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Road Map for Future Amputee Care Research

Chapter 28

ROAD MAP FOR FUTURE AMPUTEE 

CARE RESEARCH

JENNIFER COLLINGER, BSE*; GARRETT G. GRINDLE, MS†; CHRISTINE HEINER, BA‡; BRADLEY IMPINK, BSE§; 

AMOL KARMARKAR, MS¥; MICHELLE SPORNER, MS, CRC¶; PAUL F. PASQUINA, MD**; and RORY A. COOPER, 

PhD††

INTRODUCTION

PROGRAMMATIC GOALS AND OPPORTUNITIES

CONSENSUS PROCESS

RESEARCH PRIORITIES

Outcomes Research and Cost-Effectiveness Studies

Rehabilitation and Therapeutic Interventions

Advancement of Surgical Interventions

Advancement of Medical Interventions

Support Programs

Technology

Amputee Care Center of Excellence

SUMMARY

*Bioengineer, Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Human Engineering Research Laboratories, 7180 Highland 

Drive, Building 4, Floor 2, 151R1-H, Pittsburgh, Pennsylvania 15206; formerly, Graduate Student Fellow, Bioengineering, University of Pittsburgh, 

Pittsburgh, Pennsylvania

†Research Associate, Department of Rehabilitation Science and Technology, University of Pittsburgh, Human Engineering and Research Labs, 7180 

Highland Drive, Building 4, Second Floor East Wing 151R7-H, Pittsburgh, Pennsylvania 15206

‡Communications Specialist, Human Engineering Research Laboratories, VA Pittsburgh Healthcare System/University of Pittsburgh, 7180 Highland 

Drive, 151RI-HD, Building 4, 2nd Floor East, Pittsburgh, Pennsylvania 15206

§

Predoctoral Fellow, Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, 7180 Highland Drive, 151R1-H, Building 4, 2nd 

Floor East, Pittsburgh, Pennsylvania 15206; formerly, Graduate Student Researcher, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania

¥

Research Associate, Human Engineering Research Laboratories, VA Pittsburgh Healthcare System/University of Pittsburgh, 7180 Highland Drive, 

151RI-H, Building 4, 2nd Floor East, Pittsburgh, Pennsylvania 15206; formerly, Research Assistant, Department of Rehabilitation Science, State 

University of New York at Buffalo, Buffalo, New York

¶

Research Assistant, Human Engineering Research Laboratories, VA Pittsburgh Healthcare System/University of Pittsburgh, 7180 Highland Drive, 

Building 4, 2nd Floor, 151R1-H, Pittsburgh, Pennsylvania 15206

**Colonel, Medical Corps, US Army; Chair, Integrated Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center and National 

Naval Medical Center, Section 3J, 6900 Georgia Avenue, NW, Washington, DC 20307

††Senior Career Scientist, US Department of Veterans Affairs, and Distinguished Professor, Department of Rehabilitation Science and Technology, 

University of Pittsburgh, 5044 Forbes Tower, Pittsburgh, Pennsylvania 15260
732

Care of the Combat Amputee

INTRODUCTION

recovery,” which are two independent goals. Physical 

recovery is important, but functional recovery involves 

much broader challenges, including behavioral health, 

socioeconomic and educational status, family and 

community support systems, vocational interests, and 

return to active participation in the community. It is the 

responsibility of the military and Department of Veterans Affairs (VA) medical and rehabilitation teams to 

assist all injured service members in establishing both 

short- and long-term goals with the overall objective 

of helping them reach their full potential. 

