ‘‘Well, you 

know, I won’t drink anymore because there is no alcohol over 

there.’’ That needs to be addressed. 

Senator MURRAY. And one last question for you, Denise. You 

navigated this system and were an advocate on your own, it sounds 

like, quite a bit of the time. 

Ms. METTIE. Yes. 

Senator MURRAY. Thank God your son had a family that was 

able to be there. I am certain you have seen many people who do 

not have a close family member who can——

Ms. METTIE. And that is what scares me. You know, there are 

many members who are probably in nursing homes because they 

have no one to be their advocate. I think these people in particular 

need to be looked at again. 

Senator MURRAY. Were there any VA case managers that worked 

with you throughout this time? 

Ms. METTIE. Yes. 

[Laughter.] 

Senator MURRAY. That does not sound positive. Do you want 

to——

Ms. METTIE. I cannot say I received a lot of help. 

Senator MURRAY. Well, Mr. Chairman, again, I want to thank all 

of you, and I do have questions for the second panel. I have to manage the supplemental on the floor, but I hope that the VA and DOD 

officials who are testifying today will quickly respond to our questions. You have heard what these witnesses have had to say. We 

do not want any platitudes. We want to know what real solutions 

are, and we want to be able to support them from this Committee. 

So thank you very much, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Murray. 

Senator Burr? 

Senator BURR. Thank you, Mr. Chairman. 

92

I think we are all struck by the testimony—not surprised, but we 

are struck in, as I think Senator Craig put it, a very positive way. 

The challenge for us is that we all agree that we need more money 

in the system. We all agree that we need to look at the services 

provided, and that they need to represent the cases that are walking in the door, but that we cannot forget about that last generation that is walking through. 

We all agree that we need to do much better on the health IT, 

that records should follow individuals, whether they are at Walter 

Reed or Bethesda, to the communities they go to and potentially to 

the private sector stops that they make along the way. 

Jonathan, I will take one objection with something you said. 

Over 50 is not old, OK? 

[Laughter.] 

Senator BURR. But our big challenge is to try to take everything 

that you have presented to us that are personal experiences, personal observations, and extrapolate that out to the entire population and make it work. And I want to challenge my colleagues 

here that I do not think this is a construct that we can take and 

just put in legislative language and all of a sudden mandate this, 

this, and this happens. 

We recognized very early on in North Carolina that we were 

going to have a bigger deployment of Guard and reservists in this 

mission, and certainly we have seen it from every State. One of the 

smartest things I think we did was that we started a program at 

UNC-Chapel Hill to follow the deployments and the returns of all 

these Guard and reservists, and to try to accumulate the data in 

real time as we went along as to how we do each one better the 

next time. How do we make the deployment smoother? How do we 

make the return better? And I think progressively we have 

changed that process. 

And I would suggest to my colleagues that we need to look at 

how we turn outside and ask an outside entity to look at the VA, 

to look at Walter Reed and Bethesda, to look at the private sector, 

and to try to figure out how we design this in a way that we maximize the care that we provide. 

Ms. Mettie, I wish I could tell you how we can take individuals 

that may not have been as responsive as they should have, who 

work within the VA, who maybe do not make the individual assessments that they should, even with a persistent parent or persistent 

spouse. I think all of us would hope that it would work beautifully, 

and the fact is that we hear too many stories where it does not, 

so we know we have still got a tremendous amount of work to do. 

But some of the things, maybe most of the things you have 

talked about today, these are fixable, that we can integrate them 

into a seamless process that does not distinguish between public 

and private, that does not distinguish between this location or that 

location, that maximizes the talents that we have throughout the 

health care delivery system in this country. It will take some effort 

on our part to do that in a way that, quite frankly, it would work 

successfully and it would protect the VA system, which I know 

many want to. I think every Member of this Committee wants to. 

Ms. Mettie, if there was one point in your process that you sit 

there today and you say, ‘‘If the decision had been different here, 

93

we would be dealing with a different outcome, possibly,’’ what 

would that one point be? 

Ms. METTIE. Oh, no doubt about it, that would be last April when 

we transferred Evan to the private skilled nursing facility. We 

were seeing tremendous progress at that time. He was smiling. He 

was giving thumbs up. He was lifting and raising his hands to command. 

My feeling is, if he would have been in a VA facility that had 

acute care, we would have seen progress continue. But as it was, 

by the first or mid-May, he had developed five types of infections 

from being in this facility for 3 weeks, and when he was sent back 

to the VA, he had to recover from all of these infections, and we 

lost everything. 

I strongly feel that if he would have been taken better care of 

at that point, we would see a different person today. 

Senator BURR. It is my hope that our system will get better at 

identifying those critical decision points for these warriors that 

come back and for the families, and that we learn from each one 

how to do it better in the future. 

Mr. Chairman, if I could, I would like to go to Jonathan for just 

a second, because I think, Jonathan, your recovery probably mirrors to some degree, I think, what Senator Craig was talking about. 

You were at Johns Hopkins receiving some care. You were going 

back to Walter Reed for some things—or was that your buddy that 

you were talking about? 

Mr. PRUDEN. That was one of my soldiers. 

Senator BURR. That was one of your soldiers. 

Mr. PRUDEN. Yes, sir. 

Senator BURR. You know, your question was: Why couldn’t you 

do multiple things at the same place? I think that is what Senator 

Craig is getting at. Why can’t we do multiple things? And I think 

this fear that there is an attempt to lessen our emphasis on the 

VA or on DOD hospital we have to get over if we want to successfully try to create a pathway that fits every soldier that comes back 

in the system. Unfortunately, your pathway was a little bit different than your soldier’s, and Tammy’s pathway was a little bit 

different than your pathway, and certainly Evan’s has been different than yours. 

Each one is unique, and there is no doubt that when you walk 

in an emergency room as a private citizen, there is a triage person 

that makes an assessment of you and your symptoms and a decision that is made hopefully by a group as to what their treatment 

is going to be. 

My fear is that we are not evaluating the patient for the problem 

and try and determine what the best course for that individual patient, that individual soldier, that individual Marine that is coming 

back, that we are trying to fit them into a system that we have already designed. And that makes treatment bifurcated. It makes 

crucial points of decision not make sense. And it changes, more importantly, outcomes. 

I would only suggest to my colleagues, the only thing we need to 

be concerned with is the outcome. Let’s not be concerned with how 

we get there. Let’s try to raise our success rate of the outcomes of 

these troops that come back with very different injuries, very difVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00097 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
94

ferent circumstances, and let’s make sure that the outcome is more 

positive tomorrow. 

I once again want to thank each of you. 

Chairman AKAKA. Thank you very much, Senator Burr. 

Senator Tester? 

Senator TESTER. Thank you, Mr. Chairman, and I, too, want to 

thank the panel members for your testimony and your ideas. I 

think they are outstanding, and we just need to figure out a way 

we can apply them, which I think is what Senator Burr was talking about. 

First of all, to Tammy and Jonathan, thank you for your service, 

thank you for your sacrifice. I appreciate that a lot. 

To Denise, you know, the Good Lord gave us the ability to love, 

and a mother’s love for her son is pretty special, and I thank you 

for what you have done for your son. 

And thank you, Dr. Gans, for your perspective. 

I just want to touch on a couple of things, and I am not going 

to ask—most of the questions have been asked. I just want to touch 

on a couple of things, because each one of you brought up the fact, 

the need for potential outsourcing of services. And, I guess, if I was 

going to ask a question, it would be what kind of parameters would 

you put around that. From previous questions it is apparent that 

it should not be wide open, and I agree with that, by the way. But 

if it deals with prosthetics, if it deals with traumatic brain injury, 

if it deals with other areas by which we can outsource, that would 

be great to really put that into policy. 

I come from a State where it is a long ways to the veterans’ hospital. Maybe distance should also apply in there. But if there are 

ways we can figure out how to outsource in a reasonable way, I 

think you are right on. And, quite frankly, I am glad every one of 

you brought it up, because that tells me that that is probably one 

of the solutions. 

The other thing deals with testing, and I think, Tammy, you 

brought it up, and I think we need to have our testing very complete, and I appreciate that information. 

I am not going to be able to be here for the second panel, and 

I really wanted to be, but I have got a conflict. And so for Michael 

and Ellen, I just want to tell you that my first statements stand. 

Once you get into the system, they do some pretty good work, but 

there are some problems that we have to deal with, and these problems cannot be addressed, I do not think, by us alone. I think it 

is going to take a collaborative effort. I think it is going to take 

some honest assessment on services rendered, dollars needed, and 

human resources in the kind of job they are doing in the field, and 

both at the DOD level and at the VA level. And I think that is 

critically important. 

Technological and medical transfer, I think Jonathan talked 

about it, with the bacteria, or whatever you got, from the Department of Defense to the VA, I think that has got to happen. That 

is as important as passing the medical records along so we can get 

these folks the kind of treatment they need. 

But ultimately, in the end, I will just tell you this: As a policymaker in the U.S. Senate, it is going to be virtually impossible to 

fix this problem without the bureaucracy’s help. Senator Burr 

95

talked about it, the fact that if we make policies and force policies 

down on the bureaucracy, it is not going to fix the problem. We 

need to work together. And the fact that these folks are sitting 

right here today, I hope that there is not one person in the bureaucracy that says these are individual cases and this is not the 

rule. The fact is that the reason these folks are here today is because we do have some problems and we need to work on the outcomes to make sure that we have successes right down the line. 

So with that, thank you very much. I really appreciate these panelists coming up today. I appreciate your time. Thank you. 

Chairman AKAKA. Senator Brown? 

Senator BROWN. Thank you, Chairman Akaka. And thank you. I 

was at another hearing and could not hear your testimony, although I have read much of all of your testimony. 

Mr. Pruden, you said something that intrigued me about having 

an advocate, and my mother several years ago—she was in her 

early 80’s. This is a very different situation. But she fell and fractured or shattered her shoulder, and she had my brother and me 

and my wife in the hospital with her in the emergency room as an 

advocate. People were nearby. The hospital was crowded, as city 

emergency rooms often are, or all medical facilities are. And because she had family members there really advocating for her with 

doctors and nurses to get pain medication, to do all that was needed, she got better treatment, frankly, than some others that were 

there that did not have family members. 

I heard you talk about your son a little. I am sorry I did not hear 

the rest of your testimony. And, Director Duckworth, you seem to 

be generally pretty pleased with the treatment you got. Talk to me, 

the three of you, because you have all been so much a part of this, 

how important that would be to whether your experience was you 

had somebody there for you that was an advocate. If you read the 

Post stories about Walter Reed, there was the absence of that for 

them in many cases, too, and how our system, how the VA should 

do this so that every patient feels like they have someone there to 

make sure they get the care they need. 

Since you talked about it, Mr. Pruden, do you want to start? And 

then Director Duckworth and then Ms Mettie, if you would. 

Mr. PRUDEN. Thank you. Having an advocate is vitally important. I had my wife, Amy, there right along, and, you know, in my 

early days I was in ICU and on a lot of morphine, and I did not 

understand what was going on exactly. And my wife was there to 

make sure things were happening for me. 

I think a lot of times the gap that we see, the problems that I 

addressed for a lot of my soldiers as they were coming back wounded have not been because the resources were not available to them, 

but because the information was not available or there was a lack 

of communication somewhere, and they could not get from Point A 

to Point B. 

I had a soldier dragging his foot around for weeks until I saw 

him and said, ‘‘Why are you dragging your foot around?’’ ‘‘Well, 

sir,’’ he said, ‘‘they didn’t have an AFO for me.’’ It is a foot orthosis 

to correct nerve damage. And he had been dragging his foot around 

because he did not know any better. Nobody told him that he could 

get an AFO. 

96

And I can give you countless examples of incidents like that 

where people just did not know what was available. Secretary 

Nicholson’s hiring of 100 OIF/OEF patient advocates is a step in 

the right direction, and I think we need to see more of that on both 

sides of the house. 

Senator BROWN. Director Duckworth? 

Ms. DUCKWORTH. Senator, I have to say the same thing, and the 

reason Jonathan and I are here today is because we did what a lot 

of patients are doing at the medical treatment facilities, whether 

it is DOD or VA. Those of us who are more capable of advocating 

are advocating not just for ourselves but for our buddies as well. 

When I was in the ICU, I had my husband,—he is now a major 

as well, but at the time a captain. When somebody told him that 

this is the way things were with the bureaucracy—for example, in 

the first couple of days, they told my 65–year-old mom there was 

no room. She had to sleep on the floor of the ICU waiting room. 

He had 15 years in the military, just saying wrong answer, that 

is not what you do, and fight the bureaucracy. 

When I am at Hines and I go into the prosthetics lab, and as I 

walk through, the prosthetists look at me and say, ‘‘Wow, is that 

a C-leg? Can I touch it?’’ I had the wherewithal to say, ‘‘This is not 

acceptable,’’ and worked the system myself to get to a place where 

I could go to the prosthetist of my choice. But a young troop with 

a brain injury who does not have that cannot make their way 

through the system. The patient advocate at Hines, the ones that 

I use, Ivy Bryant, is excellent. But part of her doing her job is 

going to be an understanding of the military system and also an 

understanding of the medical pipeline, because she is a caseworker, 

she does not necessarily understand that a patient needs a particular medical procedure. So there is definitely need for that, and 

that is why you find people like Jonathan and me here, is because 

we found ourselves advocating for our buddies, just like there were 

guys who advocated for us when we were not capable of taking care 

of ourselves. 

Senator BROWN. Ms. Mettie? 

Ms. METTIE. I don’t know if you were here when I was talking 

about a particular test that was done on Evan last May, SSEP, 

that measures electric impulse activity. And on that one, the one 

on the top of the head that measures the cortical impulse was not 

registering anything, so the rehab doctor said it is unlikely that he 

will ever regain anything. And because of movements that we had 

seen and commands that he had done, I just told her that her test 

was wrong. I have my own faith, and we are going on my prognosis. 

Well, from that point on where we were at the VA, it was, Let’s 

see more Mom, and took care of Evan to the best of our ability. 

They took personal care of him, but there was no therapy. 

In October, he had his cranioplasty done to replace his skull, and 

when we got back to the VA, they redid the SSEP test. The rehab 

doctor called me and apologized for ever doing the first one because 

this one was normal. It was an immediate difference on how he 

was treated. All of a sudden, OT, speech, everybody was coming in 

to work with him. And all of these months I had been pushing sayVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00100 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
97

ing he is there, all you got to do is work with him. But nobody 

would. 

Senator BROWN. I guess that answers it. Thank you. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Brown. 

I want to thank this panel very much. We have further questions. We will place them in the record, and we will keep the record 

open for a week. But let me tell you, your testimonies have been 

excellent. It has been helpful to us, and as you know, we are trying 

to do our best to help the veterans of our country. And you have 

really helped us to do that. 

So, again, thank you very much for coming. Some of you had to 

travel to get here, and we really do appreciate that. And so I want 

to thank you for your testimonies again and thank the audience for 

being so patient. 

Thank you to the first panel. 

I would like to call the second panel to the desk. I welcome our 

second panel of witnesses. Dr. Kussman is acting head of the Veterans Health Administration, though I have been informed that 

your new title is Executive-in-Charge. I hope that the Administration will soon send up a nomination for the Under Secretary of 

Health position. 

Ms. Embrey is the Deputy Assistant Secretary of Defense for 

Force Health Protection and Readiness, and Director of Deployment Health Support. 

Dr. Kussman and Ms. Embrey, thank you so much for your presence. I know that it was a bit unusual to have Administration witnesses not testify first, but as I said in my opening statement, it 

is my desire to have you address the testimony of the witnesses 

who preceded you. So I thank both of you for being here today. I 

want you to know that your full statements will appear in the 

record of the Committee. 

So we will begin with testimony from Dr. Kussman. 

STATEMENT OF MICHAEL J. KUSSMAN, M.D., EXECUTIVEIN-CHARGE, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS 

Dr. KUSSMAN. Good morning, Mr. Chairman. Before I give my 

prepared remarks, if you will indulge me for a second, I do not 

know if anybody from the first panel is still here, but for the record 

I would like to say that our job is make things better, not more 

complicated. And when I hear these stories where we clearly have 

not met the expectations and done things in the manner that I 

would like to see them, it pains me both professionally and personally. 

As you know, I am a veteran and a retiree myself, and so I appreciated the testimony of the first panel. I can assure you that we 

will continue to do everything that we can to improve the system. 

Mr. Chairman and Members of the Committee, good morning. 

Mr. Chairman, thank you for the opportunity to testify today on 

the polytrauma and prosthetics issues on behalf of the Department. 

While we have learned a great deal on these subjects in the past 

few years, with your help and the help of many others, both inside 

and outside the Government, we continue to try to improve our 

98

performance. Never in the 75-year history of the Department of 

Veterans Affairs has there been a greater level of collaboration and 

cooperation between VA and the Department of Defense. 

VA has coordinated the transfer of over 6,800 injured or ill active-duty servicemembers and veterans from DOD to the VA. Our 

highest priority is to ensure that those returning from the Global 

War on Terror who transition directly from DOD military treatment facilities to VA medical centers continue to receive the best 

care available anywhere. 

This month, we are calling each of those severely injured 

servicemembers and veterans to see if they need additional support, and we are directing facilities to provide OIF/OEF program 

managers at each facility. VA social workers, benefits counselors, 

and outreach coordinators advise and explain the full array of VA 

services and benefits to servicemembers while they are still being 

cared for by DOD. In addition, our social workers help newly 

wounded soldiers, sailors, airmen, and Marines and their families 

plan a future course of treatment for their injuries after they return home. 

Case management of our patients begins at the time of transition 

from DOD and continues as their medical and psychological needs 

dictate. VA requires that every medical center will have full-time 

nurse and social worker case managers for OIF/OEF veterans’ 

needs, and we are in the process of hiring 100 OIF/OEF veterans 

to serve as ombudsmen to support severely wounded veterans and 

their families. 

Each VA medical center also has an OIF/OEF program manager 

to coordinate activities locally for OIF/OEF veterans and to ensure 

the health care and benefits needs of returning servicemembers 

and veterans are fully met. VA has distributed specific guidance to 

field staff to ensure that the roles and functions of the OIF/OEF 

program managers and case managers are fully understood and 

that proper coordination of benefits and services occurs at the local 

level. 

Mr. Chairman, 15 years ago, VA, in collaboration with the Defense and Veterans Brain Injury Center, established 4 comprehensive centers to care for veterans with traumatic brain injury. These 

centers are located in Richmond, Tampa, Minneapolis, and Palo 

Alto and provide exemplary clinical care for brain-injured patients 

and are recognized as leaders in their field. 

Today our Polytrauma System of Care provides the highest quality of medical and rehabilitation case management and support 

services for veterans and active-duty servicemembers who have 

sustained complex injuries, including traumatic brain injury, while 

in service to our country. Our ability to successfully integrate medical care and rehabilitative medicine makes our centers unique 

among health care facilities in the United States and possibly the 

world. We are a flexible, dynamic system able to adjust to the 

changing needs of combat-injured veterans and proud of the service 

we provide them. 

Last year, VA’s Prosthetic and Sensory Aids Service provided 

service to over 22,000 unique OIF/OEF veterans for a variety of 

services and products. When viewing amputee care alone since the 

beginning of the war, VA’s Prosthetic and Sensory Aids Service has 

99

served a total of 157 of the 560 OIF/OEF major amputees. Some 

of these amputees have come to us through the Polytrauma Rehabilitation Centers. 

Finally, VA provides outreach to our newest veterans through 

our Vet Center Program. Vet Centers were created by Congress as 

the outreach element in VA’s Veterans Health Administration. Our 

Vet Centers have served 180,000 combat veterans to date and have 

provided bereavement services to the families of over 900 fallen 

warriors. VA will open 15 new Vet Centers and 8 new Vet Center 

outstations at locations throughout the Nation by the end of 2008. 

At that time Vet Centers will total 232. We also expect to add staff 

to 61 existing facilities to augment the services they provide. Seven 

of the 23 new centers will open during calendar year 2007. 

Mr. Chairman, that concludes my presentation, and at this time 

I would be pleased to answer any questions you may have. 

[The prepared statement of Dr. Kussman follows:]

PREPARED STATEMENT OF MICHAEL J. KUSSMAN, M.D., EXECUTIVE-IN-CHARGE, 

VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

Mr. Chairman and Members of the Committee, good afternoon. Thank you for this 

important opportunity to discuss on the Veterans Health Administration’s (VHA) efforts to ensure a seamless transition process for our injured service men and 

women, and our ongoing efforts to continuously improve this process. 

VHA’s work to create a seamless transition for men and women as they leave the 

service and take up the honored title of ‘‘veteran’’ begins early on. Our Benefits Delivery at Discharge Program enables active duty members to register for VA health 

care and to file for benefits prior to their separation from active service. Our outreach network ensures returning servicemembers receive full information about VA 

benefits and services. And each of our medical centers and benefits offices now has 

a point of contact assigned to work with veterans returning from service in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). 

VHA has coordinated the transfer of over 6,800 severely injured or ill active duty 

servicemembers and veterans from DOD to VA. Our highest priority is to ensure 

that those returning from the Global War on Terror transition seamlessly from DOD 

Military Treatment Facilities (MTFs) to VA Medical Centers (VAMCs) and continue 

to receive the best possible care available anywhere. Toward that end, we continually strive to improve the delivery of this care. 

In partnership with DOD, VA has implemented a number of strategies to provide 

timely, appropriate, and seamless transition services to the most seriously injured 

OEF/OIF active duty servicemembers and veterans. 

VA social workers, benefits counselors, and outreach coordinators advise and explain the full array of VA services and benefits. These liaisons and coordinators assist active duty servicemembers as they transfer from MTFs to VA medical facilities. 

In addition, our social workers help newly wounded soldiers, sailors, airmen and 

Marines and their families plan a future course of treatment for their injuries after 

they return home. Currently, VA Social Worker and Benefit Liaisons are located at 

10 MTFs, including Walter Reed Army Medical Center, the National Naval Medical 

Center Bethesda, the Naval Medical Center San Diego, and Womack Army Medical 

Center at Ft. Bragg. 

Since September 2006, a VA Certified Rehabilitation Registered Nurse (CRRN) 

has been assigned to Walter Reed to assess and provide regular updates to our 

Polytrauma Rehabilitation Centers (PRC) regarding the medical condition of incoming patients. The CRRN advises and assists families and prepares active duty 

servicemembers for transition to VA and the rehabilitation phase of their recovery. 

VA’s Social Worker Liaisons and the CRRN fully coordinate care and information 

prior to a patient’s transfer to our Department. Social Worker Liaisons meet with 

patients and their families to advise and ‘‘talk them through’’ the transition process. 

They register servicemembers or enroll recently discharged veterans in the VA 

health care system, and coordinate their transfer to the most appropriate VA facility 

for the medical services needed, or to the facility closest to their home. 

In the case of transfers of seriously injured patients, both the CRRN and the Social Worker Liaison are an integral part of the MTF treatment team. They simultaneously provide input into the VA health care treatment plan and collaborate with 

100

1These services include but are not limited to wheelchairs, eyeglasses, hand-cycles, running 

legs (prostheses), mono-skis, prosthetic hands, talking GPS systems for the blind, and Personal 

Digital Assistants for Traumatic Brain Injury patients. 

both the patient and his or her family throughout the entire health care transition 

process. Video teleconference calls are routinely conducted between DOD MTF treatment teams and receiving VA PRC teams. If feasible, the patient and family attend 

these video teleconferences to participate in discussions and to ‘‘meet’’ the VA PRC 

team. 

I should note that one important aspect of coordination between DOD and VA 

prior to a patient’s transfer to VA is access to clinical information. This includes a 

pre-transfer review of electronic medical information via remote access capabilities. 

The VA polytrauma centers have been granted direct access into inpatient clinical 

information systems from Walter Reed Army Medical Center (WRAMC) and National Naval Medical Center (NNMC). VA and DOD are currently working together 

to ensure that appropriate users are adequately trained and connectivity is working 

and exists for all four polytrauma centers. For those inpatient data that are not 

available in DOD’s information systems, VA social workers embedded in the military treatment facilities routinely ensure that the paper records are manually transferred to the receiving polytrauma centers. 

Another data exchange system, the Bidirectional Health Information Exchange 

(BHIE) allows VA and DOD clinicians to share text-based outpatient clinical data 

between VA and the ten MTFs, including Walter Reed and Bethesda. 

VA case management for these patients begins at the time of transition from the 

MTF and continues as their medical and psychological needs dictate. Once the patient transfers to the receiving VAMC, or reports to his or her home VAMC for care, 

the VA Social Worker Liaison at the MTF continues to coordinate with VA to address after-transfer issues of care. Seriously injured patients receive ongoing case 

management at the VA facility where they receive most of their care. Since April 

of 2006, points of contact or case managers have been identified in every VA medical 

center. In response to the Secretary’s request this week, VA is in the process of hiring the 100 OIF/OEF veterans to serve as case advocates to support their severely 

injured fellow veterans and their families. 

Moreover, VA’s Prosthetic and Sensory Aids Service (PSAS) provided service to 

over 22,000 OIF/OEF unique veterans for a variety of services and products. 1 When 

viewing amputee care alone since the beginning of the war, Prosthetics has served 

a total of 187 of the current 554 OIF/OEF major amputees, including veterans and 

active duty servicemembers. Some of these amputees have come to us through the 

Polytrauma Rehabilitation Centers. 

VA has four Polytrauma Rehabilitation Centers, located at Tampa, FL; Richmond, 

VA; Minneapolis, MN; and Palo Alto, CA. The Army has assigned full time active 

duty Liaison Officers to each one in order to support military personnel and their 

families from all Service branches. The Liaison officers address a broad array of 

issues, such as travel, housing, military pay, and movement of household goods. 

In addition, Marine Corps representatives from nearby local Commands visit and 

provide support to each of the Polytrauma Rehabilitation Centers. At VA Central 

Office in Washington, DC, an active duty Marine Officer and an Army Wounded 

Warrior representatives are assigned to the Office of Seamless Transition to serve 

as liaisons. Both the Army and the Marine Liaisons play a vital role in ensuring 

the provision of a wide bridge of services during the critical time of patient recovery 

and rehabilitation. 

VHA understands the critical importance of supporting families during the transition from DOD to VA. We established a Polytrauma Call Center in February 2006, 

to assist the families of our most seriously injured combat veterans and 

servicemembers. The Call Center operates 24 hours-a-day, 7 days-a-week to answer 

clinical, administrative, and benefit inquiries from polytrauma patients and family 

members. The Center’s value is threefold. It furnishes patients and their families 

with a one-stop source of information; it enhances overall coordination of care; and, 

very importantly, it immediately elevates any system problems to VA for resolution. 

VA’s Office of Seamless Transition includes two Outreach Coordinators—a peersupport volunteer and a veteran of the Vietnam War—who regularly visit seriously 

injured servicemembers at Walter Reed and Bethesda. Their visits enable them to 

establish a personal and trusted connection with patients and their families. 

These Outreach Coordinators help identify gaps in VA services by submitting and 

tracking follow-up recommendations. They encourage patients to consider participating in VA’s National Rehabilitation Special Events or to attend weekly dinners 

held in Washington, DC, for injured OEF/OIF returnees. In short, they are key to 

101

enhancing and advancing the successful transition of our service personnel from 

DOD to VA, and, in turn, to their homes and communities. 

In addition, VA has developed a vigorous outreach, education, and awareness program for the National Guard and Reserve. To ensure coordinated transition services 

and benefits, VA signed a Memorandum of Agreement (MOA) with the National 

Guard in 2005. Combined with VA/National Guard State Coalitions in 54 states and 

territories, VA has significantly improved its opportunities to access returning 

troops and their families. We are continuing to partner with community organizations and other local resources to enhance the delivery of VA services. At the national level, MOAs are under development with both the United States Army Reserve and the United States Marine Corps. These new partnerships will increase 

awareness of, and access to, VA services and benefits during the demobilization 

process and as service personnel return to their local communities. 

VA is also reaching out to returning veterans whose wounds may be less apparent. VA is a participant in the DOD’s Post Deployment Health Reassessment 

(PDHRA) program. DOD conducts a health reassessment 90–180 days after return 

from deployment to identify health issues that can surface weeks or months after 

servicemembers return home. 

VA actively participates in the administration of PDHRA at Reserve and Guard 

locations in a number of ways. We provide information about VA care and benefits; 

enroll interested Reservists and Guardsmen in the VA health care system; and arrange appointments for referred servicemembers. As of December 2006, an estimated 68,800 servicemembers were screened, resulting in over 17,100 referrals to 

VA. Of those referrals, 32.8 percent were for mental health and readjustment issues; 

the remaining 67.2 percent for physical health issues. 

Congress created the Readjustment Counseling Service (RCS), commonly known 

to veterans as the Vet Center Program, as VHA’s outreach element. Program eligibility was originally targeted to Vietnam veterans; today it serves all returning combat veterans. The Vet Center Program receives high ratings in veterans’ satisfaction, employee satisfaction, and other measurable indicators of quality and effective 

care. 

The approximate number of OEF/OIF combat veterans served by Vet Centers to 

date is 165,000 (119,600 through outreach; 45,400 seen at centers). In February of 

2004, the Secretary of Veterans Affairs approved the hiring of 50 OEF/OIF combat 

veterans to support the Program by reaching out actively to National Guard, and 

Reserve servicemembers returning from combat. An additional 50 were hired in 

March of 2005. This action advanced the continuing success of our Vet Centers in 

their ability to assist our newest veterans and their families. VA Vet Centers have 

provided bereavement services to 900 families of fallen warriors. 

VA plans to expand its Vet Center Program. We will open 15 new Vet Centers 

and eight new Vet Center outstations at locations throughout the Nation by the end 

of 2008. At that time, Vet Centers will total 232. We expect to add staff to 61 existing facilities to augment the services they provide. Seven of the 23 new centers will 

open this Calendar Year 2007. 

In addition, the President has created an Interagency Task Force on Returning 

Global War on Terror Heroes (Heroes Task Force), chaired by the Secretary of Veterans Affairs, to respond to the immediate needs of returning Global War on Terror 

servicemembers. The Heroes Task Force, which had its first meeting in early March, 

will work to identify and resolve any gaps in service for servicemembers. As Secretary Nicholson said, no task is more important to the VA than ensuring our heroes receive the best possible care and services. 

Finally, The VA is partnering with the State VA Directors in the ‘‘State Benefits 

Seamless Transition Program’’ in which severely injured servicemembers can release their contact information to their home State VA Office to be educated about 

their State Benefits. 

VA staff assigned to major MTFs are coordinating with Heroes to Hometown as 

a resource to provide to servicemembers returning to civilian life. 

Mr. Chairman, this concludes my presentation. At this time, I would be pleased 

to answer any questions you may have. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA

TO MICHAEL J. KUSSMAN, M.D., EXECUTIVE-IN-CHARGE, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

Question 1. In response to [vet] account of VA’s inability to deal with his recent 

infection (acinetobacter), you stated that all relevant VA clinicians are competent to 

handle this bacterium. You also promised to look into [vet] case in order to identify 

102

any shortcomings. Please provide the Committee with a brief, informal summary of 

your conclusions as they become available. 

Response. Dr. Gary Roselle, National Program Director for Infectious Diseases, 

has reviewed the veteran’s health record and has prepared a report. As the report 

does have protected personal information it has been provided under separate cover 

to the Chairman only.

Question 2. Four times a year, VA submits to Congress a mandated report on 

medical service utilization by veterans of Operations Enduring Freedom and Iraqi 

Freedom. We have not received the latest report, which we were expecting in February. I would appreciate you looking into this and expediting the production, clearance and forwarding of this document to Committee staff. 

Response. Attached is the Veterans Health Administration’s (VHA) most recent 

report, Analysis of VA Healthcare Utilization Among US Southwest Asian War Veterans, dated April 2007.

[The Veterans Health Administration’s (VHA) report follows:] 

ANALYSIS OF VA HEALTH CARE UTILIZATION AMONG

US SOUTHWEST ASIAN WAR VETERANS

OPERATION IRAQI FREEDOM

OPERATION ENDURING FREEDOM

(VHA Office of Public Health and Environmental Hazards, April 2007) 

CURRENT DOD ROSTER OF RECENT WAR VETERANS

• Evolving roster development by DOD Defense Manpower Data Center (DMDC) 

Æ In September 2003, DMDC developed initial file of ‘‘separated’’ .Iraqi and Afghan troops using proxy files: Active Duty and Reserve Pay files, Combat Zone Tax 

Exclusion, and Imminent Danger Pay data. 

Æ In September 2004, DMDC revised procedures for creating periodic updates 

of the roster and now mainly utilizes direct reports from service branches of deployed OIF (Operation Iraqi Freedom) and OEF (Operation Enduring Freedom) 

troops. 

Æ DMDC is actively addressing the limitations of the current roster to improve 

the accuracy and completeness of future rosters 

CURRENT DOD ROSTER OF RECENT WAR VETERANS

• Latest Update of roster 

Æ Provided to Dr. Kang, Veterans Health Administration (VHA) Environmental 

Epidemiology Service, on January 11, 2007.

• Qualifications for OIF/OEF deployment roster 

Æ Contains list of veterans who have left active duty and does not include currently serving active duty personnel 

Æ Does not distinguish OIF from OEF veterans 

Æ Roster only includes separated OIF/OEF veterans with out-of-theater dates 

through November 2006

Æ 3,011 veterans who died in-theater are not included 

UPDATED ROSTER OF SW ASIAN WAR VETERANS WHO HAVE LEFT ACTIVE DUTY

• 686,306 OIF and OEF veterans who have left active duty and become eligible 

for VA health care since Fiscal Year 2002

Æ 46 percent (316,562) Former Active Duty troops 

Æ 54 percent (369,744) Reserve and National Guard 

USE OF DOD LIST OF WAR VETERANS WHO HAVE LEFT ACTIVE DUTY

• This roster is used to check the VA’s electronic inpatient and outpatient health 

records, in which the standard ICD–9 diagnostic codes are used to classify health 

problems, to determine which OIF/OEF veterans have accessed VA health care as 

of December 31, 2006. 

• The data available for this analysis are mainly administrative information and 

are not based on a review of each patient record or a confirmation of each diagnosis. 

However, every clinical evaluation is captured in VHA’s computerized patient 

record. The data used in this analysis are excellent for health care planning purposes because the ICD–9 administrative data accurately reflects the need for health 

care resources, although these data cannot be considered epidemiologic research 

data. 

103

• These administrative data have to be interpreted with caution because they 

only apply to OIF/OEF veterans who have accessed VHA health care due to a current health question. These data do not represent all 686,306 OIF/OEF veterans 

who have become eligible for VA healthcare since Fiscal Year 2002 or the approximately 1.4 million troops who have served in the two theaters of operation since the 

beginning of the conflicts in Iraq and Afghanistan.

USE OF DOD LIST OF WAR VETERANS WHO HAVE LEFT ACTIVE DUTY (2)

• Because VA health data are not representative of the veterans who have not 

accessed VA health care, formal epidemiological studies will be required to answer 

specific questions about the overall health of recent war veterans. 

• Analyses based on this updated roster are not directly comparable to prior reports because the denominator (number of OIF/OEF veterans eligible for VA health 

care) and numerator (number of veterans enrolling for VA health care) change with 

each update. 

• This report presents data from VHA’s health care facilities and does not include 

Vet Center data or DOD health care data. 

• The following data are ‘‘cumulative totals’’ since Fiscal Year 2002 and do not 

represent data from any single year. 

• The numbers provided in this report should not be added together or subtracted 

to provide new data without checking on the accuracy of these statistical manipulations with VHA’s Office of Public Health and Environmental Hazards.

VA HEALTH CARE UTILIZATION FROM FISCAL YEAR 2002 TO 2007 (1ST QT)

AMONG SW ASIAN WAR VETERANS

• Among all 686,306 separated OIF/OEF Veterans 

Æ 33 percent (229,015) of total separated veterans have sought VA health care 

since Fiscal Year 2002

Æ 97 percent (221,255) of 229,015 evaluated OIF/OEF patients have been seen 

as outpatients only by VA and not hospitalized 

Æ 3 percent (7,760) of 229,015 evaluated OIF/OEF patients have been hospitalized at least once in a VA health care facility 

VA HEALTH CARE UTILIZATION FOR FISCAL YEAR 20022007 (1ST QT) BY SERVICE

COMPONENT

• 316,562 Former Active Duty Troops 

Æ 35 percent (112,301) have sought VA health care since Fiscal Year 2002

• 369,744 Reserve/National Guard Members 

Æ 32 percent (116,714) have sought VA health care since Fiscal Year 2002

COMPARISON OF VA HEALTH CARE REQUIREMENTS

The 229,015 OIF/OEF veterans evaluated by VA over approximately 5 years from 

Fiscal Year 2002 to Fiscal Year 2007 (1st QT) represents about 4 percent 5.5 million 

individual patients who received VHA health care in anyone year (total VHA population of 5.5 million in 2006).

Frequency Distribution of SW Asian War Veterans According to the VISN Providing the Treatment 

Treatment Site 

OIF/OEF Veterans Treated

at a VA Facility 1

Frequency Percent 

VISN 1 VA New England Healthcare System ................................................................................... 11,163 4.9

VISN 2 VA Healthcare Network Upstate New York .......................................................................... 6,728 2.9

VISN 3 VA New York/New Jersey Healthcare System ....................................................................... 9,242 4.0

VISN 4 VA Stars & Stripes Healthcare System ............................................................................... 11,021 4.8

VISN 5 VA Capital Health Care System .......................................................................................... 5,821 2.5

VISN 6 VA Mid-Atlantic Healthcare System .................................................................................... 12,224 5.3

VISN 7 VA Atlanta Network .............................................................................................................. 16,597 7.2

VISN 8 VA Sunshine Healthcare Network ........................................................................................ 19,289 8.4

VISN 9 VA Mid-South Healthcare Network ...................................................................................... 13,660 6.0

VISN 10 VA Healthcare System of Ohio .......................................................................................... 6,351 2.8

VISN 11 Veterans in Partnership Healthcare Network .................................................................... 8,275 3.6

VISN 12 VA Great Lakes Health Care System ................................................................................. 14,490 6.3

104

Frequency Distribution of SW Asian War Veterans According to the VISN Providing the 

Treatment—Continued

Treatment Site 

OIF/OEF Veterans Treated at a VA Facility 1

Frequency Percent 

VISN 15 VA Heartland Network ........................................................................................................ 7,645 3.3

VISN 16 South Central VA Health Care Network ............................................................................. 19,871 8.7

VISN 17 VA Heart of Texas Health Care Network ........................................................................... 13,683 6.0

VISN 18 VA Southwest Healthcare Network .................................................................................... 11,636 5.0

VISN 19 VA Rocky Mountain Network .............................................................................................. 9,222 4.0

VISN 20 VA Northwest Network ....................................................................................................... 13,186 5.8

VISN 21 VA Sierra Pacific Network .................................................................................................. 9,781 4.3

VISN 22 VA Desert Pacific Healthcare Network .............................................................................. 18,226 8.0

VISN 23 VA Midwest Health Care Network ...................................................................................... 12,749 5.6

1 Veterans can be treated in multiple VISNs. A veteran was counted only once in any single VISN but can be counted in multiple VISN categories. The total number of OIF–OEF veterans who received treatment (n = 229,015) was used to calculate the percentage treated in any 

one VISN. 