The last time the US military healthcare system handled a large number of war injuries was in the 1970s, 

following combat actions in Vietnam. Although much 

of the knowledge gained and programmatic changes 

of this era were not thoroughly documented, significant advances in combat casualty care were achieved, 

particularly in medical and surgical resuscitation and 

medical evacuation techniques. During the intervening time, however, the focus of research within the 

Department of Defense (DoD) and VA shifted toward 

chronic care, secondary injury prevention, noncombat 

conditions, and health services research. All of these 

areas remain important; however, current conflicts in 

the global war on terror have brought about the need 

to refocus those research priorities. This chapter is an 

attempt to report on priorities that have been identified by experts in the field who have been providing 

ongoing combat casualty amputee care for the past 

6 years. Although this chapter is not meant to be all 

encompassing, some of the broader policy issues are indirectly addressed, such as balancing the VA and DoD 

portfolios in bench science, clinical studies, engineering science, and heath services research. Furthermore, 

the contributors to this textbook believe strongly that 

injured service members (and their families) must 

play a pivotal role in research and developing research 

priorities. Therefore, their participation was solicited 

whenever possible in formulating the recommendations within this chapter.

The global war on terror, like many previous conflicts, has brought about tremendous advances in 

amputee care, as well as revealing areas in need of 

further investigation. Although much can be learned 

from the care of individuals with major limb amputation among the civilian population, the military 

population is unique in many ways. Current injury 

patterns among wounded military service members 

involve complex amputations with often multiple 

complex comorbid injuries, such as burns, paralysis, 

traumatic brain injury (TBI), hearing and vision loss, 

mental health disorders such as posttraumatic stress 

disorder, and a multitude of soft tissue wounds and 

bony fractures. Combat wounds are often infected, 

requiring multiple debridements and extensive 

reconstruction. Fortunately, most members of the 

armed forces are young and highly active, often considered to be “tactical athletes.” With the advances 

in acute combat casualty care, protective gear, and 

rehabilitation, in conjunction high premorbid levels 

of fitness, injured service members are often able to 

recover from wounds that were heretofore thought to 

be fatal, and, impressively, many return to very high 

levels of activities. 

Many young service members have not yet established their long-term professional goals; for those who 

sustain a severe combat injury, this situation presents a 

significant challenge for recovery. Although some service members seek a professional military career, many 

individuals join the military as a means of exploring 

possibilities for future careers. Because much of the 

success for recovery and rehabilitation is accomplished 

through goal-driven behavior, it is helpful to have a 

clear idea of the goals and aspirations of each injured 

service member. Great success can be achieved by harnessing the military spirit of mission accomplishment, 

which may be translated to returning to active duty or 

regaining maximal functional recovery. 

It is not uncommon, however, for young service 

members to equate “physical recovery” to “functional 

PROGRAMMATIC GOALS AND OPPORTUNITIES

The military healthcare system has the obligation to 

provide expert, world-class combat healthcare delivery and rehabilitation. An active research program is 

essential to this mission. Unfortunately, most military 

clinical departments lack the research infrastructure 

typically available at major academic medical facilities. Despite this situation, many military healthcare 

providers and scientists are extremely productive 

researchers. Success is often achieved through collaboration within and among institutions, including 

military, VA, and civilian organizations. Conducting research within the military offers many unique 

opportunities, including its relative insulation from 

commercial and financial bias. Therefore, the military 

is well positioned to create and support programs 

seeking new knowledge and translating knowledge 

into practice to improve the lives of service members 

and their families.
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Road Map for Future Amputee Care Research

Numerous mechanisms are available for supporting research to ultimately improve the medical and 

rehabilitative care of injured service members and to 

facilitate successful community reintegration, including return to duty. This chapter does not attempt to 

provide a comprehensive listing of all of the funding 

opportunities available, only noting that both private 

and public organizations provide research support. 

Each mechanism has its advantages. Private agencies 

tend to award smaller grants, but are able to assume 

more risk of failure and rely less on pilot data. Federal 

research funding agencies are typically more capable 

of making larger long-term investments concerning 

broader public health issues. The DoD is somewhat 

unique in that it can provide needed funding to address unique military problems that often benefit 

civilian populations. A key to making the greatest 

positive impact in research is to establish collaborative 

partnerships. Often a team approach works best; clinicians who have patient care responsibilities frequently 

struggle to maintain a productive research program. 

Conversely, basic or engineering scientists benefit 

from working closely with clinicians to gain a greater 

understanding of clinical and medical questions. 

The challenges of current research include the many 

unknowns of treating injured or ill service members, in 

addition to limited research funding across the board, 

significant regulatory barriers and delays, restricted 

contact with study participants, and the severely 

limiting requirements of institutional review boards. 

One strong recommendation by this workgroup is for 

military treatment facilities and the Veterans Health 

Administration to establish cross-organizational centralized institutional review boards to allow submission to one board for multisite studies.

Both the VA and DoD need to invest greater resources over the long term in building research capacity. The area of greatest need is increasing the number 

of active and effective clinician-scientists, which is 

especially challenging to the military given frequent 

deployments, changes in duty assignments, and lack of 

a formal mechanism for protected long-term research 

time. Also, too few funds are available for education 

and research career development awards. Members of 

the Medical Corps, Nurse Corps, and Medical Service 

Corps have limited time and funding to participate 

in research training. The military and VA must grow 

a cadre of clinician and nonclinician scientists to address the problems facing this generation of veterans, 

as well as future generations. It is critical for students, 

residents, and fellows participating in military graduate medical educational programs and for junior attending physicians to build research relationships 

and experience. The offices of the Army, Navy, and 

Air Force surgeon generals should strongly consider 

creating career scientist awards for senior uniformed 

officers who are successful clinician-scientists, similar 

to the programs within other federal agencies. 

CONSENSUS PROCESS

To ensure optimal treatment and rehabilitation of 

combat-related amputees, the medical and rehabilitation community has been in need of a “road map” to 

provide focus for efforts and priorities. With this mission in mind, Colonel Paul F Pasquina, MD, and Dr 

Rory A Cooper organized a 3-day symposium titled 

“Rehabilitation of the Combat Amputee—Consensus 

Conference and Creating a Roadmap for the Future,” 

held at the Center for the Intrepid/Brooke Army Medical Center in Fort Sam Houston, Texas, on September 

17–19, 2007. The event brought together VA, civilian, 

and military experts in amputee care, rehabilitation, 

and community reintegration to help establish consensus on standard-of-care issues, as well as to help 

identify areas most in need of further clinical, technical, 

translational, and developmental research. A total of 18 

experts presented on current practice and knowledge 

during the symposium, including engineers, physiatrists, therapists, surgeons, historians, psychiatrists, 

neuropsychologists, neurologists, prosthetists, audiologists, and experts in pain management and veterans 

benefits. The speakers came from the VA, DoD, and 

universities, as well as private companies and institutions. The 100 to 120 symposium attendees formed five 

small discussion groups:

	 • 	 programs and systems practices,

	 • 	 surgical management and planning,

	 • 	 special medical considerations,

	 • 	 physical rehabilitation and therapeutic interventions, and

	 • 	 prosthetic devices and assistive technologies.

Prior to the conference, attendees were asked to 

prepare manuscripts within their area of expertise 

that would be the basis for the chapters within this 

textbook. Each group was challenged to come to a 

consensus on critical items and management plans as 

outlined in each chapter. Furthermore, each group was 

tasked with forming a consensus for the most critical 

areas of investigation and research needed within their 

discipline to better meet the challenges of combatrelated injuries, particularly those resulting in limb 

loss. The results are presented in the following section.
734

Care of the Combat Amputee

RESEARCH PRIORITIES

paths to success. Furthermore, initial qualitative studies should be conducted to identify issues surrounding 

acceptance of an injured service member back into his 

or her unit and the perceptions of those in the recipient 

unit. These studies will help future generations determine who is more likely to return to successful active 

duty and what interventions could be made to help 

support greater success.

The consensus panel concluded that effective outcome research could not be conducted without a more 

uniformly standard way of providing case management to injured service members and their families. 

It was agreed that military and VA institutions have 

been inconsistent in counseling individuals. These 

inconsistencies have been compounded by the rapidly 

changing benefits system, which has made it increasingly more difficult for accurate and complete information to reach those who need it. More consistent case 

management should include appropriate structural 

organization within the DoD and VA, as well as standardization of the competencies required by each case 

manager. Educational materials also must be regularly 

updated and readily available for patients, families, 

and providers. Research studies should be conducted 

on evaluating the effectiveness of case management 

programs, and model programs should be replicated 

across the country.