Demographic Characteristics of Iraqi and Afghan Veterans Utilizing VA Health Care 

Percent

SW Asian

Veterans

(n = 229,015) 

Sex 

Male ................................................................................................................................................................. 88

Female ............................................................................................................................................................. 12

Age Group 

<20 ................................................................................................................................................................. 4

20–29 .............................................................................................................................................................. 52

30–39 .............................................................................................................................................................. 23

≥40 .................................................................................................................................................................. 20

Branch 

Air Force .......................................................................................................................................................... 12

Army ................................................................................................................................................................ 66

Marine ............................................................................................................................................................. 12

Navy ................................................................................................................................................................. 10

Unit Type 

Active ............................................................................................................................................................... 49

Reserve/Guard ................................................................................................................................................. 51

Rank 

Enlisted ........................................................................................................................................................... 92

Officer .............................................................................................................................................................. 8

DIAGNOSTIC DATA

• Veterans of recent military conflicts have presented to VHA with a wide range 

of possible medical and psychological conditions. 

• Health problems have encompassed more than 7,990 discrete ICD–9 diagnostic 

codes. 

• The three most common possible health problems of war veterans were musculoskeletal ailments (principally joint and back disorders), mental disorders, and 

‘‘Symptoms, Signs and Ill-Defined Conditions.’’

• As in other outpatient populations, the ICD–9 diagnostic category, ‘‘Symptoms, 

Signs and III-Defined Conditions,’’ was commonly reported. It is important to understand that this is not a diagnosis of a mystery syndrome or unusual illness. This 

ICD–9 code includes symptoms and clinical finding that are not coded elsewhere in 

the IC–D9. It is a diverse, catch-all category that is commonly used for the diagnosis 

of outpatient populations. It encompasses more than 160 sub-categories and primarily consists of common symptoms that do not have an immediately obvious cause 

during a single clinic visit or isolated laboratory abnormalities that do not point to 

a particular disease process and may be transient.

105

Frequency of Possible Diagnoses Among Recent Iraq and Afghan Veterans 

Diagnosis (Broad ICD–9 Categories) 

(n = 229,015) 

Frequency 1 Percent 

Infectious and Parasitic Diseases (001–139) ................................................................................ 24,114 10.5

Malignant Neoplasms (140–208) ................................................................................................... 1,801 0.8

Benign Neoplasms (210–239) ........................................................................................................ 7,506 3.3

Diseases of Endocrine/Nutritional/Metabolic Systems (240–279) ................................................. 41,911 18.3

Diseases of Blood and Blood Forming Organs (280–289) ............................................................ 4,175 1.8

Mental Disorders (290–319) ........................................................................................................... 83,889 36.6

Diseases of Nervous System/Sense Organs (320–389) ................................................................. 69,767 30.5

Diseases of Circulatory System (390–459) .................................................................................... 33,218 14.5

Disease of Respiratory System (460–519) ..................................................................................... 41,144 18.0

Disease of Digestive System (520–579) ........................................................................................ 70,350 30.7

Diseases of Genitourinary System (580–629) ................................................................................ 21,484 9.4

Diseases of Skin (680–709) ........................................................................................................... 32,735 14.3

Diseases of Musculoskeletal System/Connective System (710–739) ............................................ 99,484 43.4

Symptoms, Signs and III Defined Conditions (780–799) .............................................................. 77,275 33.7

Injury/Poisonings (800–999) ........................................................................................................... 40,708 17.8

1 Hospitalizations and outpatient visits as of 12/31/2006; veterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater 

than 229,015. 

Frequency of Possible Mental Disorders Among OIF/OEF Veterans since 2002 1

Disease Category (ICD 290–319 code) 

Total Number 

of SW Asian 

War Veterans 2

PTSD (ICD–9CM 309.81) 3 ........................................................................................................................................ 39,243

Nondependent Abuse of Drugs (ICD 305) 4 ............................................................................................................. 33,099

Depressive Disorders (311) ...................................................................................................................................... 27,023

Neurotic Disorders (300) .......................................................................................................................................... 21,084

Affective Psychoses (296) ........................................................................................................................................ 14,489

Alcohol Dependence Syndrome (303) ....................................................................................................................... 6,329

Sexual Deviations and Disorders (302) ................................................................................................................... 3,735

Special Symptoms, Not Elsewhere Classified (307) ................................................................................................ 3,701

Drug Dependence (304) ........................................................................................................................................... 2,798

Acute Reaction to Stress (308) ............................................................................................................................... 2,643

1 Note: ICD diagnoses used in these analyses are obtained from computerized administrative data. Although diagnoses are made by trained 

healthcare providers, up to one-third of coded diagnoses may not be confirmed when initially coded because the diagnosis is ‘‘rule-out’’ or 

provisional, pending further evaluation. 2 A total of 83,889 unique patients received a diagnosis of a possible mental disorder. A veteran may have more than one mental disorder 

diagnosis and each diagnosis is entered separately in this table; therefore, the total number above will be higher than 83,889. 3 This row of data does not include information on PTSD from VA’s Vet Centers and does not include veterans not enrolled for VHA health 

care. Also, this row of data does not include veterans who did not have a diagnosis of PTSD (ICD 309.81) but had a diagnosis of adjustment 

reaction (ICD–9 309). 4 82 percent of these veterans (26,998) had a diagnosis of tobacco use disorder (ICD–9 305.1). 

SUMMARY

• Recent Iraq and Afghan veterans are presenting to VA with a wide range of 

possible medical and psychological conditions. 

• Recommendations cannot be provided for particular testing or evaluation—veterans should be assessed individually to identify all outstanding health problems. 

• 33 percent of separated OIF/OEF veterans have enrolled for VA health care 

since 2002 compared to 32 percent in the last quarterly report 3 months ago. As 

in other cohorts of military veterans, the percentage of OIF/OEF veterans receiving 

health care from the VA and the percentage with any type of diagnosis will tend 

to increase over time as these veterans continue to enroll for VA health care and 

to develop new health problems. 

SUMMARY (2)

• Because the 229,015 Iraqi and Afghan veterans who have accessed VA health 

care were not randomly selected and represent just 16 percent of the approximately 

1.4 million recent U.S. war veterans, they do not constitute a representative sample 

of all OIF/OEF veterans. 

• Reported diagnostic data are only applicable to the 229,015 VA patients—a population actively seeking health care—and not to all OIF/OEF veterans. 

106

For example, the fact that about 37 percent of VHA patients’ encounters were 

coded as related to a possible mental disorder does not indicate that 1⁄3 of all recent 

war veterans are suffering from a mental health problem. Only well-designed epidemiological studies can evaluate the overall health of Iraqi and Afghan war veterans. 

SUMMARY (3)

• High rates of VA health care utilization by recent Iraqi and Afghan veterans 

reflect the fact that these combat veterans have ready access to VA health care, 

which is free of charge for 2 years following separation for any health problem possibly related to wartime service. 

Also, an extensive outreach effort has been developed by VA to inform these veterans of their benefits, including the mailing of a personal letter from the VA Secretary to war veterans identified by DOD when they separate from active duty and 

become eligible for VA benefits. 

• When a combat veteran’s 2-year health care eligibility passes, the veteran will 

be moved to their correct priority group and charged all copayments as applicable. 

If their financial circumstances place them in Priority Group 8, their enrollment in 

VA will be continued, regardless of the date of their original VA application. 

FOLLOW-UP

• VA will continue to monitor health care utilization of recent Iraq and Afghan 

veterans using updated deployment lists provided by DOD to ensure that VA tailors 

its health care and disability programs to meet the needs of this newest generation 

of war veterans.

Question 3(a). What steps has VA taken to address the Inspector General’s recommendations regarding VA’s case management for victims of Traumatic Brain Injury (TBI)? 

Response. The Department of Veterans Affairs (VA) developed the Polytrauma 

System of Care (PSC) to improve access to specialized rehabilitation services for 

polytrauma and TBI patients. PSC will also facilitate delivery of care closer to 

home, and provide life-long case management services to veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) and active duty service members. VA 

facilities participating in the PSC are distributed geographically throughout the 

country so as to facilitate access to specialized care closer to the home, and to help 

veterans and their families to transition back into their home communities. Interdisciplinary teams of professionals have been designated at these facilities to work 

together to develop an integrated plan of medical and rehabilitation treatment for 

each veteran. In some cases, polytrauma may cause long-term impairments and 

functional disabilities. VA is committed to providing services and coordinating the 

lifelong care needs of these individuals. 

The four components of the PSC include:

• Polytrauma Rehabilitation Centers (PRC)—These four regional centers (Richmond, Virginia; Tampa, Florida; Palo Alto, California; and Minneapolis, Minnesota) 

are fully operational. They provide acute comprehensive medical and rehabilitation 

care for complex and severe injuries and serve as resources for other facilities in

the PSC. 

• Polytrauma Network Sites (PNS)—These 21 sites including the four PRCs, one 

in each of the Veterans Integrated Service Networks (VISN), are also fully operational. Its role is to manage the post-acute effects of TBI and polytrauma and to 

coordinate lifelong rehabilitation services for patients within their VISN. 

• Polytrauma Support Clinic Teams (PSCT)—VA has designated 72 medical centers as sites for PSCTs. These are local teams of providers with rehabilitation expertise that manage patients with stable polytrauma sequelae and respond to new 

problems that might emerge in consultation with regional and network specialists. 

They provide proactive case management and assist with patient and family support 

services. 

• Polytrauma Points of Contact (PPOC)—All other facilities provide local PPOCs. 

These are smaller facilities without the expertise or resources to meet the rehabilitation and prosthetic needs of the polytrauma patients. The PPOCs are knowledgeable of the services available for veteran with TBI within the VHA system of care 

and have the ability to coordinate care. Each of these facilities ensures that at least 

one person is identified to serve as point of contact for consultation and referral of 

polytrauma patients to a facility capable of providing the level of services required.

The Inspector General’s report included four specific recommendations, below is 

VHA response to each of the recommendations: 

107

Recommended Improvement Action(s) A. The Under Secretary for Health should 

improve case management for TBI patients to ensure lifelong coordination of care. 

Case management has a crucial role in ensuring lifelong coordination of services 

for patients with polytrauma and TBI, and is an integral part of the system at each 

polytrauma care site. PSC uses a proactive case management model, which requires 

both nurse and social work case managers to maintain regular contact with veterans and their families to coordinate services and to address emerging needs. As 

an individual moves from one level of care to another, the case manager at the referring facility is responsible for a ‘‘warm hand off’’ of care to the case manager at 

the receiving facility closer to the veteran’s home. Every combat injured veteran 

with TBI is assigned a case manager at the polytrauma system of care facility closest to his or her home. The assigned case manager handles the continuum of care 

and care coordination, acts as the point of contact for emerging medical, psychosocial, or rehabilitation problems, and provides patient and family advocacy. 

The Office of Social Work (OSW) released VHA Handbook 1010.01, ‘‘Transition 

Assistance and Case Management for Operation Enduring Freedom and Operation 

Iraqi Freedom Veterans’’ in March 2007 which details care and services provided 

to all returning veterans including those with seriously and mild TBI. Each combat 

injured veteran with TBI is assigned a case manager at the PSC facility closest to 

his or her home. The assigned case manager handles the continuum of care and care 

coordination, acts as the POC for emerging medical, psychosocial or rehabilitation 

problems and provides patient and family advocacy. 

A Polytrauma Telehealth Network (PTN) links facilities in the PSC available to 

support care coordination and case management. The PTN ensures that polytrauma 

and TBI expertise are available throughout the PSC and that care is provided at 

a location and time that is most accessible to the patient. The PTN allows provision 

of specialized expertise available at the PROs and PNSs to be delivered at facilities 

close to the veteran’s home. 

Specialized rehabilitation care for patients with polytrauma and TBI requires a 

continuum of services that may include inpatient and outpatient rehabilitation, 

long-term care, transitional living and community re-entry programs, and vocational 

rehabilitation and employment services. The 21 PNSs have completed inventories of 

VA and non-VA TBI specific services within its VISNs. These are used to coordinate 

resources to meet individualized treatment needs of patients closer to home. The 

case managers dedicated to the PSC are responsible for identifying and coordinating 

these services for the individual patient as close to home as possible. 

During the August 2006 Polytrauma System of Care Conference, polytrauma social work case managers received training on expectations for proactive and continuing case management of active duty personnel and veterans with brain injury 

and polytrauma. Monthly conference calls are held to mentor and educate the PNS 

case managers. 

The OSW, in collaboration with Physical Medicine & Rehabilitation Service 

(PM&RS), has established a social work case management work group. This group 

is developing a new model of social work TBI and polytrauma case management 

that will address the care coordination, psychosocial and family support issues of 

this special population across different sites, levels of rehabilitation, and health care 

service delivery. This group is also identifying training needs and is working with 

the Employee Education System to offer a variety of educational programs. A 1-hour 

training session was held in January 2007 via conference call to educate social 

workers concerning the signs and symptoms of mild to moderate TBI. 

VHA is publishing a new VHA Handbook on Transition Assistance and Case Management of OEF/OIF Veterans. The Handbook requires each VA medical center 

(VAMC) to appoint a master’s prepared nurse or social worker to serve as the OEF/

OIF program manager to oversee all seamless transition activities, coordination of 

care for OEF/OIF service members and veterans, and coordination of case management services for severely injured OEF/OIF service members/veterans, including 

those with TBI. The Handbook also describes the functions of 100 new transition 

patient advocates, who will be assigned to severely injured service members/veterans, including those with TBI, and their families. Recruitment for the new positions is already underway. 

The Office of Seamless Transition (OST) implemented a seamless transition performance measure for Fiscal Year (FY) 2007. Severely injured OEF/OIF service 

members/veterans who are transferred by VA/Department of Defense (DOD) liaisons 

at the military treatment facilities (MTF) must be assigned a VAMC case manager 

prior to transfer. This VAMC case manager must contact the service member/veteran within 7 calendar days of notification of the transfer. OST developed a tracking 

system which the VA/DOD social work liaisons, stationed at the MTF, enter the patients transferring to VA into. As of October 2006, the tracking system automatiVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00111 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
108

cally generates an e-mail to the receiving facility when the VA/DOD liaison enters 

a potential transfer date. The receiving facility assigns a case manager in the tracking system and the case manager must contact the patient within 7 calendar days 

of notification of the transfer. 

VA has partnered with the Army Wounded Warrior (AW2) Program to assign an 

AW2 soldier and family management specialist to 22 VAMCs located in the VISN 

21. The AW2 staff will integrate with existing polytrauma teams and will function 

as case managers for both soldiers and their families. They will work with soldiers, 

veterans and their families to ensure they are fully linked to VA care and benefits. 

Currently, 17 AW2 staff members are in place, with 5 more scheduled to begin their 

assignments by the end of 3rd quarter Fiscal Year 2007. 

Recommended Improvement Action(s) B: The Under Secretary for Health should 

work with DOD to establish collaborative policies and procedures to ensure that TBI 

patients receive necessary continuing care regardless of their active duty status, and 

that appropriate medical records are transmitted. 

The revised VA/DOD memorandum of agreement (MOA) entitled, ‘‘Department of 

Veterans Affairs (VA) and Department of Defense Memorandum of Agreement Regarding Referral of Active Duty Military Personnel Who Sustain Spinal Cord Injury, 

Traumatic Brain Injury, or Blindness to Veterans Affairs Medical Facilities for 

Health Care and Rehabilitative Services’’ is currently in the Office of the Assistant 

Secretary of Defense for Health Affairs. DOD is shifting billing and reimbursement 

under this MOA from the Military Medical Support Office to the three TRICARE 

regional offices. There are no changes that impact the transfer of clinical care between the two agencies. 

VA and DOD have developed the capability to share electronic medical records 

bidirectionally to coordinate the care of shared patients. The VA/DOD Bidirectional 

Health Information Exchange (BHIE) supports the real-time bidirectional exchange 

of outpatient pharmacy data, allergy information, lab results, and radiology reports 

between all VA facilities and select DOD host sites receiving large numbers of OEF/

OIF combat veterans such as the Walter Reed Army Medical Center (WRAMC), the 

Bethesda National Naval Medical Center (BNNMC), and the Landstuhl Army Medical Center in Germany. All VAMCs have the capability to view the DOD BHIE 

data. In addition to BHIE capability, VA and DOD have made significant progress 

toward sharing inpatient data. VA and DOD have developed the capability to permit 

the four VA regional polytrauma centers to view DOD inpatient data stored in 

DOD’s clinical information system (CIS). This capability provides unprecedented access to electronic DOD inpatient data by VA clinicians treating patients transferred 

from DOD and enhances continuity of care between DOD and VA. VA and DOD also 

conducted successful testing of the bidirectional sharing of inpatient narrative and 

discharge summaries. 

Recommended Improvement Action(s) C: The Under Secretary for Health should 

develop new initiatives to support families caring for TBI patients, such as those 

identified by patients and family members we interviewed. 

VA and DOD provided a national satellite broadcast, ‘‘Serving our Newest Generation of Veterans’’ in May 2006. This live broadcast was repeated on multiple 

dates and times to provide VA staff opportunities for viewing. The continuing education program included presentations on understanding the military culture, providing appropriate care across the lifespan; addressing the needs of families of 

polytrauma patients through supportive services; educating patients, families and 

staff about polytrauma rehabilitation (which includes a video about the four PRCs), 

amputation care, cognitive issues, physical and recreation therapy needs of 

polytrauma patients; and transforming the rehabilitation environment to better 

meet the unique needs of young polytrauma patients. 

PM&RS National Program Office identified a subject matter expert in the area 

of therapeutic support for families dealing with stress and loss. During the August 

2006 ‘‘Polytrauma System of Care Conference,’’ a nationally recognized expert, provided an educational session on the impact of trauma on the family, assisting families with coping and providing strategies for VA providers. VHA is continuing to 

work with this nationally recognized expert as a consultant. She presented at a conference for Polytrauma Rehabilitation Center staff and VA leadership in December 

2006. 

OSW has held four quarterly educational conference calls for VHA social workers 

on polytrauma and seamless transition. Each call stressed different aspects of assessing and meeting the needs of families of polytrauma and other OEF/OIF patients. 

VHA has hired seven clinical staff members who are assigned to the Center for 

Intrepid Joint Services Rehabilitation Facility (Center) at Brooke Army Medical 

Center in San Antonio, Texas. VHA staff will provide clinical services and seamless 

109

transition services to active duty service members undergoing rehabilitation at the 

Center. VHA staff further provide supportive services to families such as logistical 

support (e.g., transportation), education regarding VA services, and case management support. An MOA for VA’s role in the operation of the Center was signed by 

Secretary Nicholson in September 2006, and by the Secretary of the Army in January 2007. The Center was dedicated on January 29, 2007, and is currently receiving 

active duty patients for rehabilitation. 

The PRCs at Minneapolis, Minnesota and Palo Alto, California have Fisher 

Houses to lodge the families of active duty service members and veterans undergoing polytrauma rehabilitation. A Fisher House is under construction at the James 

A. Haley VA Hospital in Tampa, Florida with an estimated completion date of June 

2007. The Fisher House Foundation will break ground for a new Fisher House at 

the PRC in Richmond, Virginia in late Spring/early Summer 2007, with an estimated completion date of Fall 2007. 

The Fisher House Foundation has plans to build three additional Fisher houses 

in 2007 (Dallas, Los Angeles, and Seattle) and 10 additional in 2008 and 2009. The 

Fisher houses will support families of OEF/OIF patients, including polytrauma and 

TBI patients at the PNS. 

Each PRC and PNS has established a General Post Fund for family lodging and 

associated needs. Voluntary Service accepts donations made to VAMCs for family 

lodging into the Family Lodging General Post Fund. Social workers access the funds 

to help families defray the costs of hotel lodging, meals, and local transportation at 

facilities without Fisher Houses or when the Fisher House is full. 

OSW is working with the Fisher House Foundation’s Hero Miles Program to provide free airline ticket vouchers for the families of polytrauma patients so they can 

visit the patient. 

More than 200 VHA social workers attended the Uniformed Services Social Work 

& Seamless Transition Conference in August 2006. VA hosted conference offered a 

seamless transition track with workshops on transferring care from DOD to VA facilities, meeting the needs of families, treating combat stress and post traumatic 

stress disorder (PTSD), and working with veterans suffering from polytraumatic injuries. 

Recommended Improvement Action(s) D: The Under Secretary for Health should 

work with DOD to ensure that rehabilitation for TBI patients is initiated when 

clinically indicated. 

In April 2006, a VA/DOD TBI Executive Board was established. A TBI Summit 

was held in September 2006 that brought together non-VA, DOD, and VA subject 

matter experts to discuss contemporary practice concerning the identification and 

treatment of individuals with brain injuries. Outcomes of this meeting included 

identification of priority issues, and building consensus across DOD and VA concerning case management, assessment and treatment. 

In April 2007, VA sponsored a conference to educate VA and DOD staff about 

services and programs for OEF/OIF veterans. Specialized educational tracts included mental health, polytrauma and TBI, diversity and women’s health, pain 

management, seamless transition, and prosthetics and sensory aids. Each VISN developed an action plan for management of OEF/OIF veterans. 

A VA/DOD rehabilitation nurse liaison has been hired and assigned to WRAMC 

in September 2006. This individual monitors and follows the severely injured, assesses readiness for rehabilitation, communicates closely with the rehabilitation 

nurse admission case managers at the PRCs, provides updates on medical status, 

functional status, recovery progress, and nursing care issues. The rehabilitation 

nurse liaison will have close contact with families, providing education concerning 

impairments, rehabilitation process, and orientation to VA PRCs. A second nurse liaison is being hired for BNNMC, and should be in place by September 2007.

Question 3b. Additionally, can you please address Denise Mettie’s concerns about 

the care afforded to her severely brain injured son, including the fact that he was 

not initially referred to a Polytrauma Center? 

Response. While at National Naval Medical Center, this severely injured veteran 

was referred to the PSC and evaluated by the Palo Alto VA PRC. Considering the 

medical presentation of the patient, plans were made to move him to a PNS closer 

to his family—the Puget Sound VA Medical Center. The Polytrauma case manager 

has worked closely with the veteran’s family, coordinating evaluations from another 

VA PRC and two private sector facilities. All consulting medical facilities concur 

that his care needs are currently best met by a skilled nursing facility. The case 

manager continues to be actively involved in his care and support of his family.

Question 4. I am concerned that some younger veterans have been placed into 

long-term care facilities intended for older patients with dementia or other age-reVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00113 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
110

lated conditions. It seems that the need for age-appropriate care for some of our 

younger veterans has been well established. What is VA doing to ensure that younger veterans with traumatic brain injuries receive this type of long-term care, including opportunities for continued therapy and mental stimulation, if warranted? 

Response. VA is taking measures to recognize the generational differences of this 

population and incorporate them into the care routines as well as cohort them in 

the nursing home with populations that are similar in ability to communicate and 

interact. In VA nursing homes, transforming the culture of care to make the living 

space more home-friendly is important. Having an Internet cafe, computer games, 

or age appropriate music and videos available for nursing home residents is necessary. Allowing for family, especially children, to visit, and perhaps even stay over 

when needed; personalizing care routines such as bathing and dining times; offering 

food items that are palatable to younger persons are examples of the changes occurring in VA nursing home care. Unlike other cohorts of veterans in nursing home 

care, this cohort thrives on independence, is physically strong, and is part of a generation socialized differently than their older counterparts. 

VA has and will continue to admit young veterans into VA nursing homes when 

the veteran presents with sufficient functional impairment or health care needs that 

cannot be adequately addressed in a home and community based setting. Many returning veterans are presenting with multiple and severe disabilities including 

speech, hearing and visual impairment as well as loss of limbs and compounded 

with behavioral issues due to the stress of combat as well as brain injury. In addition, they have families, including children, who want to be actively involved in 

their care.

Question 5. Denise Mettie’s testimony touched on the need of families of veterans 

with traumatic brain injuries for support and assistance during the initial rehabilitation stage and throughout subsequent years. How does VA plan to provide these 

families with the support and training that they need in order to successfully care 

for their loved ones? 

Response. Consistent with VA’s legal authorities, while patients are being treated 

in an inpatient setting at a PRC, their families have access to the following services:

• A social work case manager who is responsible for coordinating care, ensuring 

access to psychosocial services for patient and family, providing caregiver support 

within their scope of practice, and coordinating support services to meet family 

needs. 

• Accommodations at a Fisher House, if available, hotel accommodations where 

a Fisher House is not yet available, transportation, telephone cards, and gift certificates for meals and entertainment. 

• Clinical psychologists and social work case managers who facilitate caregiver 

support groups and/or individual interventions to address issues such as the role of 

bereavement in family transition, expected role changes within the family, intra-familial conflicts, marital strife, and other family stressors. 

• Referrals as appropriate to mental health or medical resources. 

• Chaplain services providing counseling and spiritual support for families and 

caregivers.

Consistent with VA’s legal authorities, while patients are being treated in the outpatient setting at a PNS or by a PSCT, their families have access to the following 

services:

• Interdisciplinary team that includes a social work and nurse case manager. 

Clinical and psychosocial case management and coordination of the veteran’s lifelong care needs by an interdisciplinary team. 

• VA paid home care services (skilled home nurse care, home health aide, homemaker, respite care, adult day health care) required by the veteran. 

• VA Home and Community Care Services (home based primary care, adult day 

health care). 

• A 24/7 Polytrauma helpline through the call center operated by the Dayton 

VAMC. 

• VA Vet Centers that offer counseling services to combat veterans and their families/significant others to help with readjustment issues, including treating combat 

stress and PTSD and helping families and caregivers deal with the effects of combat 

service.

For those patients that require long term care, VA provides access to the following 

services:

• VA nursing home care units with access to rehabilitation therapies. 

• Contract nursing home care in the local community. 

• VA medical foster care. 

111

• Veterans and their families continue to receive psychosocial support and case 

management throughout the continuum of care. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN D. ROCKEFELLER IV 

TO MICHAEL J. KUSSMAN, M.D., EXECUTIVE-IN-CHARGE, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

Question 1. What is the VA policy regarding health care professionals and research experts who are willing to volunteer their expertise for the care of returning 

veterans? 

Response. VHA Handbook 1620.1, dated July 15, 2005 provides direction for 

healthcare professional volunteers. Volunteer assistance by physicians, dentists, 

nurses, and other professionally licensed persons to assume full responsibility for 

professional services in their respective fields may be accepted under certain circumstances. All such volunteer assignments must first be approved in advance by 

the facility chief of staff, or designee, who must ensure that any resulting volunteer 

appointment is first processed through all applicable credentialing and privileging 

procedures as described in VHA Handbook 1100.19. Any volunteer serving in this 

capacity must have appropriate training, work under the supervision of a VA compensated clinical staff member, and meet the other criteria for acceptance as a volunteer in VA’s Voluntary Service (VAVS) program. Limited health care procedures, 

not requiring certification, can be approved as volunteer assignments by the clinical 

service involved. Any volunteer serving in this capacity must have appropriate 

training, work under the supervision of a VA compensated clinical staff member, 

and meet the other criteria for acceptance as a volunteer in the VAVS Program. The 

assignment must be in the area of supplementary assistance, and may be performed 

by either a lay or professionally licensed person working as a volunteer. 

In addition, the professional may not be assigned to their ‘‘area of expertise.’’ For 

example, a surgeon may not be assigned to be in an area where they would perform 

surgery. We would use them where their skills could best serve the veteran and enhance patient care.

Question 2(a). Can you provide information on the number of VA rehabilitation 

beds and services? 

Response. VA supports 1768 rehabilitation beds nationwide—578 inpatient rehabilitation beds, 241 beds allocated for blind rehabilitation, and 949 spinal cord injury (SCI) specialty beds. Additionally, VA has implemented a rehabilitation treatment specialty within nursing homes to further expand availability of rehabilitation 

services for veterans as necessary. 

VA provides highly specialized acute inpatient rehabilitation for veterans and active duty service members with TBI and polytrauma at four Level I PRCs. Each 

PRC has 12 rehabilitation beds (48 of the total 578 inpatient beds) that are accredited for brain injury rehabilitation and comprehensive rehabilitation by the Commission for Accreditation of Rehabilitation Facilities (CARF). Referral patterns and bed 

occupancy at the PRC are monitored on a weekly basis and VA has consistently 

maintained adequate capacity for patients with polytrauma/TBI. 

An additional 245 rehabilitation beds (of the total 578 inpatient beds) are located 

across 17 Component II PNS that are not co-located with a PRC. These beds are 

CARF accredited for comprehensive inpatient rehabilitation and have not required 

a high demand for inpatient care to date; i.e., typically one or two OIF/OEF inpatients at a time.

Question 2(b). What action has VA taken to date to provide for such care, and 

what are the long term costs to maintain such capacity? 

Response. VA’s General Purpose Funding is distributed to its facilities based on 

the Veterans Equitable Resource Allocation (VERA) model, which includes funding 

to maintain capacity for rehabilitation care. Conditions such as TBI, SCI and blindness are specifically addressed for funding as separate patient classes within the 

complex care group. Long range planning models for these groups of patients use 

higher incidence and prevalence statistics to account for combat-related injuries. 

Additionally, the PRC and PNS receive Special Purpose Funding from VA Central 

Office to support a portion of the rehabilitation specialists, consultants, staff training, and equipment used in rehabilitation care. The VISNs and medical centers have 

also provided additional resources to meet specific program needs.

Question 2(c). Has VA considered other rehabilitation centers to meet immediate 

needs? 

Response. VA contracts with the private sector to provide services to eligible veterans as a complement to its system of care whenever indicated and authorized. DeVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00115 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
112

cisions to contract care are determined based on the needs of the individual patient, 

and VA staff coordinates episodes of contracted civilian care in support of the continuum of lifelong care for veterans with long-lasting disabilities.

Question 3. What new research is VA undertaking or commissioning to study the 

interactions of TBI and PTSD? What research is VA doing on the effects of vision 

loss and hearing loss on TBI diagnosis and care? 

Response. VA’s Office of Research and Development (ORD) supports a broad portfolio in TBI and related neurotrauma research and estimates devoting over $29.6 

million to this research in Fiscal Year 2007. 

This includes studying the interactions of TBI and PTSD. In one ongoing study, 

VA researchers collaborating with DOD are collecting risk factor and health information from military personnel prior to their deployments to Iraq. These soldiers 

will be reassessed upon their return and several times after that to identify possible 

changes that occurred in emotions or thinking as a result of their combat exposures, 

and to identify predisposing factors to PTSD as well as other health conditions. A 

goal of this study is to determine whether neuropsychological findings observed from 

pre- to post-deployment persist until long-term follow-up, and to examine the associations at long-term follow-up of neuropsychological changes and self-reported traumatic brain injury with the development of PTSD. 

ORD has also issued a solicitation for new research in combat casualty 

neurotrauma seeking to advance treatment and rehabilitation for veterans who suffer TBI and other traumas from improvised explosive devices and other blasts. The 

solicitation is still active and applicants are asked to pay special attention to cooperative projects in TBI with DOD, including co-morbid conditions with TBI such as 

PTSD. ORD has also issued a special solicitation for new research on TBI and 

polytrauma (i.e., combinations of multiple injuries, including brain injuries, sensory 

loss, nerve damage, infections, emotional problems, amputations and/or spinal cord 

injuries) that includes studying the interactions of TBI and PTSD. 

These solicitations are also seeking new research examining sensory loss and TBI. 

Ongoing ORD projects in this area are aiming to identify and characterize deficits 

in neural processing relevant to vision and hearing among veterans suffering from 

blast-related injuries, including those with TBI, and to develop effective rehabilitation therapies that improve visual and hearing functions important to everyday life. 

The overarching goals of these projects are to develop earlier detection strategies 

and enhanced treatment of blast-related injuries with respect to hearing, vision and 

potentially other important neural consequences. 

In addition, VA recently established a Polytrauma and Blast-Related Injury Quality Enhancement Research Initiative (PT/BRI QUERI) coordinating center to use 

the results of research to promote the successful rehabilitation, psychological adjustment and community reintegration of OEF/OIF veterans. The scope of the PT/BRI 

QUERI includes the full range of health problems, healthcare system and psychosocial factors that impact returning veterans, and focuses on the complex pattern 

of co-morbidities and related functional problems and healthcare needs among the 

combat-injured. The PT/BRI QUERI links VA investigators with VA’s polytrauma 

system of care, including the four lead centers located in Minneapolis, Richmond, 

Tampa, and Palo Alto. The polytrauma QUERI has two particular emphases: (1) to 

accelerate the diffusion and use of new knowledge generated by VA research in the 

areas of traumatic brain injury, sensory loss, prosthetics and amputation, and (2) 

to identify and address the needs of informal caregivers such as spouses or parents 

in order to allow veterans to remain in home and community-based settings.

Question 4. What type of comprehensive screening is VA doing for returning veterans on 161, PTSD, vision loss, and hearing loss? 

Response. In regards to screening veterans for TBI, VA has developed a comprehensive approach to screening and evaluation of TBI by implementing a mandatory TBI screening clinical reminder across the VA. This includes a screening instrument that uses a data system prompt with an algorithm to refer patients with 

positive screens to a Level II or Level Ill polytrauma team for complete evaluation. 

All OIF/OEF veterans receiving medical care in VA facilities will be screened for 

possible TBl. The patient’s medical record is checked at every visit through the use 

of computerized clinical reminders, software built into VHA’s electronic medical 

record, to determine if screening has been completed. If screening was missed or has 

not yet done, VA providers will be ‘‘reminded’’ through the use of the computerized 

clinical reminder to perform screening. This approach helps ensure that patients 

who may have been missed or came before screening was mandatory get screened. 

Those who screen positive for TBI will be offered further evaluation and treatment 

by clinicians with expertise in the area of TBI. 

113

Veterans receive comprehensive eye examinations by ophthalmologists and/or optometrists in VAMC Eye Clinics. Veterans documented with vision loss are referred 

to VAMC Low Vision Clinics and Blind Rehabilitation Centers, where they receive 

clinical visual rehabilitation examinations by Optometrists or Ophthalmologists. Vision rehabilitation therapists at these centers conduct functional vision assessments 

to determine veterans’ abilities in activities of daily living, literacy abilities, orientation and mobility, etc. Patients with moderate to severe polytrauma and TBI receive 

vision evaluations as part of the comprehensive rehabilitation management procedures. 

VA does not routinely screen returning veterans for hearing loss; however, active 

duty service members receive a post-deployment health survey that addresses hearing-related concerns. Audiology services are routinely provided for veterans injured 

on active duty and undergoing physical evaluation boards within MTFS. Injured 

veterans transferred to the VA health care system are typically screened for hearing 

loss by an audiologist or speech-language, and more comprehensive evaluation and 

treatment is completed by an audiologist as warranted (e.g., hearing aids, assistive 

alerting and listening devices, cochlear implants). All veterans with hearing concerns may file a claim for military service-related disability with the Veterans Benefits Administration. 

VA screens all returning veterans who come to VA for care for PTSD, depression 

and alcohol abuse using questions that are used annually for all veterans. A screening tool for mild TRI is currently being released nationally. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BERNARD SANDERS

TO MICHAEL J. KUSSMAN, M.D., EXECUTIVE-IN-CHARGE, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

Question 1. Is screening for TBI and PTSD currently mandatory at VA? If so, then 

what efforts are being made to re-screen those veterans that may have been missed 

or misdiagnosed, when they first returned, before screening was mandatory? 

Response. Screening for PTSD has been mandatory since 2004 for all veterans, 

and screening for TBI in OEF/OIF veterans became mandatory as of April 2, 2007. 

Enrolled veterans who screen positive for PTSD or other mental disorders are assessed to determine if the diagnosis is accurate or if there are other problems which 

need treatment. If a patient is found to have a problem other than PTSD, that condition is treated. Also there is re-screening of all enrolled OEF/OIF veterans for 

PTSD every year for the first 5 years after the initial screen. There is also annual 

re-screening for depression and alcohol abuse. 

In regards to screening veterans for TBI, VA has developed a comprehensive approach to screening and evaluation of TBI by implementing a mandatory TBI 

screening clinical reminder across VA. This includes a screening instrument that 

uses a data system prompt with an algorithm to refer patients with positive screens 

to a Level II or Level III polytrauma team for complete evaluation. All OEF/OIF 

veterans receiving medical care within the VA will be screened for possible TBI. The 

patient’s medical record is checked at every visit through the use of computerized 

clinical reminders, software built into VHA’s electronic medical record, to determine 

if screening has been completed. If screening was missed or has not yet done, VA 

providers will be ‘‘reminded’’ through the use of the computerized clinical reminder 

to perform screening. This approach helps ensure that patients who may have been 

missed or came before screening was mandatory get screened. Those who screen 

positive for TBI will be offered further evaluation and treatment by clinicians with 

expertise in the area of TBI. 

Question 2. Can you tell me how many veterans in Vermont are currently being 

treated for TBI? And PTSD? Since there are reports of reoccurrence of PTSD with 

older veterans, please break down the answers for PTSD into two categories: OEF/

OIF and all other veterans. Please also provide the answers to the above questions 

for New England as a whole. In addition, how many veterans have been diagnosed 

with TBI or PTSD but have not sought treatment? Again, please break down the 

answers for PTSD into two categories: OEF/OIF and all other veterans. Please also 

provide the answers to the above questions for New England as a whole. My staff 

has asked VA for this data but has not received it. This information is crucial for 

my office to understand the patient levels that the facilities in my state and surrounding states should plan for and are currently serving. 

Response. The Defense Manpower Data Center roster of 686,306 OEF/OIF veterans was matched against VA’s inpatient (PTF) and outpatient (OPC) treatment 

records to retrieve all VA treatment data as of December 31, 2006. A total of 

229,015 veterans have sought care from a VAMC from the start of OEF in October 

114

2001 to December 2006. Using these health care records, 129 OEF/OIF veterans 

were identified as having been evaluated or treated for a condition possibly related 

to a TBI from VISN 1. 

These conditions are listed as follow:

• ICD–9–CM 310.2: Postconcussion Syndrome: n=21 • ICD–9 CM 800: Fracture of skull: n=0 • ICD–9 CM 801: Fracture of base of skull: n=0 • ICD–9 CM 802: Fracture of face bones: n=27 • ICD–9 CM 803: Other and unqualified skull fracture: n=0

• ICD–9 CM 804: Multiple fractures involving skull or face with other bones: n=1

• ICD–9 CM 850: Concussion: n=47

• ICD–9 CM 851: Cerebral laceration and contusion: n=1

• ICD–9 CM 852: Subarachnoid, subdural, and extradural hemorrhage, following 

injury: n=0

• ICD–9 CM 853: Other and unspecified intracranial hemorrhage following injury: 

n=0

• ICD–9 CM 854: Intracranial injury of other and unspecified nature: n=41

• ICD–9 CM 950: Injury to optic nerve and pathways: n=2

Of these 129 veterans, 18 patients resided in Vermont. 

Because there is no ICD–9 code specific to TBI, the above number should be considered tentative and provisional. The sum of the number of patients corresponding 

to each ICD–9 code (n=140) is more than 129 because a patient may carry more 

than one ICD–9 code. 

VHA does not have data on veterans diagnosed with TBI or PTSD who have not 

sought treatment. 