As with other outcomes of interest, tools to measure 

the effectiveness of interventions, particularly in multimodal pain management, role of regional anesthesia, 

and integrated rehabilitation strategies for polytrauma 

care still need to be developed. Lastly, better outcome 

measures to assess the effectiveness of prosthetic components and technology, particularly as they relate to 

individuals with upper limb amputation, are needed 

to help physicians, therapists, and prosthetists better determine the device best suited for a particular 

individual.

Rehabilitation and Therapeutic Interventions

Very few longitudinal studies have been conducted on individuals with amputation, which has 

left significant gaps of knowledge for professionals 

attempting to determine how factors (such as demographics, health, and environmental factors) influence 

the use of a prosthesis and other mobility devices 

after amputation. This knowledge gap is especially 

wide for the cohort of active young service members 

with traumatic amputations, since most studies have 

focused on older, civilian patients with amputation 

related to vascular disease or diabetes. Significant 

Outcomes Research and Cost-Effectiveness Studies

Consensus opinion highlighted the importance of 

outcome-related research. Specific outcomes of interest 

included programmatic issues, vocational rehabilitation, return-to-duty demographics, and the effects of 

therapeutic interventions. Participants identified the 

lack of well-designed longitudinal and retrospective 

epidemiological studies analyzing the incidence rates 

of amputation in combat casualties and the impact 

that etiologic and demographic data have on shortand long-term outcomes. In particular, factors such 

as level of amputation and extent of comorbidities 

should be examined to establish their impact on functional performance, quality of life, depression, return 

to duty/work/community, and healthcare costs, as 

well as acute and chronic pain. To effectively quantify 

the success of the treatment programs available to 

service members, better tools, especially for functional 

measures, must be designed. Additionally, the extent 

to which other comorbidities, especially cognitive or 

behavioral problems, have on outcome measures must 

be fully investigated. Because existing literature on best 

care practices is scarce, a process for making clinical 

decisions based on evidence-based studies must be 

better established.

The group also agreed that more research on vocational rehabilitation (VR) is needed. Although all 

healthcare professionals recognize the importance of 

recovery to the point of meaningful vocation, the best 

approach to VR intervention, as well as when during 

the recovery phase VR should begin, remain unclear. 

Additionally, tools to measure the effectiveness of VR 

interventions, as well as validated tools to evaluate 

community reintegration, should be developed. These 

tools will provide a framework for researchers to assess 

predictors of successful VR interventions. VR-related 

research should also investigate the effectiveness of 

rehabilitation technologies and explore barriers that 

may exist to return to military duty. 

When an injured service member returns to active duty, it is important to establish a longitudinal 

registry to track information such as how long he or 

she remains on active duty and both the successes 

and difficulties that individuals experience. Data elements should include promotions, military awards, 

performance in military schooling, and attainment 

of advanced degrees, as well as possible subsequent 

related physical or psychological health problems. 

Keeping such a longitudinal registry of these individuals, including those who change military occupations, 

will allow further analysis of effective and ineffective 
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Road Map for Future Amputee Care Research

challenges also exist in examining the effectiveness 

of continually advancing technology. It is generally 

believed that advances in technology, particularly in 

prosthetic devices and wheelchairs, improve function, 

preserve the musculoskeletal system, and decrease 

energy expenditure over time, but it has been difficult 

to prove this scientifically. Recent studies advocate 

the use of prosthetic prescription models that take 

into consideration factors such as age, demographic 

characteristics, health, and behavioral-related factors 

in predicting successful prosthetic rehabilitation. 

These studies, however, do not take into consideration 

the functional performance levels often observed in 

young, otherwise healthy injured military service 

members. Nor do these studies take into account the 

importance attributed to a prosthetic device by the 

user, which undoubtedly has an impact on use and 

overall patient satisfaction.1,2 Therefore, dedicated 

research is needed to inform innovative therapeutic 

approaches and advanced rehabilitation techniques 

for higher functioning younger amputees with the 

goal of returning to sports and military duty.