VISN 1 specific OIF/OEF veterans coded with potential PTSD through 1st Qt Fiscal Year 2007

Number of Unique OIF/OEF Veterans with PTSD Using VA Facilities During

Fiscal Year 2002–1st Qt Fiscal Year 2007

VISN-Facility 

Inpatients Outpatients Total Patients1 Vet Centers4

Grand 

Total5

Primary2 Any3 Primary2 Any3 Primary2 Any3 PTSD SubPTSD Other 

1-BEDFORD ................ 9 29 162 181 62 186 44 6 51 222

1-BOSTON .................. 25 66 485 565 488 581 270 18 430 713

1-MANCHESTER ......... 142 179 142 179 123 9 441 261

1-NORTHAMPTON ....... 18 24 159 171 160 172 77 1 1,416 209

1-PROVIDENCE .......... 11 30 296 348 297 352 106 1 676 404

1-TOGUS .................... 2 12 240 282 240 285 220 78 373 410

1-WEST HAVEN .......... 6 17 441 483 441 484 186 8 543 556

1-WHITE RIVER JCT ... 10 15 180 229 180 230 110 726 539 306

VISN 1 .............. 77 178 2,008 2,312 2,010 2,329 1,136 847 4,469 2,906

1 The ‘‘total patient’’ counts were generated by matching a cumulative roster of 686,306 unique OIF/OEF veterans, who had been separated 

from active duty as of November 30, 2006, with VA inpatient (PTF) and outpatient (OPC) databases for Fiscal Year 2002, 2003, 2004, 2005, 

2006 and through 1st Qt Fiscal Year 2007. The DOD Defense Manpower Data Center identified and provided the identity of these veterans to 

the VA Environmental Epidemiology Service on January 11, 2007. 2 The number for ‘‘Primary’’ indicates the total number of unique veterans whose primary reason for the inpatient or outpatient visit was 

for treatment or evaluation of PTSD. 3 The number for ‘‘Any’’ indicates the total number of unique veterans with PTSD, whether or not the primary reasons for the inpatient or 

outpatient visit was for treatment or evaluation of PTSD. 4 The Vet Center counts were based on matching the DMDC OIF/OEF roster with Vet Center user’s record through 1st Qt Fiscal Year 2007. 5 The number for ‘‘Grand Total’’ (n=4552l) indicates the sum of ‘‘Any Total Patients’’(n=39243) and ‘‘Vet Center PTSD’’ (n=11660) after excluding known duplicates (n=5382). 

The overall number of unique veterans in VISN 1 who received treatment for 

PTSD in FY 2006 was 19,356.

Question 3. What do you think of mandatory mental health screening by DOD for 

all service members that are deployed, when they return from service? Could this 

help remove the stigma of service members having to ask for mental health treatment, if everyone was required to be screened for mental health issues? 

Response. DOD currently screens all returning service members for health issues 

when they return from deployment using the Post Deployment Health Assessment 

(PDHA) and again 3–6 months post deployment using the Post Deployment Health 

Reassessment (PDHRA). Both the PDHA and PDHRA include mental health questions. VA also has mandatory screening of OEF/OIF veterans who come to VA for 

care using questions on PTSD, depression and alcohol abuse. These questions are 

115

the same as those used annually to screen all veterans. It is believed that screening 

all service members and veterans is an approach that can reduce stigma and at the 

same time ensure assessment of the population at risk. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHNNY ISAKSON

TO MICHAEL KUSSMAN, M.D., EXECUTIVE-IN-CHARGE, VETERANS HEALTH

ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

Question 1: Do you have any plans to expand the Active Duty Rehabilitation program at the Augusta VA Medical Center? 

Response: The Department has no current plans to expand the Active Duty Rehabilitation program at the Augusta Veterans Affairs Medical Center (VAMC). The 

Augusta Department of VAMC has been able to meet the military’s needs for all 

inpatient rehabilitation referrals; 93 percent of the referrals come from the southeast regional medical command. Fort Gordon remains the primary referral source 

with 66 percent of referrals, followed by 10 percent from Fort Campbell and 7 percent from Fort Stewart. The occupancy rate for the 30-bed active duty rehabilitation 

(ADR) inpatient unit at the Augusta VAMC has increased in recent months from 

35 percent to 86 percent, VA will continue to monitor occupancy rates to determine 

the need for additional rehabilitation services in the future.

Question 2: Do you have any plans to expand the Active Duty Rehabilitation program to other VA Medical Centers across the country? 

Response: The Veterans Health Administration (VHA), in consultation with the 

Department of Defense (DOD), is presently evaluating the need for additional 

polytrauma rehabilitation centers (PRC) to augment the services currently being 

provided at VAMCs across the country. VHA currently provides the highest quality 

medical, rehabilitation, and support services for veterans and active duty 

servicemembers through the VHA integrated polytrauma/traumatic brain injury 

(TBI) system of care, consisting of: (1) four regional polytrauma/TBI rehabilitation 

centers providing acute intensive medical and rehabilitation care for complex and 

severe polytraumatic injuries; (2) 21 polytrauma/TBI rehabilitation network sites, 

which implement the post-acute rehabilitation plan of care; and (3) 72 polytrauma/

TBI support clinic teams located at local medical centers throughout the 21 Veterans Integrated Service Networks (VISN), which provide routine follow-up of care 

for veterans with a history of TBI and polytrauma.

Question 3: Do you feel that treating active duty troops at VA medical centers 

benefits the Department of Veterans Affairs? 

Response: VA mission is to ‘‘care for him who has borne the battle.’’ Meeting the 

comprehensive health care needs of returning Operation Enduring Freedom (OEF) 

and Operation Iraqi Freedom (OIF) veterans and servicemembers is the Departments highest priority. VA works closely with the Department of Defense to ensure 

our returning servicemen and women receive the highest quality of care and seamless transition of benefits, without regard to where their care is provided.

Chairman AKAKA. Thank you very much, Dr. Kussman. 

Ms. Embrey? 

STATEMENT OF ELLEN P. EMBREY, DEPUTY ASSISTANT

SECRETARY, HEALTH AFFAIRS/FORCE HEALTH PROTECTION AND READINESS, DEPARTMENT OF DEFENSE 

Ms. EMBREY. Mr. Chairman, thank you very much the opportunity to be here today. On behalf of the Assistant Secretary of Defense for Health Affairs, I am going to be talking to you about 

health care needs of returning servicemembers and new veterans. 

The Department of Defense, and the military health system specifically, is committed to protecting the health of our 

servicemembers, providing the best and world-class health care to 

more than 9 million beneficiaries and coordinating the transition of 

servicemembers’ medical care to the Department of Veterans Affairs whenever necessary and appropriate. 

Over the last several years, our two Departments have fostered 

a more effective, aligned Federal health care partnership by coordiVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00119 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
116

nating and developing common health care and support services 

along the continuum of care. The Global War on Terrorism has 

posed a particular challenge to both Departments in adapting particularly for long-term rehabilitative care for our complex wounded, 

injured, and ill combat veterans. We owe very much to them, as 

demonstrated by the first panel, for their sacrifice to our Nation, 

and we are committed to working together to ensure that they get 

the very best that our health systems can offer and, consistent with 

Dr. Gans’ testimony, working with the civilian industry if that is 

appropriate to get them the best care that they need. 

The DOD/VA Joint Executive Council established the core partnership, a strategic plan and goals to better align and coordinate 

the health and benefits services of each of our two Departments. 

Before continuing more about these efforts, I would like to briefly 

discuss the Department of Defense response to the recent findings 

of inadequate administration of support services, care coordination, 

and disability processing. 

The Department of Defense is strongly committed to taking corrective actions to improve performance in these areas. Secretary 

Gates has formed an Independent Review Group to advise him on 

the actions that need to be taken, and they have 45 days to complete their assessment, and that is coming up here very shortly. 

In addition, each military department has undertaken a focused 

review to take actionable actions immediately as they find them. 

And the Under Secretary of Defense for Personnel and Readiness, 

Dr. David Chu, has convened a working group to assess ways to 

improve the policies and programs of the Department based on the 

results of these ongoing reviews. 

DOD is also cooperating with the President’s Commission, as 

well as the interagency Veterans Affairs task force that was established to review these matters as well. 

DOD’s collective focus in these areas is on five major programs: 

facilities; caseworkers and case managers, along with the family 

support that goes with that; the disability determination process; 

traumatic brain injuries and treatment of severely injured; and 

post-traumatic stress disorders and mental health. 

With respect to TBI, or traumatic brain injury, I thank you very 

much and your distinguished colleagues in Congress for your interest and support in expanding TBI research and treatment within 

the Department. 

Now, I would like to refocus my remarks on overall DOD and VA 

partnerships in health care. The VA and DOD established and collaborated on the use of Joint Incentive Fund to eliminate budgetary constraints as a possible determinant for that sharing. Designated funding covers startup costs associated with innovative and 

unique sharing agreements, and at the end of 2006, 47 Joint Incentive Fund projects accounting for $88.8 million of the $90 million 

in the fund has been approved by the Executive Health Council. 

We are jointly staffing DOD and VA Federal health facilities at 

several locations around the country and have sharing agreements 

between DOD medical treatment facilities and Reserve component 

units with 157 VA medical centers. 

This increased sharing has facilitated improved but not perfect 

coordinated transition of servicemember care from DOD to VA. 

117

This transition involves effectively managing medical care and benefits during the transition from active duty to veteran status to ensure continuity of care and services. 

The Department has been working with VA on streamlining and 

better aligning our support for coordinated transition in three main 

areas: medical care and disability benefits, transition to home and 

community, and sharing servicemember personnel and health information. The first panel spoke to all three of these and the issues 

that are at hand and the challenges before us. 

Servicemembers who transition directly from DOD medical treatment facilities to one of the VA polytrauma centers are met by a 

familiar face in uniform. In 2006, the VA expanded their 4 centers 

for polytrauma to a polytrauma network with an additional 21 

sites, and DOD assets will be there as well. The VA has placed 

their assets in our military treatment facilities. Their Joint Seamless Transition Program has been worked by the VA in coordination in with the military services and which facilitates a more timely receipt of benefits for the severely injured servicemembers while 

they are still on active duty. There are currently 12 VA social 

workers and counselors assigned at 10 military treatment facilities. 

As of the end of last month, VA social workers supported 7,082 

new patient transfers to the Veterans Health Administration from 

participating military hospitals. The VA has also placed liaisons at 

each of our three TRICARE regional offices to enhance communications and coordination between us to better support our shared 

beneficiaries. 

DOD and VA partnering has been a key focus with respect to 

shaping common clinical services for our beneficiaries. An area of 

particular concern is our shared clinical focus on identification and 

treatment and follow-up for traumatic brain injuries. DOD fielded 

a clinical practice guideline for the management of mild TBI in 

CENTCOM, the theater of operations, in August of 2006, including 

requiring field use of a standard military acute concussion evaluation tool to assess in the field and document TBI for medical 

records upon return. 

Efforts to build a more comprehensive DOD-wide program, including VA experts, is now underway to establish common protocols 

and procedures to identify, treat, document, and follow up on those 

who have suffered a TBI while either deployed or in garrison. 

I see that my time is up, and I would be happy to yield the floor 

back to the Chairman for further questions. 

[The prepared statement of Ms. Embrey follows:]

PREPARED STATEMENT OF ELLEN P. EMBREY, DEPUTY ASSISTANT SECRETARY, HEALTH AFFAIRS/FORCE HEALTH PROTECTION AND READINESS, DEPARTMENT OF

DEFENSE

Thank you, Mr. Chairman, for the opportunity to speak to you today on behalf 

of the Assistant Secretary of Defense for Health Affairs regarding the health care 

needs of returning servicemembers and new veterans. 

The Department of Defense, and the military health system in particular, is committed to protecting the health of our Servicemembers, providing world-class 

healthcare to more than 9 million beneficiaries, and, seamlessly coordinating the 

transition of Servicemembers’ medical care to the Department of Veterans Affairs 

(VA) whenever necessary. 

Over the last several years, our two Departments have made significant strides 

in coordinating and developing common health care and support services along the 

entire continuum of care. Both agencies have been making concerted efforts to work 

118

closely to maintain and foster a more effective, aligned Federal healthcare partnership. The Global War on Terrorism poses a challenge to both Departments, as the 

severity and complexity of wounds, and the increased survival rates yield increasing 

demands on our system for long term rehabilitative care for our wounded, injured 

and ill combat veterans. We owe much to them for their sacrifice to our nation, and 

we are committed to work together to ensure they get the very best that our health 

systems can offer, and keeping their associated bureaucratic burdens to a minimum. 

In April 2003, a DOD–VA Joint Executive Council (JEC), chaired by the Under 

Secretary of Defense for Personnel and Readiness and the Deputy Secretary of the 

Department of Veterans Affairs, was established to jointly set strategies, goals and 

plans to better align and coordinate the health and benefit services of the two Departments. The JEC meets quarterly to review progress against the mutually developed plans. 

The VA/DOD Joint Strategic Plan reflects common goals from both the VA Strategic Plan and the Military Health System (MHS) Strategic Plan—and specifically 

articulates the shared goals and objectives developed and ratified by DOD/VA leadership. Three weeks ago, Dr. David S.C. Chu, Under Secretary of Defense for Personnel and Readiness, and Mr. Gordon H. Mansfield, Deputy Secretary, Department 

of Veterans Affairs, directed additional joint initiatives to improve alignment, leverage shared resources, and improve delivery of care to our returning combat veterans. The spectrum of DOD–VA collaboration and sharing activities encompasses clinical services, education and training, research and development, patient administration, and information/data technology sharing. Before providing an overview of these 

activities, I’d like to briefly highlight the Departments’ response to the recent findings of inadequate administration of support services, care coordination, and disability processing. The Department is strongly committed to taking corrective actions to improve performance in these areas. Secretary Gates has formed an Independent Review Group (IRG) to advise him on actions that need to be taken, each 

Military Department has undertaken a focused review of these matters, and the 

Under Secretary of Defense for Personnel and Readiness Dr. Chu, has convened a 

working group to assess ways to improve policies and programs based on the results 

of these ongoing reviews. DOD is also cooperating with the President’s Commission 

on Care for America’s Returning Wounded Warriors and is participating actively in 

the Interagency Task Force on Returning Global War on Terror Heroes. 

DOD’s collective focus is centered on five major program areas: 

1. Facilities. DOD’s medical facilities, outpatient housing, medical barracks, and 

the full spectrum of hotel services provided by the Department are being assessed 

to ensure standards of quality our Servicemembers and families expect and deserve 

are met. 

2. Case Workers/Case Managers and Family Support. Practices for case management, including care coordination, case-manager-to-patient ratios, family support 

models, and related support services are being assessed to ensure our wounded and 

ill Servicemembers get needed support throughout their healthcare delivery and rehabilitation, regardless of whether their care is delivered in DOD or VA facilities. 

In some instances, patients will continue to obtain care in both systems. For that 

reason, establishing case-management protocols and systems that seamlessly support all configurations of care in both systems is a high priority. 

3. Disability Determination Processes. Medical, personnel, and disability-benefit 

determination experts within and outside the DOD are actively involved in an effort 

to develop and recommend a streamlined process that minimizes delay while providing fair, consistent, and timely determinations for all Servicemembers. 

4. Traumatic Brain Injuries (TBI) and Treatment of the Severely Injured. Since 

the Global War on Terrorism began, DOD has been collaborating with VA on the 

full spectrum of combat wounds, injuries and associated illnesses, particularly those 

occurring as a result of improvised explosive devices. Both Departments are working 

together to identify best practices for providing and supporting highest quality acute 

and long term care for severely injured and ill servicemembers, as well as to determine the most effective means to screen, diagnose, and treat individuals who experience a TBI. Civilian TBI experts and researchers are important collaborators to both 

Departments in shaping how to apply available research outcomes in establishing 

an evidence-based, comprehensive program in both systems to detect, diagnose and 

treat this health risk to our servicemembers and veterans. 

5. Post-Traumatic Stress Disorder (PTSD)/Mental Health. The short-term and 

long-term mental health needs of our Servicemembers and veterans are major priorities of both Departments. To further transition support, a VA/DOD Mental Health 

Working Group was formed in 2003 under the Joint Executive Council to focus specifically on mental health initiatives and transition of care. DOD continues to critiVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00122 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
119

cally evaluate its capabilities, policies and programs to ensure effective support for 

returning servicemembers and new veterans’ mental health needs, including their 

families. This includes looking at improved methods of information sharing from VA 

medical records regarding mental health conditions and treatments for Reserve 

Component members that may contraindicate future deployments. With the renewed support of the line commanders and leaders, new approaches to reducing the 

stigma of seeking mental-health treatment will be explored. We will continue to pursue expanded opportunities for collaboration with VA to ensure the coordinated 

transition of veterans with mental-health needs. 

Supporting all of these collaborative efforts, we will continue to grow, enhance, 

align, and integrate the technology infrastructure that supports both systems, enabling greater access to clinical and administrative information for the benefit of the 

people we serve. 

The following provides greater detail on our comprehensive sharing initiatives: 

OVERALL DOD–VA SHARING EFFORTS

As a result of the National Defense Authorization Act for Fiscal Year 2003, VA 

and DOD have been actively collaborating on a wide spectrum of joint initiatives. 

Section 721 of that Act required that the departments establish, and fund on an annual basis, an account in the Treasury referred to as the Joint Incentive Fund (JIF). 

The JIF provides a means to eliminate budgetary constraints as a possible deterrent 

to sharing initiatives by providing designated funding to cover the startup costs associated with innovative and unique sharing agreements. At the end of Fiscal Year 

2006, 47 JIF projects—accounting for $88.8 million of the $90 million in the fund—

had been approved by the Health Executive Council out of a total of more than 200 

proposals. The 2006 projects cover such diverse areas of medical care as mentalhealth counseling, Web-based training for pharmacy technicians, cardio-thoracic surgery, neurosurgery, and increased physical therapy services for both DOD and VA 

beneficiaries. 

We also are jointly staffing a number of Federal health facilities. These include: 

• The Center for the Intrepid—opened in January 2007, provides a state-of-theart facility in San Antonio, Texas, explicitly to rehabilitate wounded warriors. This 

follows the Walter Reed Amputee Training Center’s example of onsite collaboration. 

• Integrated DOD–VA operations in several locations, for example: North Chicago 

(Great Lakes Naval Station); New Mexico (Kirtland AFB); Nevada (Nellis AFB); 

Texas (Fort Bliss); Alaska (Elmendorf AFB); Florida (NAS Key West); Hawaii (Tripler AMC), and California (Travis AFB). 

• At the end of Fiscal Year 2006, DOD military treatment facilities and Reserve 

Units were involved in sharing agreements with 157 VA Medical Centers, enabling 

improved visibility of medical needs in VA for reservists entitled to VA care after 

returning from combat operations. 

COORDINATED TRANSITION

Coordinated transition involves effectively managing medical care and benefits 

during the transition from active duty to veteran status to ensure continuity of services and care. Efforts to date have focused on enabling Servicemembers to enroll in 

VA healthcare programs and file for VA benefits before separation from active duty 

status. Additionally, the Department has been engaged with VA on initiatives and 

programs supporting coordinated transition focused on three general areas: (1) medical care and disability benefits, (2) transition to home and community, and (3) sharing Servicemember personnel and health information. The Joint Executive Council 

has established a Coordinated Transition Working Group to examine and make recommendations for improvement to the transition process. 

For Servicemembers who transition directly from DOD military treatment facilities to VA medical centers, DOD and VA implemented the Army Liaison/VA 

Polytrauma Rehabilitation Center Collaboration program—also called ‘‘Boots on the 

Ground’’—in March 2005. This program is designed to ensure that severely injured 

Servicemembers (primarily Army soldiers) who are transferred directly from a military treatment facility to one of the four VA Polytrauma Centers—in Richmond, 

Tampa, Minneapolis, and Palo Alto—are met by a familiar face and a uniform. A 

staff officer or non-commissioned officer assigned to the Army Office of the Surgeon 

General is detailed to each of the four locations, to provide support to the family 

through assistance and coordination with a broad array of such issues as travel, 

housing, and military pay. This coordination process has been working exceptionally 

well. However, this transition has not always worked as well when Servicemembers 

are transferred to other locations around the country. In response, VA opened 21 

new Polytrauma Network Sites in Fiscal Year 2006 to provide continuity of care to 

120

injured Servicemembers. The Department deeply values the sacrifices that these 

veterans and their families have made. With our VA colleagues, we are committed 

to doing all we can to improve our coordination and case management of 

Servicemembers who transition to any VA facility. 

VA also is placing personnel in our medical facilities. The Joint Seamless Transition assists severely injured Servicemembers while they are still on active duty so 

that they can receive benefits in a timely manner. There are 12 VA social workers 

and counselors assigned at 10 military treatment facilities, including Walter Reed 

Army Medical Center and the National Naval Medical Center in Bethesda. These 

social workers ensure the seamless transition of healthcare, including a comprehensive plan for treatment. Veterans Benefits Administration counselors visit all severely injured patients and inform them of the full range of VA services, including 

readjustment programs, educational and housing benefits. As of February 28, 2007, 

VA social worker liaisons had processed 7,082 new patient transfers to the Veterans 

Health Administration from participating military hospitals. 