Consensus panel members identified the need to 

examine the impact of long-term prosthetic use in 

this unique patient population. To date, data has been 

lacking on overuse and repeated injuries related to 

prosthetic use. Unlike research on wheelchair-related 

technology, which has generated literature that strongly supports clear prescription guidelines for manual 

wheelchairs that preserve upper limb functioning,3

similar data is lacking for prosthetic prescriptions. It is 

essential to look for findings of cumulative traumatic 

and overuse changes, both during the first year of 

prosthesis use as well as over subsequent years of longterm prosthetic use. This information will contribute 

to the development of early therapeutic and technological interventions to prevent excessive stresses on 

joints and the occurrence of chronic painful conditions 

such as low back and limb pain, which may lead to 

significant functional impairment and disability. It is 

equally important to objectively assess any occurrence 

of pathological changes on the nonamputated side 

from overuse, abnormal posture, or gait deviations 

to develop intervention protocol for preventing these 

secondary injuries. 

Rehabilitation has traditionally been considered to 

involve a patient and his or her provider; however, 

interdisciplinary teamwork is becoming increasingly 

important for success, as has been demonstrated in the 

stroke literature.4 Also, anecdotal evidence has been 

observed by the consensus group that family members, 

friends, and peer supporters have both positive and 

negative effects on rehabilitation outcomes. At each 

DoD amputee care program, family members are able 

to obtain local lodging, which allows them to participate directly in their loved one’s care. In addition, a 

formal peer visitation program is well established at 

each DoD site, and all staff support and contribute to 

the therapeutic milieu. Further investigation, however, is needed to better understand the dynamics of 

recovery and how to best incorporate all parties into 

improving outcomes. Qualitative analyses, through 

interviews and focus groups with family members, 

could help in understanding their perspectives and 

potentially optimize their role in the recovery process 

of each service member. 

Rehabilitation research on upper limb amputation 

was noted to be significantly lacking, particularly as 

compared to that on lower limb amputation. This is 

in part due to the complex nature of the rehabilitation 

process after upper limb amputation and the higher 

rejection and abandonment rate of upper limb prostheses. Research determining probabilities of upper 

limb prosthesis rejection, based on level of amputation 

and amputation of dominant versus nondominant 

upper limb, could be crucial for determining the 

course of the rehabilitation process and the prescription of particular prosthetic devices. The use of novel 

techniques such as metronome-based intervention 

was specifically mentioned as a potential means of 

improving body symmetry and postural control to 

aid in upper limb prosthetic rehabilitation. A study 

on differences of upper limb prosthesis acceptance 

based on hand dominance might drive protocols that 

address the inherent differences in a patient’s acceptance and accommodation to use of a prosthetic device. 

With increasing use of functional magnetic resonance 

imaging and positron emission tomography, such 

a study could also include cortical scans to explore 

any difference in brain hemispheric activity based on 

hand dominance and prosthetic use. Other areas of 

potential research that may provide further insight 

on user preferences include investigating the effect of 

training variables, the patient’s perceived benefit of 

the device, the quality and durability of components, 

and level of amputation. In summary, many research 

avenues should be explored within this new generation of upper limb amputees. Therapists working with 

this patient population should be diligent in seeking 

new knowledge to improve efficiency and minimize 

variability within care delivery methods. 

As technology progresses, rehabilitation techniques 

and the sophistication of outcomes measurement tools 

must advance as well. All panel members agreed 

that systems such as motion analysis, kinematic and 

kinetic assessment techniques, and virtual-reality–

based assessment and treatment modalities all warrant 

further development and clinical research funding. 
736

Care of the Combat Amputee

Furthermore, systems that are able to acquire more 

real-time data on prosthetic usage, function, and effects on quality of life will be much more useful than 

the traditional patient recall methodology. 

Advancement of Surgical Interventions

The consensus panel identified research priorities 

related to both acute and long-term medical and surgical care. Among those considered most important 

in the acute phase of care are optimizing surgical 

approaches and wound management strategies. 

Improving surgical techniques during the initial 

combat wound care as well as during the definitive 

amputation will have an impact on an individual’s 

short-term recovery and likely positively influence 

his or her quality of life. Specific research emphasis 

should focus on techniques to improve peripheral 

nerve management associated with limb amputation 

to maximize sensory and motor function of the residual 

limb. Research is needed to evaluate the optimal way 

to manage sectioned nerves—for example, targeted 

reinnervation (see Chapter 27, The Future of Artificial 

Limbs)—which may reduce acute and chronic pain as 

well as improve future prosthetic control strategies. 

Also, data must also be collected to establish infection 

rates and investigate new methods of infection prevention and treatment. Furthermore, research is required 

to develop novel methods for wound management at 

all echelons of care. This should include investigation 

of various biomarkers and wound matrix analyses to 

better predict wound healing and optimize timing of 

surgical debridement, closure, or use of any bio-healing 

products. 

Panel members reported a particular concern with 

the formation of prevalence of heterotopic ossification 

seen in war extremity trauma. Heterotopic ossification 

is the abnormal formation of bone that can limit joint 

range of motion and cause pain. A better basic science 

understanding of what turns on and off bone matrix 

formation is needed. Additionally, surgeons strive to 

optimize limb length, limb shape, and muscle/soft tissue balance. While a longer residual limb may provide 

increased function when an individual is not using a 

prosthesis, current prosthetics technology often requires extra space to accommodate more sophisticated 

components, and therefore in some circumstances 

a shorter residual limb may be desirable. Additionally, the residual limb shape needs to conform to the 

intended prosthetic device, adding another confounding factor. Likewise optimizing muscle length during 

attachment with either a myodesis or myoplasty may 

have a significant effect on residual limb muscle balance, strength, and function. 

Considering residual limb bone management, 

participants did not reach a consensus about when 

bone-bridging techniques should be used in transtibial 

amputations. Some patients present with a divergent 

fibula because of injury to the syndesmosis or the 

proximal tibia–fibula joint, which may result in pain 

and/or hypermobility of the residual limb. Many 

bone-bridging techniques exist, but none have been 

proven superior because limited research data on 

functional outcomes following surgery is available. 

Additionally, the effect of timing (acute or revision) for 

bone-bridging procedures must be explored. 

Panel members recommended that further research 

be conducted to explore the potential for and safety of 

osseointegration. Osseointegration is the direct skeletal attachment of a prosthesis to the residual limb, by 

implanting a metallic pin/buttress to the distal bone 

and allowing it to extend through the skin to connect 

with a prosthetic device. Current challenges include 

proper design, materials, surgical intervention techniques, and postoperative rehabilitation techniques. 

Emphasis should be placed on discovering methods 

to achieve direct skin growth/adherence to the metal 

implant to avoid infection, because combat wounds 

have an increased susceptibility to infection. Panel 

members agreed that if this technology becomes available it will likely revolutionize prosthetic fitting and 

require surgeons to change their current approach to 

residual limb-shaping procedures. 

 Advances in regenerative medicine may also 

have a significant impact on the medical and surgical 

management of amputees. Further investigation of 

composite tissue allografts and limb regeneration is 

necessary to explore the limits of this science and its 

application for injured service members. Additionally, 

further advances in peripheral vessel and nerve regeneration, grafting, and transplants may allow severely 

mangled limbs to heal to a point where amputation is 

not indicated. 

Advancement of Medical Interventions

 Polytrauma care for the combat amputee requires a 

complex medical treatment plan. Panel members noted 

that little is currently known about the neuroendocrine 

aspects of polytrauma care. Although the majority of 

combat-wounded soldiers are male, it is important 

to understand the effect of gender in healing and 

recovery. Specifically, research should be conducted 

to investigate the role that hormones, particularly 

testosterone, play in behavioral tendencies as well as 

healing following polytraumatic injuries. 