VA also partners with DOD medical facilities through a Cooperative Separation 

Physical Examination and Benefits Delivery at Discharge (BDD) program which 

began in 2004. The BDD program eliminates the disadvantage of previous procedures, in which Servicemembers were required to undergo two physical examinations within months of each other. Under VA’s BDD program, Servicemembers can 

begin the claims process with VA up to 180 days before separation at any of the 

131 DOD sites where local agreements have been established. 

Finally, VA has placed liaisons in each of our three TRICARE Regional Offices 

in Washington, DC, San Antonio, TX, and San Diego, CA, providing an important 

communications and coordination link between the DOD and VA to better support 

our shared beneficiaries. 

Within DOD, providing assistance and support to the families of wounded or ill 

servicemembers during this tumultuous time of transition continues to be a high 

priority. Thus, the Military Severely Injured Center (MSIC), established in February 

2005 within the Military Community and Family Policy Office, operates a hotline 

center which functions 24 hours a day, 7 days a week. The Center’s mission is to 

identify and resolve policy and program gaps in support and augments and reinforces the support that each of the Service-specific programs —the Army Wounded 

Warrior Program, the Navy Safe Harbor program, the Air Force Helping Airmen Recover Together (Palace HART) program, and Marine4Life—provide. 

CLINICAL SERVICES

DOD and VA are working together on some of the most complex clinical matters 

emerging from the current war. We are developing joint Evidenced-Based Clinical 

Practice Guidelines that are means for disseminating throughout our systems the 

most current scientific and medical knowledge. These guidelines allow our organizations to provide fact-based state-of-the-art medical care that is easily transferable 

between the two medical care delivery systems. 

Although our range of shared clinical activity spans most specialty areas, we are 

placing a particular focus in the following areas: 

Mental Health 

Mental-health services are available for all Servicemembers and their families before, during, and after deployment. Servicemembers are trained to recognize sources 

of stress and the symptoms of distress in themselves and others that might be associated with deployment. Combat-stress control and mental healthcare are available 

in-theater. In addition, before returning home, we brief Servicemembers on how to 

manage their reintegration into their families, including managing expectations, the 

importance of communication, and the need to control alcohol use. 

After returning home, Servicemembers are provided easy and direct access to 

mental healthcare services following a continuum of care model. Same-day appointments and daily walk-in appointments are available in military mental health clinics, and behavioral healthcare providers are integrated into primary care clinics in 

both the DOD and VA. TRICARE also is available for 6 months after return for Reserve and Guard members and TRICARE Reserve Select programs are available for 

continuing health insurance coverage for Reserve and Guard members and their 

families after the 6-month transition period. To facilitate access for all 

Servicemembers and family members, especially Reserve Component personnel, the 

Military OneSource Program—a 24/7 referral and assistance service—is available by 

telephone and on the Internet. In addition, we provide face-to-face counseling in the 

local community for all Servicemembers and family members. We provide this nonmedical counseling at no charge to the member, and it is completely confidential. 

For clinical care, family members can access mental health services directly in the 

121

TRICARE network. Up to eight sessions are available without a referral from a primary care manager and without pre-authorization requirements from TRICARE. 

The Periodic Health Assessment (PHA) was added to the continuum of assessments in February 2006. This annual requirement for all deployable assets of the 

Department includes a robust mental health section that complements the deployment health assessment process, allowing the opportunity for assessment, referral 

to care, and treatment outside the deployment cycle. 

To supplement mental-health screening and education resources, we added the 

Mental Health Self-Assessment Program (MHSAP) in 2006. This program provides 

Web-based, phone-based, and in-person screening for common mental health conditions and customized referrals to appropriate local treatment resources. The program also includes parental screening instruments to assess depression and risk for 

self-injurious behavior in their children, along with suicide prevention programs in 

DOD schools. Spanish versions of the screening tools are available as well. 

Traumatic Brain Injury (TBI) 

The Department is working on a number of measures to evaluate and treat 

Servicemembers affected or possibly affected with traumatic brain injury (TBI). For 

example, in August 2006, a clinical practice guideline for management of mild TBI 

in-theater for the Services was developed and fielded. Detailed guidance was provided to Army and Marine Corps line medical personnel in the field to advise them 

on ways to deal with TBI. The clinical practice guideline included a standard Military Acute Concussion Evaluation (MACE) tool to assess and document TBI for the 

medical record. TBI research in the inpatient medical area is also underway. 

A program to integrate the outstanding work completed in TBI by the military 

departments has been initiated to establish a comprehensive DOD program, and experts from VA are included in this effort. This comprehensive program will provide 

system-wide common protocols and procedures to identify, treat, document, and follow up on those who have suffered a TBI while either deployed or in garrison. In 

addition, it will address TBI surveillance, transition to non-DOD care, long-term 

care, education and training, and research. 

DOD has also modified the questions asked during the Post-deployment Health 

Assessment, the Post-deployment Health Reassessment, and the Periodic Health Assessment to help identify individuals who may have suffered a TBI. 

ADMINISTRATION AND LOGISTICS

The DOD/VA Health Executive Council worked with industry to synchronize data 

on approximately 16,000 items from 17 manufacturers and more than 160,000 items 

from Prime Vendor distributors. A contract was awarded for a data synchronization 

pilot study to determine the best purchase of medical items from the healthcare industry. We continue to make progress on joint procurement activities. As of September 2006, there were 77 joint National contracts, 7 Blanket Purchase Agreements (BPAs) and 46 medical/surgical shared contracts. 

Both Departments face a challenge familiar to health organizations, insurers, employers and individuals across the country—the rising costs of healthcare. One 

area—pharmacy—is particularly noteworthy. Nearly 6.7 million beneficiaries use 

our pharmacy benefit, and in Fiscal Year 2006, our total pharmacy cost was more 

than $6 billion. Our partnership with VA on joint contracting for prescription drugs 

is part of this solution, and our collective purchasing efforts have saved DOD more 

than $784 million in Fiscal Year 2006. 

OCCUPATIONAL EXPOSURES

DOD and VA have collaborated on a number of recent projects related to occupational and environmental exposures. Projects related to chemical warfare agents and 

depleted uranium are two examples. DOD undertook a wide-ranging initiative to 

identify all exposures to chemical and biological agents from World War II to the 

present. To date, DOD has provided more than 19,000 names of test participants 

to VA. As part of this effort, DOD declassified the medically relevant information 

from test records and identified the records of approximately 6,700 soldiers who 

were involved in testing of chemical agents, placebos, and/or pharmaceuticals in 

Edgewood, MD, during the period of 1955–75. DOD provided the names of these individuals, the dates of the tests, and the types of exposures to VA. VA and DOD 

collaborated on writing a letter to veterans to explain the history of the testing program and to provide information about the availability of VA healthcare. VA started 

mailing notification letters in June 2006. 

We continue to monitor the health affects of our Servicemembers exposed to depleted uranium (DU) munitions. DOD policy requires urine uranium testing for 

122

those wounded by DU munitions. We also test those in, on, or near a vehicle hit 

by a DU round, as well as those conducting damage assessments or repairs in or 

around a vehicle hit by a DU round. The policy directs testing for any 

Servicemember who requests it. More than 2,215 Servicemember veterans of Operation Iraqi Freedom have been tested for DU exposures. Of this group, only nine 

had positive tests, and these all had fragment exposures. 

Testing continues for veterans exposed to DU munitions from the 1990–1991 Persian Gulf War. The 74 individuals with the most significant exposures to DU in a 

Department of Veterans Affairs medical follow-up program have been extensively 

studied with physical exams and laboratory analyses for over 12 years. To date, 

none have developed any uranium-related health problems. This DU follow-up program is in place today for all Servicemembers with similar exposures. 

HEALTH INFORMATION TECHNOLOGY AND DATA SHARING

In the health information technology arena, DOD and VA have engaged in a number of important efforts to share essential clinical and management information in 

support of health care services to our wounded servicemembers and all eligible 

former military members who seek care from VA. 

The work of capturing and sharing relevant clinical information between the DOD 

and VA begins on the battlefield. With the expanded use of the Web-based Joint Patient Tracking Application (JPTA), our medical providers should have improved visibility into the continuum of care across the battlefield, and from theater to sustaining base. DOD grants access to JPTA for VA providers who are treating 

Servicemembers in VA. In addition, we are working with VA to explore ways to 

share relevant patient injury/wound trend data to assist VA in predicting and preparing for treatment of OIF and OEF combat veterans. 

Since September 2003, DOD has provided a roster to VA periodically, which lists 

OIF and OEF veterans who have either deactivated back to the Reserve/National 

Guard, or who have separated entirely from the military. VA uses this roster to 

evaluate the healthcare utilization of OIF/OEF veterans. VA performed its most recent analysis related to 631,174 veterans in November 2006. Thirty-two percent of 

these individuals had sought VA healthcare at least once. The three most common 

diagnostic categories were musculoskeletal disorders (mostly joint and back disorders), mental disorders, and dental problems. These data are quite useful in VA’s 

planning for allocation of healthcare resources. 

Servicemembers who have substantial medical conditions are evaluated in the 

Physical Evaluation Board (PEB) process to determine if they are fit to stay on active duty or if they should be medically separated. DOD provides the names of individuals who enter the PEB process to VA, to facilitate the transition of care and 

to assist in starting the paperwork to provide VA benefits. In 2005, DOD and VA 

signed a memorandum of understanding that stated that DOD would send these 

data to VA. In October 2005, DOD delivered the first list to VA of names, current 

locations, and medical conditions. Since then, DOD has sent a list of names to VA 

periodically, which will continue in the future. Data on more than 16,000 individuals have been transferred to VA. The Veterans Health Administration and Veterans Benefit Administration plan to send letters to these individuals to inform 

them about the availability of VA healthcare and disability benefits, respectively. 

The Federal Health Information Exchange (FHIE) enables the transfer of protected electronic health information from DOD to VA at the time of a 

Servicemember’s separation. Every month, DOD transmits laboratory results, radiology results, outpatient pharmacy data, allergy information, discharge summaries, 

consult reports, admission, disposition and transfer information, elements of the 

standard ambulatory data records, and demographic data on separated 

Servicemembers. As of February 2007, DOD had transmitted more than 182 million 

messages to the FHIE data repository on more than 3.8 million retired or discharged Servicemembers. This number grows each month. 

DOD expanded the breadth of data transferred under the FHIE in recent years. 

In September 2005, we began monthly transmission of the electronic Pre- and PostDeployment Health Assessment information to VA, followed in November 2006 with 

monthly transmission of Post-Deployment Health Reassessments (PDHRAs) for separated Servicemembers and demobilized National Guard and Reserve members. 

Weekly transmission of PDHRAs for individuals referred to VA for care or evaluation started in December 2006. As of February 2007, VA has access to more than 

1.6 million assessment forms on more than 681,000 separated Servicemembers and 

demobilized Reserve and National Guard members. 

The FHIE has been successful in improving data sharing as Servicemembers’ 

transition from DOD to VA care. In some communities, however, beneficiaries eligiVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00126 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
123

ble for both DOD and VA care may obtain care from both systems. The Bidirectional 

Health Information Exchange (BHIE) enables the real-time sharing of allergy, outpatient pharmacy, demographic, laboratory, and radiology data between DOD BHIE 

sites and all VA treatment facilities for patients treated in both DOD and VA facilities. As of January 2007, BHIE was operational at 14 DOD medical centers, 17 hospitals, and more than 170 outlying clinics. In the 3rd Quarter Fiscal Year 2007, all 

DOD sites and all VA sites will be able to view allergy information, outpatient pharmacy data, radiology reports, and laboratory results (chemistry and hematology) on 

shared patients. 

We have begun testing our ability to share inpatient information, and successfully 

completed initial testing at Madigan Army Medical Center (AMC) and VA Puget 

Sound Health Care System (HCS) in August 2006—enabling access to inpatient discharge summaries from Madigan AMC’s Clinical Information System (CIS) and VA’s 

VistA system. We implemented this functionality in November 2006 at Tripler AMC 

where we make emergency department discharge summaries available to VA on 

shared patients. We also installed this functionality at Womack AMC in February 

2007. We plan further deployment in additional DOD sites in Fiscal Year 2007. In 

the future, we will make additional inpatient documentation, such as operative 

notes and inpatient consultations available to VA. 

We also began the exchange of important clinical information between each of our 

clinical data repositories. The Clinical Data Repository/Health Data Repository 

(CHDR) establishes interoperability between DOD’s Clinical Data Repository (CDR) 

and VA’s Health Data Repository (HDR). In September 2006, the CHDR interface 

successfully exchanged standardized and computable pharmacy and medication allergy data between William Beaumont AMC and El Paso VA HCS on patients who 

receive medical care from both healthcare systems. Exchanging computable pharmacy and allergy data supports drug-drug and drug-allergy order checking for 

shared patients using data from both DOD and VA. 

In December 2006, DOD also began deployment and VA continued field testing 

at Eisenhower AMC and Augusta VA Medical Center (MC) and at Naval Hospital 

Pensacola and VA Gulf Coast HCS. During the 2nd Quarter Fiscal Year 2007, the 

organizations implemented CHDR at Madigan AMC and VA Puget Sound HCS, 

Naval Health Clinic Great Lakes and North Chicago VA HCS, Naval Hospital San 

Diego-Balboa and VA San Diego HCS, and Mike O’Callaghan Federal Hospital and 

VA Southern Nevada HCS. By July 2007, DOD will send out instructions to sites 

to allow remaining DOD AHLTA locations to begin using CHDR. 

Finally, the Laboratory Data Sharing Initiative (LDSI) facilitates the electronic 

sharing of laboratory order entry and results retrieval between DOD, VA, and commercial reference laboratories for chemistry tests. LDSI is available to all DOD and 

VA sites with a business case for its use. Either Department may function as a reference lab for the other. We are currently testing the addition of laboratory anatomic pathology and microbiology orders and results retrieval using the Logical Observation Identifiers Names and Codes (LOINC) and Systematized Nomenclature of 

Medicine Clinical Terms (SNOMED CT) standards. 

While the DOD and VA are pleased with this accelerated data sharing over the 

last several years, we remain interested in even more collaborative efforts in the information technology arena. Both Federal health systems are proud of their successful deployments of enterprise-wide health information technologies, AHLTA and 

VistA, yet we both are seeking a new inpatient electronic medical record system. 

Consequently, we have embarked on a study to explore the potential for a joint inpatient system. This would offer several potential benefits. First and foremost, electronic sharing of inpatient data would enhance our ability to provide ‘‘seamless transition’’ of medical data for our severely injured and wounded Servicemembers to VA 

care. Second, there are potential cost efficiencies that would derive from joint-license 

procurements and joint-development activities. Finally, such an effort would likely 

proliferate opportunities for additional data sharing between DOD and VA. The Departments have embarked on a joint assessment that will recommend to DOD and 

VA leadership the best strategy for accomplishing these objectives. 

Our efforts in enhancing DOD–VA collaboration over the last several years have 

been successful. Yet, we are not satisfied that we have achieved all that is possible. 

We have an aggressive plan to work through some of the greater technological and 

management challenges in the coming year. With the support of the Congress, we 

are confident we will be successful. 

124

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO ELLEN

EMBREY, DEPUTY ASSISTANT SECRETARY, HEALTH AFFAIRS/FORCE HEALTH PROTECTION AND READINESS, DEPARTMENT OF DEFENSE

Question 1. What are your thoughts on providing seriously injured, separating 

servicemembers or their families with an electronic medium containing as complete 

a medical record as possible, perhaps to include scanned representations of paper 

records? This matter was raised by Senator Burr at the Committee’s hearing. I 

would appreciate your thoughts on the feasibility of this additional precaution on 

behalf of our injured veterans. 

Response. Separating Servicemembers may receive a copy of their medical records 

now. Further, providing Servicemembers with their electronic health information is 

part of the Military Health System strategic plan. But it is not clear that scanning 

older paper records for all is the best approach. Rather, we should focus on those 

with serious injuries, as we are doing with patients going to the VA polytrauma 

clinics.

Question 2. The Fiscal Year 2007 Defense Authorization Bill mandated that DOD 

include brain injury-related questions on its Post-Deployment Health Assessment 

(PDHA) questionnaire, which is administered to all returning servicemembers. This 

action was supposed to have occurred within 6 months of the bill’s passage. As we 

have now reached this deadline, has DOD added this requirement to the PDHA in 

compliance with the law? Additionally, has DOD begun to distribute the new questionnaire for use by returning units? 

Response. The existing Post-Deployment Health Assessment (PDHA) questionnaire has always contained questions about several general symptoms that are often 

associated with traumatic brain injury (TBI) or post-concussive syndrome. Also, the 

Post-Deployment Health Re-Assessment (PDHRA) questionnaire specifically asks if 

the servicemember was exposed to a blast or explosion during their deployment. The 

DOD issued policy guidance to add two TBI-specific screening questions to all assessments, and is in the process of modifying the various electronic versions of these 

assessment tools. The Assistant Secretary of Defense for Health Affairs’ policy 

memo mandating the use of these screening questions set an implementation date 

of June 1, 2007. 

In addition, in August 2006, a clinical practice guideline for management of mild 

TBI in-theater was developed and fielded. The clinical practice guideline included 

a standard Military Acute Concussion Evaluation (MACE) tool to assess and document TBI for the medical record. This clinical practice guideline and the MACE are 

in use in the USCENTCOM Theater of Operation today.

Question 3. Several weeks ago, the Committee staff requested from DOD’s legislative office a detailed listing of non-mortal casualties of the Global War on Terror, 

by specific type of injury or condition. They were told that such information will 

take some time to obtain, as each service keeps its own detailed casualty records. 

Please expedite the collection of the data that staff has requested, and forward it 

as soon as possible. 

Response.

Injuries and Wounded in Action 

Operation

Enduring

Freedom (OEF) 

Operation 

Iraqi Freedom 

(OIF) 

Total 

Total ....................................................................................................................... 1,133 24,187 25,320

Returned to duty within 72 hours ......................................................................... 40% 56% 55%

Source: Defense Manpower Data Center, as of March 17, 2007. 

Disease and Non-Battle Injuries (DNBI) USCENTCOM (OEF/OIF) Combined 

[Overall DNBI rate—4% of forces per week] 

Injuries, all types .................................................................................................................................. 26%

Respiratory (colds, allergies, etc.) ....................................................................................................... 13%

Dermatologic (rashes, lesions, etc.) ..................................................................................................... 12%

Diarrhea and other abdominal problems ............................................................................................. 6%

Mental Health ....................................................................................................................................... 3%

Combat Stress ...................................................................................................................................... 2%

125

Disease and Non-Battle Injuries (DNBI) USCENTCOM (OEF/OIF) Combined—Continued

[Overall DNBI rate—4% of forces per week] 

All other categories combined .............................................................................................................. 38%

Source: Air Force Institute for Operational Health, as of March 10, 2007. 

Question 4. Director Duckworth testified at the Committee’s hearing about the 

need for States to be able to track returning servicemembers and new veterans. 

What is DOD doing to ensure that State Directors of Veterans Affairs have the most 

complete and up-to-date information on separating servicemembers? 

Response. The Department of Defense (DOD) is coordinating with the Department 

of Veterans Affairs (VA) and State Directors of Veterans Affairs in the ‘‘State Benefits Seamless Transition Program.’’ This initiative expands the communication links 

and coordination between VA, DOD, and the State departments of Veterans Affairs. 

This program began as a pilot project with the Florida State Department of Veterans’ Affairs in September 2006. The Defense Veterans Program Coordination Office, in DOD, has participated in the planning of this program since its inception. 

The State Benefits Seamless Transition Program involves VA staff located at ten 

DOD medical facilities around the country. The VA personnel at the military hospitals identify injured servicemembers who will transfer to VA facilities, such as the 

four VA Polytrauma Centers. After veterans sign an informed consent form, VA 

staff contact State Veterans’ Affairs offices on behalf of the veterans. The State offices, in turn, contact the veterans to inform them about available State benefits. 

This should facilitate earlier access to State benefits and enhance the States’ capabilities to provide long-term support to veterans and their families. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO ELLEN

EMBREY, DEPUTY ASSISTANT SECRETARY, HEALTH AFFAIRS/FORCE HEALTH PROTECTION AND READINESS, DEPARTMENT OF DEFENSE

TRAUMATIC BRAIN INJURY

Secretary Embrey, I’ve been having a very hard time getting real numbers from 

your department on how many servicemembers need treatment for Traumatic Brain 

Injury (TBI). 

I asked the Defense Secretary last month. He got back to me last week with a 

preliminary figure. He said that 2,121 Iraq and Afghanistan war veterans have been 

treated for TBI since October 2001. 

But—and this is important—he said that number is incomplete because it does 

NOT include cases from every Pentagon medical facility. And it does NOT include 

all mild-to-moderate cases of TBI that occur in the field. 

As I said, if we don’t have accurate numbers, we can’t set the right budgets, and 

we can’t solve the problem. 

One solution is to document any time that a servicemember is exposed to an IED 

incident. This would be noted in their medical records—so even if they don’t suffer 

an immediate injury—we can follow up with them later to see if they have TBI. 

I understand that in August 2006—your office received a report from an Armed 

Forces advisory board outlining a comprehensive plan to address the TBI problems.

Question 1. Is that system up and running today? If not, why not? 

Response. The Department of Defense (DOD) has responded to the recommendations of the Armed Forces Advisory Board. In November, we convened a panel of 

experts to address detection and treatment of mild traumatic brain injury. From 

that meeting and other efforts in the DOD, we now have clinical practice guidelines 

for in-theater management of mild traumatic brain injury as well as a tool, the Military Acute Concussion Evaluation (MACE), to help assess the severity of a possible 

traumatic brain injury. Both the clinical practice guidelines and the MACE are in 

use in the Operation Iraqi Freedom and Operation Enduring Freedom theaters of 

operation. 

In addition, the Assistant Secretary of Defense for Health Affairs has requested 

a comprehensive plan to address TBI within the DOD. I am the lead, with Vice Admiral Arthur, the Navy Surgeon General in support. We have planned meetings in 

April and May with the Service Surgeons General and personnel from the Services’ 

Manpower and Reserve Affairs offices, along with representatives from the Department of Veterans Affairs and the principal supporting DOD organizations such as 

the U.S. Army Medical Research and Materiel Command, and the Defense and Veterans Brain Injury Center. The goal is to coordinate all current Service and DOD 

126

efforts to develop a comprehensive program from the point of injury to resolution. 

This will include attention to baseline assessment, field evaluation, and treatment, 

screening post-deployment and in the periodic health assessment, education for military and family members, and research into protective, mitigating, and post-incident 

treatment and rehabilitation techniques that will maximize recovery.

Question 2. Have you run into anyone at the Pentagon who’s opposed to tracking 

IED exposure in medical records for servicemembers who are not visibly injured on 

the battlefield? 

Response. No. The primary issue regarding recording exposure to IED explosions 

in the medical record is setting boundaries for what is determined to be an IED exposure. Any person injured or symptomatic after an exposure is considered exposed. 

For those not injured and not symptomatic, we do not have a methodology to decide 

who was ‘‘exposed.’’ Such a determination might be dependent on distance from the 

explosion, whether the explosion occurred near buildings or in an open environment, 

etc.

JOINT PATIENT TRACKING APPLICATION (JPTA)

Secretary Embrey, today we don’t have a ‘‘seamless transition’’ between the Pentagon and the VA. More than two years ago, Congress required the Pentagon to improve patient tracking and management. This would ensure that servicemembers do 

not fall through the cracks and that their records move with them so they can get 

timely, complete care. It would create one record of all medical services a patient 

receives from the battlefield onward. It’s known as the Joint Patient Tracking Application. 

Question 3. Is this system up and running today? If not, why not? 

Response. The DOD has improved patient tracking and management from the 

theater to definitive care facilities. The Theater Medical Information Program 

(TMIP) is running today on the battlefield, and it includes capabilities to document 

inpatient, outpatient, and ancillary care in an electronic health record. The Joint 

Patient Tracking Application (JPTA) is also up and running today and it tracks patients as they move from our combat support hospitals into receiving facilities. The 

JPTA is only one of several information sources the DOD makes available to the 

Department of Veterans Affairs (VA) to provide information that helps VA providers 

care for our wounded servicemembers. The JPTA is a Web-based patient tracking 

application that gives DOD and VA providers an ability to track and report some 

of their patient data, but it is not an electronic health record. When DOD patients 

transfer to the VA for care, the DOD sends copies of all medical records documenting treatment provided by the referring DOD facility along with them. Other 

sources of medical records for the VA are available through the Bidirectional Health 

Information Exchange and the Federal Health Information Exchange, where we 

have transferred over 182 million messages on more than 3.8 million retired or discharged servicemembers. Through these systems, the VA has access to patients’ 

electronic health records and medical histories.

Question 4. Why didn’t your office follow through with the new policy? 

Response. The Department has made great strides to assure compliance with the 

law as documented in the Joint Medical Readiness Oversight Committee Report to 

Congress on our implementation of the National Defense Authorization Act of Fiscal 

Year 2005. The Joint Patient Tracking Application (JPTA) was developed at 

Landstuhl Regional Medical Center to streamline the process of tracking patients 

for Operations Enduring Freedom and Iraqi Freedom as they moved from the 

USCENTCOM Theater. The system was piloted and put into use to track patients 

from USCENTCOM to Landstuhl beginning in January 2004. In November 2004, 

the Assistant Secretary of Defense for Health Affairs issued a memorandum directing JPTA be implemented for patient tracking throughout the Military Health System by November 2007.

Question 5. How many stateside military hospitals do not use JPTA as required 

by law? 

Response. Currently all 21 receiving facilities in CONUS that support movement/

transition of servicemembers from theater use the Joint Patient Tracking Application (JPTA). More facilities will implement the tracking capabilities when required. 

Additionally, there are currently 17 Department of Veterans Affairs (VA) receiving 

facilities using the JPTA for tracking VA eligible patients coming from the Department of Defense.

Question 6. What reason would they have for not using it? 

Response. The Joint Patient Tracking Application (JPTA) is but one of several capabilities used to meet our force health protection imperatives, and it is not an elecVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00130 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
127

tronic health record. Most physicians are aware of JPTA as a patient tracking system to assist in transfer of essential patient information to the next level of care. 

The physicians who do use JPTA as a means to capture electronic information do 

so if no other primary or authoritative system for patient care is available, e.g., Theater Medical Information Program systems or Service-specific health care applications. Common JPTA users are patient administrators, clinicians, case managers, 

and the medical liaisons who track servicemember locations for commanders.

Question 7. Do you agree that not following the law places the wounded soldier 

at a disadvantage and creates delays in data collection while denying access to care 

and compensation? 

Response. The Department has made great strides to assure compliance with the 

law as documented in the Joint Medical Readiness Oversight Committee Report to 

Congress on our implementation of the National Defense Authorization Act of Fiscal 

Year 2005. I believe our ongoing initiatives address Congressional direction and enable us to increase responsiveness to medical situations from the point-of-injury 

through the health care continuum. The Theater Medical Information Program systems are a critical part of AHLTA that empowers us to collect information to provide the most complete electronic medical record possible. This helps to promote 

quality and efficient health care for our servicemembers throughout the continuum 

of care.

Question 8. If you truly want a seamless transition why have you not implemented the law? 

Response. The Department has made great strides to assure compliance with the 

law as documented in the Joint Medical Readiness Oversight Committee Report to 

Congress on our implementation of the National Defense Authorization Act of Fiscal 

Year 2005. DOD initiatives directly support coordinated transition and title 10 (Subtitle A, Part II, Chapter 55, Section 1074f) requirement for electronic capture of 

medical data in theater. It supports Public Law 105–85, subtitle F, section 765, 

which states that the ‘‘Secretary of Defense shall establish a system to assess the 

medical condition of members of the Armed Forces... who are deployed outside 

the United States . . . as part of a contingency operation . . . or combat operation.’’ DOD initiatives also support the Presidential Executive Order Promoting 

Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs, Presidential Special Directive, dated April 2004, and 

Presidential Directive/Endorsement, dated November 1997.

Question 9. What do you think happens when soldiers have to wait on paperwork 

the DOD is required by law to collect and produce? 

Response. The Department is committed to protect the health of our 

servicemembers as one of our highest priorities. With or without the Joint Patient 

Tracking Application (JPTA), the Department of Defense (DOD) provides information on servicemembers who are treated in Department of Veterans Affairs (VA) facilities or are on their way to the VA for care. When our patients are referred to 

the VA for care, DOD sends with them copies of all paper and electronic records 

from AHLTA and JPTA, documenting treatment provided by the referring DOD facility. Normally, a discussion of the details of the case takes place between the referring DOD physician and the receiving VA physician. 

It is important to note that JPTA does not contain all patient medical information 

and, therefore, must be included with other data system information to ensure a 

more complete transfer of patient information to the VA. 

In addition, the Bidirectional Health Information Exchange and the Federal 

Health Information Exchange support information exchange between DOD and VA, 

and the DOD has transferred over 182 million messages on more than 3.8 million 

retired or discharged servicemembers. Through these systems, the VA has access to 

patients’ electronic health records and medical histories. 

The DOD welcomes the opportunity to brief Members of the Committee on DOD’s 

strategy and current capabilities for managing in-theater medical tracking and surveillance.

AMPUTATION

Question 10. Please define the locations and dates for the ‘‘Global War on Terror 

(GWOT),’’ ‘‘Operation Iraqi Freedom (OIF),’’ ‘‘Operation Enduring Freedom (OEF),’’ 

the Iraq War, the Afghanistan War, and ‘‘Operation Noble Eagle’’ (ONE). 

Response. Global War on Terror (GWOT): September 11, 2001—current, multiple 

locations. 

Operation Iraqi Freedom (OIF): March 19, 2003—current, location: Iraq. 

128

Operation Enduring Freedom (OEF): October 7, 2001—current, location: Afghanistan. 

The Iraq War is the same as Operation Iraqi Freedom. 

The Afghanistan War is the same as Operation Enduring Freedom. 

Operation Noble Eagle: September 11, 2001—current, location: various, primarily 

homeland defense and civil support. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

ELLEN EMBREY, DEPUTY ASSISTANT SECRETARY, HEALTH AFFAIRS/FORCE HEALTH

PROTECTION AND READINESS, DEPARTMENT OF DEFENSE

Question 1. Is screening for TBI and PTSD currently mandatory at DOD? If so, 

then what efforts are being made to re-screen those servicemembers that may have 

been missed or misdiagnosed when they first returned, before screening was mandatory? 

Response. The existing Post-Deployment Health Assessment (PDHA) questionnaire always contained questions about several general symptoms that are often associated with traumatic brain injury (TBI) or post-concussive syndrome. Also, the 

Post-Deployment Health Re-Assessment (PDHRA) questionnaire specifically asks if 

the servicemember was exposed to a blast or explosion during their deployment. On 

March 8, 2007, the Assistant Secretary of Defense for Health Affairs issued policy 

guidance that requires the addition of two TBI-specific screening questions to both 

the PDHA and PDHA self-reporting tools as well as the Health Assessment Review 

Tool (a required part of each servicemember’s annual Periodic Health Assessment), 

with an effective date of June 1, 2007. All three of these assessment tools already 

include the validated four-question Primary Care Post-Traumatic Stress Disorder 

screening scale. In addition, in August 2006, a clinical practice guideline for management of mild TBI in-theater was developed and fielded. The clinical practice 

guideline included a standard Military Acute Concussion Evaluation (MACE) tool to 

assess and document TBI for the medical record. This clinical practice guideline and 

the MACE are in use in the USCENTCOM Theater of Operation today. 

There is no plan to re-screen servicemembers, except at the time of their Periodic 

Health Assessments or next deployments. Because the Periodic Health Assessment 

is an annual requirement, all servicemembers will have been screened after the passage of one year.

Question 2. What do you think of mandatory mental health screening by the DOD 

for all servicemembers that are deployed, when they return from service? Could this 

help remove the stigma of servicemembers having to ask for mental health treatment, if everyone was required to be screened for mental health issues? 

Response. There already is mandatory mental health screening accomplished during every Post-deployment Health Assessment and the Post-deployment Health Reassessment. This is accomplished through the inclusion of various mental health 

screening questions on the two self-reporting tools, the responses of which are then 

evaluated by primary care providers who interview the individuals and make clinical judgments regarding the need for additional evaluation or treatment, including 

potential referral to mental health specialists. We have no evidence that a mandatory screening by a mental health professional would be more effective than the current approach. A trial program is underway at Fort Lewis and a formal validation 

study is underway to compare mental health outcomes of the two different approaches. The results of the study are expected in 2008.

Question 3. How many OIF/OEF soldiers, who have their home of record in 

Vermont, has the DOD diagnosed with PTSD or some form of TBI? 

Response. From 2002, the number of servicemembers from Vermont with a PTSD 

diagnosis is 73. For TBI, there have been 11. 

RESPONSE TO WRITTEN QUESTION SUBMITTED BY HON. JOHNNY ISAKSON TO ELLEN

EMBREY, DEPUTY ASSISTANT SECRETARY, HEALTH AFFAIRS/FORCE HEALTH PROTEC- TION AND READINESS, DEPARTMENT OF DEFENSE

Question. Do you feel that treating active duty troops at Department of Veterans 

Affairs (VA) medical centers benefits the Department of Defense (DOD)? 

Response. The VA’s treatment of active duty personnel continues to be of great 

benefit to DOD. VA medical facilities have been providing a wide range of health 

services to active duty personnel under agreements with the military services and 

DOD for more than twenty years. These agreements range from basic medical servVerDate 0ct 09 2002 10:12 Sep 06, 2007 Jkt 000000 PO 00000 Frm 00132 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\34513.TXT SENVETS PsN: ROWENA
129

ices in geographically remote areas to specialized care for personnel with severe 

brain and spinal cord injuries.

Chairman AKAKA. Well, I thank you both very much for your testimony. 

One of the concerns has been medical hold. Mr. Pruden’s testimony discussed a veteran who was in medical hold for 3 years and 

8 months, and it is difficult to think that that has happened. 

Ms. Embrey, both Mr. Pruden and Ms. Mettie talked about 

lengthy medical holds and holdovers. It is our understanding that 

the Army maintains patients in medical hold much longer than the 

Navy and the Marines. 

What is DOD doing to ensure that medical holds are appropriate 

and are not unnecessarily long? 

Ms. EMBREY. Mr. Chairman, I believe that the Army was dedicated to giving the most time possible for injured and ill reservists 

who are put on medical holdover—those are the principal population that are retained on active duty—to give them an opportunity to heal so that they could return to duty. And medical hold 

is a status for individuals where they are allowed the time to heal 

until such time that no further or additional medical treatment 

would improve their outcome. And for some individuals, that is a 

very long time, and for others it is a very short time. 

In 2004, the Department initiated a monthly reporting process 

where we reviewed the number of gains and losses to the medical 

hold process from each of the services, and we get that monthly report and we actively engage each of the Surgeons General in the 

Departments to ask what they are doing to address the time that 

is involved while these individuals are in the medical hold status. 

So, I think, we have actively working with the services to make 

sure that it is being effectively managed. It is clear that we could 

do a better job. 

Chairman AKAKA. I am glad to note that. We know that VA’s 

prosthetics services are geared toward patients with diabetes and 

other diseases rather than combat wounds. DOD has the best prosthetics around, but at some point DOD will shed some of its prosthetic and rehabilitation functions. 

Dr. Kussman, the Department of Defense has taken primary responsibility for rehabilitating young combat amputees and for fitting them with state-of-the-art prosthetic devices. Director 

Duckworth testified about her view that the Hines VA does not 

have the same level of prosthetic care that exists at Walter Reed. 

We also know about the state-of-the-art work being done at the 

Center for the Intrepid. In time, some of the newer veterans will 

come to VA for prosthetic replacements or for other reasons. 

What steps is VA taking to ensure that VA will be prepared to 

take over the care of these amputees from war zones? 

Dr. KUSSMAN. Thank you, Mr. Chairman, for the question. I also 

obviously listened to the testimony that was given by the first 

panel. 

We have been a national leader with prosthetics for a long time, 

as you know, and there is no argument about the fact that prior 

to the war, half of our patients were over 60 years of age, and by 

that mere nature, most of the amputees. 

130

But we have adapted to do that. We have over 600 contracts with 

private contractors around the country to provide the care, 63 labs, 

125 certified prosthetists throughout the system. 

One of the challenges has been that some of the care that comes 

at Walter Reed, for instance, is truly state-of-the-art and only 

available there because it is research. And so a lot of times when 

somebody comes to us, it is done in a partnership with the handoff, 

and the patients go back to Walter Reed because the expertise and 

the technology is not available anywhere but at Walter Reed. 

With our leadership of Fred Downs, who is there on a weekly 

basis, who runs our prosthetic services, he meets with all the amputees, explains to them the services that are available. In truth, 

Walter Reed contracts a large amount of its prosthetic care, just 

like we do. And so we believe that we have the services available. 

As Major Duckworth talked about, she preferred to see a specialist down in Florida—which, by the way, we are paying for—and 

she also commented on a physical therapist not being able to come 

with her today. I do not know the specifics about that, but we sent 

the prosthetists from Hines with her down to Orlando, I believe, to 

see what was going on and to be sure that we could provide her 

the same level of care in Hines. 

So I think that we are continuing to improve. I think we have 

a robust program. For somebody to say, a prosthetist in our system 

to say they have never seen a C-leg or whatever, I can’t—I 

wouldn’t take umbrage with the comment except that we certainly 

provide a large number of C-legs and anything else that is commercially available. 

Chairman AKAKA. Thank you very much. We will have a second 

round. 

Now I would like to call on Senator Burr. 

Senator BURR. Thank you, Mr. Chairman. 

I want both of you to know how much we appreciate your service. 

You are in two vitally important areas to this country and, more 

importantly, to our military and to our veterans. 

Having said that, I hope that both of you really did listen to the 

witnesses before—and I appreciate the recap of everything we are 

doing. Ms. Embrey, your testimony is filled with a tremendous detail of collaboration between the VA and DOD in so many areas—

clinical service, education, training, research and development, patient administration, joint initiatives to improve alignment, leverage shared resources. 

We are now in the fifth year of this current conflict. At what 

point do we actually look at what is going on and implement 

changes? I get the impression—and I say this to you, Dr. Kussman, 

with the firm reality you have not been there that long from the 

standpoint of what you are doing now. How many real-life experiences do we have to listen to before we do away with the committees and the working groups and the interagency collaboration efforts and we actually implement some of this in the system? 

So my question, Ms. Embrey, is real simple. Does DOD have the 

capabilities today to electronically transfer the records to VA of 

people that we are transferring over into that system? 

Ms. EMBREY. Yes. 

Senator BURR. And do we do that? 

131

Ms. EMBREY. Yes. 

Senator BURR. Then how can somebody enter the VA system or 

how can a mother be entrusted to be the delivery point of a son’s 

medical records if we have got a system that electronically transfers that into the other side that works? 

Ms. EMBREY. That is a good question. 

Senator BURR. It is an important question. 

Ms. EMBREY. I think that both Departments have implemented 

initiatives in their electronic health systems that allow them to 

capture electronic health records, but they do not necessarily transfer along—they have laboratory information and things like that, 

but they do not give that electronically directly to the individual, 

and the individual is entitled to their medical records, copies of 

their medical records as well. 

Senator BURR. But do you not agree that the single most important thing in that transfer to the VA is to transfer all of the medical data that is pertinent to that patient? 

Ms. EMBREY. And we believe we are doing that. We have extensive meetings. We have a comprehensive management plan that we 

discuss DOD providers are the individual to be transitioned to the 

VA. There are conference calls. There are dialogues between the 

losing provider and the gaining providers. There is a plan for how 

that individual is supposed to be managed, and the records that go 

along with that are transferred electronically. 