Pain management was also cited as an important 

aspect of management needing further investigation. 
737

Road Map for Future Amputee Care Research

Opioid use, in particular, which is often prescribed 

for pain management related to polytrauma, remains 

controversial because little is known about its shortand long-term effects on combat-wounded soldiers. 

Issues such as opioid-induced hyperalgesia have 

been reported, but little is understood about the 

pathophysiology of this phenomenon. Therefore, the 

safety and effectiveness of prescribing opioids for 

pain management needs to be assessed. Likewise, 

further investigation is needed to evaluate the effectiveness of other pain management techniques, 

including pharmacological and nonpharmacological 

treatments such as mirror treatment, acupuncture, 

therapeutic modalities, biofeedback, and electrical 

stimulation.

Residual and phantom limb pain often significantly 

impact the lives of combat-wounded amputees; however, little is known about what causes these phenomena or how to best treat them. Research efforts should 

focus on improving knowledge of the etiology and 

pathophysiology of residual and phantom limb pain. 

Further investigation should evaluate genetic predisposition to such pain syndromes as well as advanced 

neuroimaging and biological measures to achieve a 

more objective measurement of pain. Interventions 

such as regional anesthesia have been cited by the 

symposium’s expert panel as extremely helpful in 

managing extremity pain syndromes and minimizing 

opioid use; however, further documentation is needed 

to translate these findings into everyday practice.5

New diagnostic tests as well as novel treatments must 

be developed for these complex pain syndromes, and 

better data is needed to capture the incidence and 

etiologies of residual limb and phantom pain in this 

patient population. 

Further needs identified include improved medical 

prevention and treatment of conditions such as venous 

thrombosis, pulmonary embolism, heterotopic bone 

formation, osteoporosis, and osteoarthritis. Additionally, treatment and prevention of other causes of longterm morbidity and mortality associated with major 

limb loss such as cardiovascular disease, hyperlipidemia, hypertension, peripheral vascular disease, and 

diabetes should be fully investigated. Such advances 

would benefit not only the combat-wounded amputee, 

but the general population as well. An additional area 

of research that has not yet been examined is the effect 

that comorbid TBI has on the rehabilitation and recovery of an individual with limb loss. Panel members 

reported up to a 60% incidence of brain injury in the 

combat amputee population. Although the majority of 

these cases are classified as “mild” TBI, it is likely that 

sequencing and training regiments could be optimized 

for these patients.

Support Programs

Multiple support groups and programs have been 

developed for injured service members. Programs such 

as Navy Safe Harbor, Marine Corps Wounded Warrior 

Regiment, Military Severely Injured Center, and Army 

Wounded Warrior (AW2) program have all been designed to assist wounded service members and their 

families. It remains unclear, however, how effective 

each of these programs are or how that effectiveness 

is being measured. Moreover, it is possible that multiple programs, while well-intended, may be adding 

to the confusion of patients and their families. Similar 

opportunities exist for recreational and sporting participation; however, it is unclear how to maximize the 

impact of these programs. Scientific methodology must 

be applied to these interventions to better understand 

their effect and document outcomes. 

Technology

Advances in prosthetic design have led to greater 

emphasis on technology, which in turn has produced 

research priorities in this area. One of the most important of these questions is validation of these advanced 

designs. Research is needed to determine the best 

methods for validation. Once validation methods have 

been established, the efficacy of technologies can be 

objectively considered.

Future prosthetic research should include developing performance standards for prosthetic components 

and devices. The combat amputee population tends 

to be more active and is likely to participate in rigorous recreational activities, which must be considered 

when establishing these performance criteria. Another 

important consideration is that some members of this 

population will return to active duty. Prosthetic devices, therefore, must be able to perform at extremely 

high levels of function, reliability, and durability to 

prevent failure in the field or tactical environment.