Senator BURR. Does it concern you that out of the two witnesses 

that spoke on today, they had trouble having their medical records 

provided in the VA system? 

Ms. EMBREY. I think that is absolutely evident, and I would wonder what the root cause is. I think we have institutional structures 

in place to make that happen, but at the individual level, I believe 

some things don’t get included because somebody didn’t update 

something. 

Senator BURR. Well, let me suggest rather than to make this 

complicated, if we admit there is a problem, and if, in fact, DOD 

has the capacity today to download the medical records of any patient, why don’t we invest in little flash drives and why don’t we 

download the information to the patient, to the parent, to the 

spouse, to whoever, as well as transferring it to the VA so that at 

least in full detail we have got some redundancy? Because, clearly, 

the system of electronically transferring it isn’t either doing it successfully or in total or, in fact, we need to look at the DOD system 

and, in fact, ask ourselves, ‘‘Does it truly capture all the medical 

data that is needed by the patient or by the next facility, VA or 

private sector?’’

Let me ask you, Dr. Kussman: Are you getting the medical 

records for all the——

Dr. KUSSMAN. I believe that we are getting all the information 

that is available. As you know, the Secretary made an announcement a few weeks ago, concurrently with Dr. Winkenwerder, to 

work on a combined single inpatient electronic health record. The 

information that is presently available is lab tests and x-rays and 

other things, and both Departments have worked hard to get that 

going. But the record itself still is in paper. 

132

Senator BURR. And I have tremendous respect for the Secretary 

and Dr. Winkenwerder, whom I talk to on an occasional basis. But 

let me go back to you, Ms. Embrey. We do have the capabilities 

within DOD to produce all the medical records electronically. Is 

that correct? 

Ms. EMBREY. We do not have a common inpatient system, electronic system. Each of the services uses different applications, and 

so that is, again, going back to what Dr. Kussman just said, both 

of us need to and have agreed to collaborate on acquiring or developing a joint application for inpatient care that would provide complete seamless transaction inpatient care to both systems. 

Senator BURR. So the data exists within DOD. We just cannot 

pull it all together. Is that what you are saying? Or part of the 

DOD is still paper and part is electronic? 

Ms. EMBREY. That is correct. 

Senator BURR. OK. So that makes it impossible to capture all the 

data. 

Ms. EMBREY. Some of the military treatment facilities capture inpatient data electronically, but it differs between services. And so 

there is no common way for us to set up an exchange electronically 

with the VA. Our solution to that has been to capture as much information as has been available to capture electronically and put 

it into a central data repository, and it is that repository we use 

to provide VA with the information. 

Senator BURR. You know, an amazing thing happened before I 

came to this hearing. I need to know something real quick, and I 

went to my computer, and I Googled it. And instantaneously it 

looked at a lot of different databases around the world, and it came 

up with the information that I needed. 

We are way past needing to combine databases, if, in fact, we 

want to glean the information out of multiple databases. If we are 

trying to merge databases, whether it is DOD or whether it is 

CMS, we are going to be sitting here years from now not having 

the capabilities to extract the information we need for somebody 

who really needs the information. 

So, one, we have learned something today. If, in fact, even 

though they are different, each area electronically stores the information, we can get it today. If we cannot figure it out, call Google. 

They can tell us how to do it. 

If, in fact, we are not electronically storing it today, then we 

know the first step. We do not need the collaboration between the 

Secretary and Dr. Winkenwerder. We know exactly what we need 

to do, and we probably ought to have done that years ago. 

The transfer between the two of you, if, in fact, we fix those first 

two pieces, is easy. It did not take a working group to do it. It did 

not take any collaborative agreement. It took sitting down and figuring out what is it we need to do to have this capability. And, Mr. 

Chairman, it frustrates me. 

Again, I have great respect for both of you for everything that 

you commit to do. I pledge continually, whether it is DOD or VA, 

to be here as an ally to make sure that we have got sufficient resources. But to me, for us not to move forward as quickly as we 

can at a time that you have heard witnesses say we are not doing 

it, time is absolutely essential to the outcome of the individuals 

133

that are affected, and we are dealing with something as it relates 

to medical records that does not really need a tremendous amount 

more study. 

And as I said at the beginning, the thing that frustrates me is 

the road blocks that you are currently running into. We cannot 

even get a piece of legislation out of this body that addresses 

health IT from the standpoint of the private sector because of the 

competing—so I understand how difficult it is, but the difficulty is 

both of you are in areas that have very specific responsibilities. You 

can do this tomorrow if, in fact, you will just commit to doing it. 

And I will follow up with Secretary Nicholson, and I will follow up 

with Dr. Winkenwerder to make sure that at least this piece is emphasized with them, and my hope is that you will take to heart the 

fact that three of these witnesses told very personal stories today. 

And I believe that we could rotate those chairs and you could hear 

personal stories, like I do, as long as we are willing to sit here. And 

each of those stories are unique and they are different, and all of 

them we have made the same promise to, that this will be the best, 

that this will address their needs, and the fact that we still fall 

short—and we probably always will in some cases—just lets us 

know how important the work that we are going to do is. 

So, again, I thank both of you. I thank you, Mr. Chairman, because I know I went over my time. 

Chairman AKAKA. Thank you very much, Senator Burr. I want 

to thank you for your thoughtful questions and your remarks that 

touch on collaboration and coordination that we are seeking here. 

Let me go on to a second round and touch on the diseases that 

were mentioned by our first panel. 

A program has been developed by medical staff at Fort Sam 

Houston in conjunction with Walter Reed to provide guidance to 

military clinicians on diagnosing and treating severe infection. We 

heard Mr. Pruden and Director Duckworth talk about this issue. 

Ms. Embrey, what is DOD doing about serious illnesses and fatalities in DOD facilities resulting from antibiotic-resistant infections, some of which may have been picked up in Iraq? Has DOD 

shared this expertise with VA? 

Ms. EMBREY. The acinetobacter infection that was referred to is 

endemic in Iraq. It does embed in the wounds of injured and 

wounded soldiers. Early in the conflict, we did discover this, and 

an aggressive infection control program was developed and issued 

and is abided by in theater and at every receiving facility in the 

United States because it could spread, especially if it is resistant 

to antibiotics. 

We have issued bulletins. We have clinical working groups with 

the VA who participate with us on all of the protocols that we learn 

as we care for our wounded servicemembers, and we share that 

with the VA. VA is well aware of the acinetobacter threat, and they 

issue guidance to their community as well. 

So I believe we are doing everything we can to aggressively address infection control in our treatment facilities. 

Chairman AKAKA. Yes. Another seeming problem that has occurred has been tracking of veterans. Dr. Kussman and Ms. 

Embrey, Director Duckworth testified about the need for States to 

be able to track returning servicemembers and veterans. What is 

134

being done to ensure that State Directors have the best and most 

up-to-date information? 

Dr. Kussman? 

Dr. KUSSMAN. Mr. Chairman, before I answer the question, if I 

could go back for just a second to the acinetobacter thing. As Ms. 

Embrey said, we have had combined teams looking at the protocols 

and clinical guidance we put out to all our facilities years ago when 

this first came up. So I was really disturbed about Captain 

Pruden’s comment that an infectious disease specialist there said 

he did not know what to do about that, and I certainly will look 

into it because it is well known as a problem, and we have certainly disseminated that knowledge. 

Major Duckworth raised the issue. We had a test case in Florida. 

The Governor of Florida approached the VA and said, look, we do 

not have any exposure of when people are going to leave your facilities and come home. And we tested that for about 3 or 4 months, 

and it was a great success. We now have agreements with 19 

States. I don’t know why exactly Illinois is not part of that, but I 

will certainly contact Major Duckworth and see how we can move 

Illinois. But our hope is that all 50 or 52 jurisdictions—we take 

Puerto Rico and the District, and others—that we will have that 

in place where all the States—we have a very robust memorandum 

of agreement with the States, as well as the Reserve and National 

Guard, to be sure that we are communicating with them regularly. 

When it does not work, we need to know about it, and we need 

to fix it. 

Chairman AKAKA. Yes, Ms. Embrey, would you like to comment 

on that? 

Ms. EMBREY. I just want to say that Guard and Reserve individuals who continue to serve in the Department of Defense, we are 

very interested in maintaining visibility on their treatment and 

continuing health and wellness to continue to serve. And so I took 

and listened with interest on the State VA’s role in helping us work 

with our Reserve component members and sustaining their health. 

And so we will be doing that. We will be looking into that. 

Chairman AKAKA. Well, thank you. 

Director Duckworth made the case for increasing the window of 

automatic eligibility for VA care from 2 to 5 years. This is something that I believe is important for dealing with what we call ‘‘invisible wounds,’’ which sometimes do not manifest itself for many, 

many years. 

Secretary Nicholson has testified before this Committee that the 

current 2-year period provides ample opportunity for a veteran to 

apply for enrollment in the VA system, and that an expansion of 

this window is not necessary. 

Dr. Kussman, has VA’s position changed on this? 

Dr. KUSSMAN. I think it is under review, but if I could comment 

on it, when the 2 years pass, these patients are not refused or not 

eligible for care. As you know, they are all veterans. They all have 

got a DD214. So whether it is 3 years or 10 years later, you can 

come to the VA, be evaluated, and if it is for—certainly for TBI 

that is related to things that have happened when you are on active duty or PTSD, it will be determined to be service connected 

and the person would continue to get care. 

135

The only difference of the 2 years or greater is that for those 2 

years we automatically enroll the person as a Priority 6, a level 6, 

with no copays, regardless of what their income status or anything 

else is. But after that, they still could come and regardless of what 

their income status is, if they have a service connection, they would 

still be eligible to enroll and get compensation and pension for that 

injury. 

Chairman AKAKA. Dr. Kussman, as Mr. Pruden testified, VA 

seems to be out of practice in dealing with injuries resulting from 

war rather than from diseases or illness. What can be done about 

this so that we are giving our younger veterans the care they need 

in the most sensitive manner? 

Dr. KUSSMAN. As I mentioned, there are some learning things related to some of the new prosthetics and everything. But as far as 

the injuries related, we have been a national and international expert for the last almost 30 years on PTSD, and since 1991 when 

we developed our four traumatic brain injury centers in partnership with DOD, the Defense and Veterans Brain Injury Center, we 

have actually been leading the country in the treatment of that. 

And as you know, Major Duckworth did mention about screening 

and things and checking. For quite a while now, we have had an 

automatic screen in our electronic health record for PTSD. So 

whenever an OIF/OEF veteran comes in, regardless of what the 

symptoms are—because generally they will not come and say, ‘‘I 

have got PTSD,’’ or ‘‘I have got a mental health problem.’’ They 

come for something else. We have an automatic drop-down menu 

that requires the primary care person, who generally sees that person, to ask the questions related to PTSD. 

As you probably know, we have developed that same thing for 

TBI. We have tested it in 12 sites, and the only reason we did not 

implement it right away totally was that we have a very robust 

electronic health record, probably the world’s leader in that, and 

that we wanted to be sure that when we put this electronic dropdown menu we did not break something in the electronic health 

record. 

But as of April 1st, this electronic reminder for TBI as well as 

PTSD will be implemented around our system because, obviously, 

people don’t come and say, ‘‘I have got TBI,’’ just as they do not 

say—and I applaud your comments on invisible illness. So we need 

to be aggressive in our outreach to determine whether the individuals have it. If they are positive for the screen, then they are referred to more sophisticated neuropsychiatric evaluation. As you 

know, it is difficult. We all know what to do with significant, severe 

traumatic brain injury. Those are the ones that come back in the 

medical evacuation chain and then come to us generally through 

our polytrauma centers. But mild to moderate TBI is a challenge 

in the civilian community as well as in the DOD and VA. And we 

are trying to develop—we have worked with DOD and the civilian 

community to develop this screening mechanism that will allow us 

to try to determine mild to moderate TBI where the individual 

might not even know they have got a problem, no one has picked 

it up. And we need to track these people to be sure that whatever 

we can do to help them, we should do it. 

136

Chairman AKAKA. I would tell you that this has been a good 

hearing today, and I thank you so much for your responses. I want 

to thank all the witnesses for appearing at today’s hearing. We 

truly appreciate your taking the time to give us all a better understanding of the issues that our servicemen and women are facing. 

My hope is that today’s hearing will help promote more thoughtful and focused interaction between VA and DOD, particularly 

when they are taking care of seriously injured servicemembers. 

And, again, I want to thank you so much for being helpful to the 

cause, and we are here to try to improve the system. And we can 

do well doing it together. 

Thank you very much, and this hearing is adjourned. 

[Whereupon, at 12:12 p.m., the Committee was adjourned.] 

(137)

A P P E N D I X 

[Note: The following questions were submitted by Hon. Daniel K. Akaka to Hon. 

Daniel L. Cooper at the hearing held on March 7, 2007, which was already at press 

when the Committee received VBA’s response.]

QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO HON. DANIEL L. COOPER, 

UNDER SECRETARY FOR BENEFITS, DEPARTMENT OF VETERANS AFFAIRS

Question 1. What would be the cost of expanding the BDD program to all OIF/

OEF veterans? 

Response. Resources necessary to open additional intake sites include dedicated 

funds, staffing reallocation, support infrastructure, equipment, and telecom needs. 

DOD is required to establish a Memorandum of Understanding with VA at each site 

and the military installation must provide space. Given the significant level of investment, one of the criteria in establishing the current BDD intake sites was the 

size of the separation site. 

A BDD claim is a pre-discharge claim taken from a servicemember at one of the 

140 BDD intake sites and processed through the BDD program. There are specific 

criteria for BDD claims to include servicemembers having 60–180 days remaining 

on active duty and availability for all required medical examinations. However, any 

servicemember may file a pre-discharge claim for disability compensation. A pre-discharge claim may be accepted from a servicemember with 180 days or less remaining on active duty. All claims from servicemembers who have participated in the 

Global War on Terrorism receive priority handling of their claim.

Question 2. What is VBA’s rationale for rating headaches associated with traumatic brain injury at 10 percent while migraines are rated at 50 percent? What type 

of guidance has VBA provided to the field concerning rating headaches that stem 

from traumatic brain injuries? 

Response. The diagnostic code for rating headaches is 8100. Although it is titled 

‘‘Migraine,’’ any type of headache can be evaluated analogously under this diagnostic code. The possible evaluation levels are 0, 10, 30, and 50 percent, depending 

on the severity (the frequency and duration of attacks and whether or not they are 

prostrating). 

There is not currently a special diagnostic code or set of evaluation criteria for 

headaches from traumatic brain injury. Subjective complaints such as headache, 

dizziness, insomnia, etc., recognized as symptomatic of brain trauma are rated 

under a hyphenated diagnostic code, 8045–9304 with a maximum rating of 10 percent, according to instructions contained in diagnostic code 8045. We are currently 

in the process of reviewing and potentially revising the entire neurology section of 

the rating schedule. We plan to address all types of headaches, including headaches 

due to trauma. 

We are preparing additional training material for adjudicators on evaluating the 

residuals of traumatic brain injury. This will include a discussion of post-traumatic 

headaches.

138

[Note: The following is a summary of the VA/DOD seamless transition study conducted by the Government Accountability Office.]

DOD AND VA HEALTH CARE: CHALLENGES ENCOUNTERED BY INJURED

SERVICEMEMBERS DURING THEIR RECOVERY PROCESS*

WHAT GAO FOUND

Despite coordinated efforts, DOD and VA have had problems sharing medical 

records for servicemembers transferred from DOD to VA medical facilities. GAO reported in 2006 that two VA facilities lacked real-time access to electronic medical 

records at DOD facilities. To obtain additional medical information, facilities exchanged information by means of a time-consuming process resulting in multiple 

faxes and phone calls. 

In 2005, GAO reported that VA and DOD collaboration is important for providing 

early intervention for rehabilitation. VA has taken steps to initiate early intervention efforts, which could facilitate servicemembers’ return to duty or to a civilian occupation if the servicemembers were unable to remain in the military. However, according to DOD, VA’s outreach process may overlap with DOD’s process for evaluating servicemembers for a possible return to duty. DOD was also concerned that 

VA’s efforts may conflict with the military’s retention goals. In this regard, DOD 

and VA face both a challenge and an opportunity to collaborate to provide better 

outcomes for seriously injured servicemembers. 

DOD screens servicemembers for PTSD but, as GAO reported in 2006, it cannot 

ensure that further mental health evaluations occur. DOD health care providers review questionnaires, interview servicemembers, and use clinical judgment in determining the need for further mental health evaluations. However, GAO found that 

22 percent of the OEF/OIF servicemembers in GAO’s review who may have been 

at risk for developing PTSD were referred by DOD health care providers for further 

evaluations. According to DOD officials, not all of the servicemembers at risk will 

need referrals. However, at the time of GAO’s review DOD had not identified the 

factors its health care providers used to determine which OEF/OIF servicemembers 

needed referrals. Although OEF/OIF servicemembers may obtain mental health 

evaluations or treatment for PTSD through VA, VA may face a challenge in meeting 

the demand for PTSD services. VA officials estimated that follow-up appointments 

for veterans receiving care for PTSD may be delayed up to 90 days. 

GAO’s 2006 testimony pointed out problems related to military pay have resulted 

in debt and other hardships for hundreds of sick and injured servicemembers. Some 

servicemembers were pursued for repayment of military debts through no fault of 

their own. As a result, servicemembers have been reported to credit bureaus and 

private collections agencies, been prevented from getting loans, gone months without paychecks, and sent into financial crisis. In a 2005 testimony GAO reported that 

poorly defined requirements and processes for extending the active duty of injured 

and ill reserve component servicemembers have caused them to be inappropriately 

dropped from active duty, leading to significant gaps in pay and health insurance 

for some servicemembers and their families. 

[Note: The following is a summary of the VA/DOD seamless transition study conducted by the VA Office of Inspector General.]

HEALTH STATUS OF AND SERVICES FOR OEF/OIF VETERANS

AFTER TRAUMATIC BRAIN INJURY REHABILITATION *

EXECUTIVE SUMMARY

In response to the influx of servicemembers returning from recent conflicts in Afghanistan and Iraq, the Office of Inspector General, Office of Healthcare Inspections 

undertook an assessment of selected aspects of the health care and other services 

provided for these patients by the Department of Veterans Affairs. This review addresses the care of individuals with traumatic brain injury (TBI), focusing on their 

status approximately 1 year following inpatient rehabilitation. We interviewed a 

group of these patients to directly ascertain their overall well-being, functional status, and social integration, and to measure their perceptions of VA health care and 

services. In order to gauge the effectiveness of VA rehabilitation efforts, we also 

compared outcomes with those of TBI patients in the largest national civilian database. Finally, we visited Veterans Health Administration (VHA) facilities, met with 

139

TBI program leaders, and surveyed those responsible for coordination of care for 

TBI patients. 

Our inspection found that many of the 52 patients we interviewed continued to 

suffer some degree of cognitive or behavioral impairment approximately 16 months 

after injury. These patients had very similar outcomes when compared with a 

matched group of TBI patients from the private sector. 

VHA has enhanced case management for TBI patients, but long-term case management needs further improvement. In addition, improvement is needed in coordination of care, so that patients are able to make a smoother transition between Department of Defense (DOD) and VA care. A recent VHA Directive, published after 

data collection for this report, defines roles for staff at all VHA facilities to ensure 

a seamless transition of care for servicemembers and veterans from DOD to the VA 

health care system. 

We found that families often provide heroic support for injured servicemembers, 

but we also found that they frequently do so with limited assistance. To adequately 

meet the needs of its TBI patients, VHA needs to provide additional help for the 

family members and other caregivers so vital to the well-being of these patients in 

the long-term. 

We recommended that the Under Secretary for Health should: (a) improve case 

management for TBI patients to ensure lifelong coordination of care, (b) work with 

DOD to establish collaborative policies and procedures to ensure that TBI patients 

receive necessary continuing care regardless of their active duty status and that appropriate medical records are transmitted, (c) develop new initiatives to support 

families caring for TBI patients, and (d) work with DOD to ensure that rehabilitation for TBI patients is initiated when clinically indicated.

Æ