 Despite the great advances in prosthetic technology, more research and development is needed. Specific areas of interest include powered prosthetics, 

advanced robotics for manipulation, incorporation of 

artificial intelligence, and improved prosthetic–body 

interfaces. In addition to advancing the technology 

of prosthetic devices themselves, research should 

also focus on developing devices that may enhance 

the rehabilitation process. Specifically, systems that 

incorporate real-world simulations or virtual reality have great potential in this area. Novel systems 

such as the Computer-Assisted Rehabilitation Environment (CAREN [MOTEK Medical, Amsterdam, 

Netherlands]) should be further explored as a means 
738

Care of the Combat Amputee

of providing multisystem rehabilitation training in a 

highly user-engaging fashion. 

Efforts should also be made to incorporate advanced rapid prototyping technologies to the assistive 

technology (AT) prescription process. Technologies 

such as stereolithography, selective laser sintering, 

and three-dimensional scanners may allow for costeffective manufacturing of small numbers of custom 

components. The ability to readily procure custom 

components would enable individualized solutions 

that may increase the usefulness of commercially 

available AT or fill a gap where no commercial product exists.

AT advancement may also help prevent secondary 

injuries. Studies examining the use of prosthetics in 

combination with wheeled mobility as a means of preserving intact joints, or the development of techniques 

to mitigate overuse of the upper extremities over time, 

may have a significant long-term impact on quality of 

life. Initial studies should examine current AT usage 

within the combat amputee population. This line of 

research would provide the answer to key questions, 

such as what types of AT are in use, how often these 

technologies are used, and whether AT is being used 

to it fullest potential. 

Lastly, longitudinal studies should be conducted 

to assess how a user’s need for technology changes 

over time. In all likelihood the types of AT used will 

change as this population faces decreasing function 

associated with aging. Research should be conducted 

to identify strategies for transitioning between types 

of AT. Studies of this nature could facilitate predictions 

for technology needs of this population, as well as 

provide insight into device adaption as users age. Additionally, methods of increasing access to AT must be 

established; programs should be established to increase 

awareness of available AT among both the end users 

and the clinicians who prescribe them.

Amputee Care Center of Excellence

A central lesson learned through the care of military 

service members during the global war on terror is the 

need to provide a coordinated system of care. At the 

core of this system should be an amputee “center of 

excellence” (ACoE), with a critical mass of healthcare 

professionals, research scientists, benefits coordinators, and strong leadership, including collaboration 

between VA and DoD and strong ties to academic 

institutions. Adequate resources are necessary to 

ensure the ACoE’s success during war and in peace. 

These resources should include, but not be limited to, 

state-of-the-science research equipment and facilities, 

state-of-the-art clinical tools, diverse and talented staff, 

inclusion of activities for families, and a supportive 

environment for patients. 

It is crucial that ACoE expertise be maintained as 

deployment and high operational tempos diminish. 

Although much has changed since earlier military 

conflicts, the experiences gained during World War II 

and Vietnam provided important insights. The postwar 

decision to disband and decentralize services should 

not be repeated. An ACoE would allow patients to 

continue being treated in sufficiently large groups to 

maintain interaction, provide a large enough cohort 

to advance research, and preserve an environment for 

clinical excellence. Ultimately, an ACoE will improve 

military and VA medicine while helping veterans with 

major limb amputations, who deserve the best that 

medicine and science have to offer.

SUMMARY

Armed forces’ recruiting advertisements and slogans are designed to attract individuals of courage, 

commitment, and patriotism. Nowhere are these characteristics more evident than in the military amputee 

population. Hundreds of stories have been presented 

throughout the media across the globe illustrating the 

dedication and courage of injured American soldiers. 

In addition to the multiple stories in the press praising the work of the military medical community, the 

US DoD and VA are in unique positions to lead other 

countries and universities in the research and care of 

traumatic amputees. The ability of military and VA 

healthcare providers to pursue cutting-edge research 

in amputee care will foster a climate of enhanced job 

satisfaction across multiple medical, healthcare, and 

engineering disciplines. National and international 

recognition of the military and VA in this unique area 

of medicine and rehabilitation will also likely improve 

recruitment of medical specialists within the DoD 

medical departments and VA, but most importantly 

greatly contribute to the continued improvements in 

care delivery to the nation’s heroes.

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Road Map for Future Amputee Care Research

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Care of the Combat Amputee